STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, EXHIBIT vs. Case No. 2004010770 47. SUNSHINE ACRES ASSISTED LIVING FACILITY d/b/a LS- O | | Y SUNSHINE ACRES, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or . “Agency, *), by aud fuough its undersigned counsel, aud files this Aduiuisteative Complaint against Sunshine Actes Assisted Living Facility d/b/a Sunshine Acres (“Respondent” or __-= = aiginshine Acres) pursuant to Fla. Stat. Sectioris 120-569, and 120.57 (2004), and alleges: NATURE OF THE ACTION 1. This is an action to revoke Respondent’s assisted living facility license, pursuant to Fla. Stat. Section 400, Part Ii (2004) and Fla. Admin. Code Chapter 58A-5 (2004). PARTIES 2. AHCA is the licensing and enforcing authority with regard to assisted living facility laws and rules, pursuant to Fla. Stat. Chapter 400, Part TI and Fla. Admin. Code 58A-5. 3 The Respondent is an assisted living facility located at 25 63 River Road, | Caryville, FL 32427. The Respondent is and was, at all times material fret, i) licensed facility under Fla. Stat, Chapter 400, Part II (2004), and Fla. Admin. Code Chapter 584-5 (2004), having been issued license number 5461. 4. JURISDICTION AND VENUE This Agency has jurisdiction pursuant to Fla. Stat. Chapter 400, Part TL, Scctions 120,569 and 120.57, and Fla. Admin, Code Chapter 28-106. 5. Venue lies in Washington County, Florida, pursuant to Fla. Stat. §120.57 (2004), Fla, Admin. Code R. 58A-5 and 28-106.207 (2004). COUNT I ELEVEN CLASS “HI” DEFICIENCIES WERE CITED AGAINST THE RESPONDENT ON A SINGLE SURVEY AND HAVE NOT BEEN CORRECTED WITHIN THE TIME 6. if fully set SPECIFIED $400.414(1)(e)(3), Fla. Stat. (2004) AHCA repeats, re-alleges, and incorporates paragraphs one (J) through five (5) as forth herein. — oT _ conjunctio “Gar Gr about August 18, 2004, AHCA éandveted an unannounced survey in with Operation Spot Check. Bleven deficiencies were cited, based upon the following findings: a, Based on record review and interview, the facility failed to maintain an up-to-date record of major incidents for 1 of 6 residents, A review of the facility’s incident reports revealed the last incident report on record was dated 2/25/01. An interview with the administrator at 9:15 am revealed the facility had an incident of elopement on 4/9/04. The administeator admitted the facility did not complete an incident record to include a desvription of the incident, time, place, and names of the mdividnals involved, witnesses, actions taken, whom provided services, and step taken to prevent recurrence. b. Based on record review and interview the facility failed to maintain an up-to-date record of adverse incidents for 1 of 6 sampled residents. An interview with the administrator on 8/18/04 at 9:15 am revealed the facility had no record af adverse incidents for the last 2 years. The facility had an clopenment on 4/9/04 and did not have a record of this incident. G. Based vu xecord review and interview, the facility failed to obtain a copy of the medical examination report for 1 of 5 sampled residents. ‘A review of resident’s record #1 did not contain a medical ae TET |= di. Busod on record review and interview the facility failed to initiate a weight record on admission to the facility for 1 of 5 sampled residents. A roviow of resident’s rccord #1 revealed the resident was admitted on 5/21/04, The resident weight record listed the admission date but a weight was not recorded. ‘An imerview with the administrator on 8/18/04 at 10:30 am confirmed there was not a weight record for this resident. t. Based on record review and interview the facility failed to maintain semi aunval weights on 4 of S sampled residents, 1. ‘A review of resident #2 record revealed the last weight obtained was on 7/9/03. 2. A review of resident #3 record revealed the last weight obtained was on 8/14/03. 3. A review of resident #4 record revealed the last weight obtained wa¢ on 8/14/04, 4, A review of resident #5 record revealed the last weight obtained was on 7/9/04, 5. ‘An interview with the administrator on 8/18/04 at 10;30 confirmed there was not any further weights on theses residents. Based on record review and interview the facility failed to obtain a statement from a health care professional stating the resident was free of communicable disease for lof $ sampled residents, A review of resident #1 record did not contain a statement of freedom from communicable diseases. The resident was admitted on 5/21/04. An interview with the administrato; on 8/18/04 at 10:30 am confirmed the facility did not have a statement of freedom from communicable disease for this resident. : Based on medical record review and interview the facility failed to ensure the resident was exarnined by the physician and a medical examination report completed for 1 of 5 sampled residents. A review of resident #1 record did not contain a medical examination by a health care professional. An interview with the administrator on 8/18/04 at 10:30 am confirmed the facility did not have documentation of a medical examinatian within 30 days of admission to the facility. ‘The resident was admitted on 5/21/04. ® A Based on obscrvation the facility failed to maintain the enviroment for out bathroom. During a tour of the brick building housing residents the main bathroom was found to have a grab bar to the me en __.— -wall, which was-rusted-with-peeling paint- The tub has-an-area-of approximately + anr-witrbrowa Tust. ‘Ihe showerhead was rusted with rusting around the tub drain. The grab rail to the outside of the tub was rusted. The bathroom did not contain toilet paper and the toilet paper holder did not have a bar for the toilet paper roll. . i. Based on record review and interview the facility failed to maintain an up-to-date log of mental health residents. A review of the facilitios admission and discharge log cid not indicate which residents were mental health residents. An interview with the administrator on 8/18/04 at 9:15 am revealed the current census as 44, The administrator was unable to indicate how many residents were mental health. The log contained a hand written jist titled “Mental Health Residents,” The list did not list the dates of admission and discharge. The administrator stated this list was “old” and he/she did not have 4 current list. j. Bases on record review and interview the facility failed to obtain a community living support plan for 1 of S sampled residents, A review of resident #1’s medical record revealed diagnosis of “Schizophrenia Disorder, Disorganized Type, Continuous.” The resident was admitted on 5/21/04. The medical record lists “Life Management” as the case manager. The medical record did not contain a mental health community living support plan. A mterview with the administrator on 8/18/04 at 10:30 arm confirmed the resident is a Limited Mental Health resident and the facility does not have a community living support plan for this resident. k. Based on record review and interview the facility failed to ensure the mental health community living support plan as updated annually for 1 of 5 sampled residents. Record review of resident #2’s medical record revealed a “Community Living Support Plan” dated 3/21/03 An interview with the administrator on 8/18/04 at 10:30 pm (sic) revealed the facility did not have an annual update, which was due 3/21/04, for this resident. 8. All of the deficiencies cited by AHCA on August 18, 2004 were class “III” deficiencies, The date of correction mandated by the Agency was September 18, 2004. G. On or about November 2, 2004, AHCA attempted to complete a combined complaint investigulion und follow-up survey to the August 18, 2004 Operation Spot Check survey in which eleven class Il deficiencies were cited against the Respondenit’s facility. One of the complaints being investigated by the Agency included allegations of the facility administrator threatening residents with a gun. For safety, Agency personnel were accompanied by a deputy of the Washington County Sheriff's Department. 10. The facility failed to allow the right of entry and inspection in order to determine the state of compliance with the applicable statutes and rules based upon the following: On 11/02/04 at approximately 11:20 am a Registered Nurse Specialist and a Health Care Facility Evaluator I attempted to conduct two complaint investigations and a follow up survoy to Operation Spot Check. hostile and accusatory. The attempted visit was then terminated by the accompanying Sheriff's Deputy, and the surveyors were escorted off the premises (a copy of the deputy's report is attached as Exhibit A). li. By failing to allow completion of the inspection of Lhe facility on November 2, 2004, the Respondent failed ta comply with the date of correction mandated by the Agency. The eleven class “ff” deficiencies cited against the respondent on the single survey conducted August 18, 2004 have not been corrected within the time specified. 12. The applicable Florida statutes and regulatory provisions of the Florida Administrative Code are as follows: §400.414(1)(e)(3) Denial, revocation, or suspension of license; imposition of administrative fines; grounds— (1) The agency may deny, revoke, or suspend any license issued under this part, or impose an administrative fine in the manner provided in chapter 120, for any of the following actions by an assisted living facility...: Cio {e) A citation of any of the following deficiencies as defined in s. 400.419: me (3) Five or more cited class IMI deficiencies that have been cited on a single survey and have not bee corrected in the time specified. 13. The foregoing violation constitutes five or more class II deficiencies that have been cited on a single survey and have not been corrected in the time specified, warranting revocation of the Respondent’s license. WHEREFORE, AHCA demands the following relief: 1. Entry of factual and legal findings as set forth in the allegations in this Administrative Complaint. 2. Revocation of the Respondent’s license. Respondent is notified that it has the right to request an administrative hearing pursuant to Fla. Stat.120.57 (2004). Specific options for administrative action axe set out in the attached Election ___. ef Rights (one page)-and-explained in-the attached Explanation-of Rights (one page): All reques pee STS for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Agency Clerk. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Submitted on this / ?) day of eaumber 2004 on behalf of the Agency for Health Care Administration by, Fla. Bar. No. 540129 Agency for Health Care Adrainistration 2727 Mahan Drive Bldg. 3, MSC #3 Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 413-9313 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and of Rights\form have been sent by U.S. Certified Mail, Return Receipt Requested, on the ik _day of {NE fh 2 __ 7004 ta Bruce D. Hall, Administrator, Sunshine Acres, 2563 iver Road, Caryville, FL 32427. is &, Rosenthal Assistant General Counsel __..

Docket for Case No: 05-000119