STATE OF FLORIDA us ke AGENCY FOR HEALTH CARE ADMINISTRATION 85 STATE OF FLORIDA Wish “hy 9 AGENCY FOR HEALTH CARE CAS She ADMINISTRATION, MG Es Petitioner, vs. Case No. 2004004203 2004006049 ALTERRA HEALTHCARE CORPORATION d/b/a ALTERRA STERLING HOUSE OF CAPE CORAL. CS-O70| Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against ALTERRA HEALTHCARE CORPORATION, d/b/a ALTERRA STERLING HOUSE OF CAPE CORAL., (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Fla. Stat., (2003), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $2,600.00 based upon Respondent being cited with four repeat State Class Il deficiencies, one uncorrected State Class Ul deficiency and one uncorrected State Class IV deficiency, pursuant to §400.419(2)(c) and (d) Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. AG a PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Florida Statutes, and; Chapter S8A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 50-bed assisted living facility located at 1416 Country Club Blvd., Cape Coral, Florida 33990, and is licensed as an assisted living facility, license number 9358. 5. Respondent was at all times matcrial hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rulcs, and statutes. COUNT 1 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, facility staff who provide direct care to residents, other than nurses, certified nursing assistants, or home health aides trained in accordance with Rule 59A- 8.0095, F.A.C., must receive a minimum of 1 hour in-service training in infection control, including universal precautions, and facility sanitation procedures before providing personal care to residents, Documentation of compliance with the staff training requirements of 29 CFR 1910.1031, relating to blood bome pathogens, may be used to meet this requirement. Fla. Admin. Code R. 58A-5.0191(2)(a). Training required by the rules must be documented in the facility’s personnel files, said documentation to include the title of the training program, the course content, date of attendance, the training provider’s name and credentials, and the number of hours of training. Fla. Admin. Code R. 58A-5.0191(10)(e), Fla. Admin. Code R. 58A- 5.024(2)(a)(1), Section 400.4275 Fla. Stat. (2003). 8. That on May 21, 2002, the Agency conducted a Biennial Licensure Survey of the Respondent. 9. That based upon the review of records and interview, the Respondent failed to ensure that direct care staff received | hour in-service training in infection control before providing assistance to residents for onc of eight sampled records. 10. That Petitioncr’s representatives reviewed the personnel records of the Respondent's staff. 11. That Respondent’s staff member number five was hired on January 15, 2002 as a Resident Aidc to provide care to the residents. 12. That the personnel file of staff member number five did not contain documentation to verify that staff member number five had completed the requisite one hour in-service training on infection control before providing assistance to the residents. 13. That staff member number one does not meet any of the exemption criteria of the applicable rule. 14, That the Petitioner’s representative interviewed the Respondent’s Health Care Coordinator. 15. That the Respondent’s Health Care Coordinator confirmed that staff member number five had not received the required in-service training on infection control prior to providing assistance to the residents. 16. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 17. That the Agency provided the Respondent with a mandatory correction date of June 21, 2002. 18. That during a re-visit survey conducted July 9, 2002, the Agency determined that the Respondent had corrected the deficiency. 19. That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 20. That based upon the review of records and interview, the Respondent failed to ensure that direct care staff received 1 hour of in-service training in infection control before providing assistance to residents for one of five sampled records. 21. That Petitioner’s representatives reviewed the personnel records of the Respondent’s staff on April 20, 2004. 22. That staff member number one provides direct care to residents. 23. That staff member number one does not meet any of the exemption criteria of the applicable rule. 24. That the personnel file of staff member number one did not contain documentation to verify that staff member number five had completed the requisite one hour in-service training on infection control before providing assistance to the resident. 25. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class III deficiency. 26. That the Agency provided the Respondent with a mandatory correction date of May 21, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2003). COUNT I 27. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28. That pursuant to Florida law, staff who provide direct care to residents, other than nurses, CNA’s, or home health aides trained in accordance with Rule 59A-8.0095, must receive 3 hours of in-service training within 30 days of employment that covers resident behavior and needs and providing assistance with activities of daily living. Fla. Admin. Code R. 58A-5.0191(2)(d). Any training required by the rules must be documented in the facility’s personnel files, said documentation to include the title of the training program, the course content, date of attendance, the training provider's name and credentials, and the number of hours of training. Fla. Admin. Code R. 58A-5.0191(10)(e), Fla. Admin. Code R. 58A-5.024(2)(a)(1), Section 400.4275 Fla. Stat. (2003). 29, That on May 21, 2002, the Agency conducted a Biennial Licensure Survey of the Respondent. 30. That based upon the review of records and staff interview, the Respondent failed to ensure that direct care staff received the required 3 hours training covering resident behavior and needs and providing assistance with the activities of daily living within 30 days of employment for one of eight sampled records. 31. That Petitioner's representatives reviewed the personnel records of the Respondent's staff during the survey. cian nemo me saan nena or ene em em = 32. That Respondent's staff member number four was hired on April 4, 2001 as a Resident Aide to provide care to the residents. 33. That the personnel file of staff member number four did not contain documentation to verify that staff member number four had completed the requisite three hour in-service training covering resident behavior and needs and providing assistance with activities of daily living within thirty days of employment. 34. That staff member number four does not meet any of the exemption criteria of the applicable rule. 35. That the Petitioner’s representative interviewed the Respondent’s Health Care Coordinator on May 21, 2002. 36. That the Respondent’s Health Care Coordinator confirmed that staff member number four had not received the required in-service training covering resident behavior and needs and providing assistance with activities of daily living within thirty days of employment. 37, That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 38. That the Agency provided the Respondent with a mandatory correction date of June 21, 2002. 39. That during a re-visit survey conducted July 9, 2002, the Agency determined that the Respondent had corrected the deficiency. 40. That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 41. That based upon the review of records and staff interview, the Respondent failed to ensure that direct care staff received the required 3 hours training covering resident behavior and needs and providing assistance with the activities of daily living within 30 days of employment for one of five sampled records. 42. That Petitioner’s representatives reviewed the personnel records of the Respondent’s staff during the survey. 43. That Respondent’s staff member number one provides direct care to residents and does not meet any of the applicable exemptions from training. 44. That the personnel file of staff member number one did not contain documentation to verify that staff member number four had completed the requisite three hour in-service training covering resident behavior and nceds and providing assistance with activities of daily living within thirty days of employment. 45. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class III deficiency. 46. That the Agency provided the Respondent with a mandatory correction date of May 21, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2003). COUNT III 47. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. That pursuant to Florida law, an assisted living facility shall offer personal supervision, as appropriate for each resident, including daily observation by desi gnated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. Fla. Admin. Code R. 58A-5.0182(1)(b). 49. That on November 18, 2002, the Agency conducted an Extended Care Center Survey of the Respondent. 50. That based upon observation, clinical record review of four resident records and interview with the Respondent’s administrative staff, the facility did not ensure communication and coordination of care for resident number three and did not ensure a fluid restriction was communicated and coordinated between the resident and staff for resident number two thereby failing to offer personal services to and being aware of the general health, safety, and physical well-being of the residents. 51. That Petitioner’s representative observed an intravenous pump present in the room of resident number three during a tour of the facility. 52. That Petitioner’s representatives interviewed resident number three. 53. That resident number three indicated that a home health care nurse to administer monthly medications for the resident utilized the intravenous pump. 54. That the Petitioner’s representative reviewed the clinical records of resident number three. 55. That the resident’s records contained no documentation relating to this intravenous medication or any documentation regarding the Respondent’s coordination with the home health agency. 56. That Petitioner’s representatives interviewed the Respondent's administrative staff on oe ND LE NR Se November 18, 2002. 57. That the Respondent’s staff indicated that though the staff was aware that resident number three received intravenous medications on a monthly basis, the staff lacked knowledge as to the type of medication being administered to the resident or a familiarity with the home health care agency which provided care to resident number three. 58. That the Petitioner’s representative reviewed the clinical records of resident number two. 59. That resident number two’s clinical record reflected the following: a. That resident number two was admitted to the Respondent facility on August 5, 2002; b. That resident number two had a health assessment completed on August 12, 2002; c. That resident number two’s health assessment provided that the resident was to be provided a diabetic diet; d. That resident number two was evaluated by the resident’s physician on October 28, 2002 for edema of the lower extremities; e. That the resident’s physician ordered that the resident’s fluids be restricted to eight hundred ccs daily; f. That the resident’s physician ordered that the resident obtain TED hose. 60. That during a tour of the facility by the Petitioner’s representatives, the resident was noted to have a pitcher of water in her room. 61. That no recording of the resident’s fluid intake was observed in the resident’s room. 62. That resident number two’s record contained no entries or documentation to reflect that the fluid intake of resident number two was being monitored by the Respondent to ensure that a semen ee SO nN A a A maximum intake of eight hundred cc was being maintained. 63. That the Petitioner’s representative observed resident number two at lunch at which the resident was provided a cup of coffee, a glass of punch, and a serving of soup. 64. That when Petitioner’s representative inquired of Respondent's staff regarding the resident’s fluid intake restrictions, the resident was given a choice of keeping the cup of coffee or the glass of punch. The resident chose the glass of punch and the cup of coffee was removed from the table. 65. That the Petitioner’s representative interviewed resident number two. 66. That resident number two indicated an awareness of the eight hundred cc fluid restriction, but believed eight glasses of water daily was necessary and that the resident did not drink enough. 67. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class Ill deficiency. 68. That the Agency provided the Respondent with a mandatory correction date of December 18, 2002. 69. That during a re-visit survey conducted December 20, 2002, the Agency determined that the Respondent had corrected the deficiency. 40, That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 71. That based upon clinical record review of five resident records and interview with the Respondent’s administrative staff, the facility did not ensure communication and coordination of care for resident number five and did not ensure awareness of wound care status for resident number five thereby failing to offer personal services to and being aware of the general health, safety, and physical well-being of the residents. 72. That the Petitioner’s representative reviewed the clinical records of resident number five. 73. That resident number five’s clinical records reflected the following: a. That resident number five had developed a open area in the palm of the hand on February 18, 2004; That the nurse’s notes described the same as a "large open area on the left hand under the resident's brace;” That the resident’s physician was notified; That general skin care was provided to the resident until February 19, 2004 when zinc oxide was administered; That on February 21, 2004, a home health care agency admitted resident number five to its care; f. That the home health care agency provided care to resident number five thru April 8, 2004; 74. That resident number five’s clinical records did not contain the following; a. Any annotation of facility staff regarding the size of the wound; b. Any description of the wound after the home health care agency commenced treatment; c. Any indication of communication between the Respondent and the home health care agency regarding the size, shape, and depth of the wound or whether the wound was open, closed, or whether the wound was draining open or closed or if it had drainage. al oa eens nee RR ey FA | REE nce 75. That the Petitioner’s representative interviewed the Respondent’s staff. 76. That the Respondent’s staff could locate no documentation in resident number five’s record which addressed further description of the wound. 77. That the Respondent failed to maintain an awareness of resident number five’s wound and treatment thereof once home health care commenced, thereby failing to maintain a daily awareness of the resident’s general health, satety, and physical well-being. 78. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class III deficiency. 79. That the Agency provided the Respondent with a mandatory correction date of May 21, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2003). COUNT IV 80. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 81. That pursuant to Florida law, all direct care staff providing care to residents in an extended congregate care program must complete at least 2 hours of in-service training provided by the facility within 6 months of beginning employment in the facility. The training must address extended congregate care concepts and requirements, including statutory and rule requirements, and delivery of personal care and supportive services in an extended congregate care facility. Fla. Admin. Code R. 58A-5.0191(7)(c). The administrator or owner of a facility shall maintain personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule. Section 400.4275(2) Fla. Stat. (2002), see also Fla. Admin. Code R. 58A- 5.024(2)(a)(1), Fla. Admin. Code R. S8A-5.0191(10)(c). 82. That on May 21, 2002, the Agency conducted a Biennial Licensure Survey of the Respondent. 83. That based upon the review of records and interview, the Respondent Administrator failed to ensure that direct care staff providing care to residents in an Extended Congregate Care (hereinafter ECC) program received at least 2 hours in-service training addressing extended congregate care concepts and requirements, including statutory and rule requirements, and delivery of personal care and supportive services in an extended congregate care facility within 6 months of employment for three of eight sampled records. 84. That Petitioner’s representative reviewed the personnel records of the Respondent. 85. That staff members number two, three, and four, hired on June 1, 2001, September 8, 1998, and April 4, 2001 respectively, provide direct care to residents in an ECC program. 86. That the personnel files of staff members two, three and four contained no documentation to verify that the staff had received at least 2 hours in-service training within 6 months of employment addressing extended congregate care concepts and requirements, including statutory and rule requirements, and delivery of personal care and supportive services in an extended congregate care facility. 87. That the Petitioner’s representative interviewed the Respondent’ administrator and health care coordinator. 88. That Respondent’s administrator and health care coordinator confirmed that the subject employee’s lacked documentation of the required training. 89. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 90. That the Agency provided the Respondent with a mandatory correction date of June 21, 2002. 9}. That during a re-visit survey conducted July 9, 2002, the Agency determined that the Respondent had corrected the deficiency. 92. That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 93. That based upon the review of records and interview, the Respondent Administrator failed to ensure that direct care staff providing care to residents in an Extended Congregate Care (hereinafter ECC) program received at least 2 hours in-service training addressing extended congregate care concepts and requirements, including statutory and rule requirements, and delivery of personal care and supportive services in an extended congregate care facility within 6 months of employment for three of eight sampled records. 94, That Petitioner’s representative reviewed the personnel records of the Respondent. 95. That staff members numbered one and five, hired on November 16, 2003 and October 7, 2002 respectively, provide direct care to residents in an ECC program. 96. That the personnel files of staff member one contained no documentation to verify that the staff had received at least 2 hours in-service training within 6 months of employment addressing extended congregate care concepts and requirements, including statutory and rule requirements, and delivery of personal care and supportive services in an extended congregate care facility. 97. That the personnel file of staff member number four reflects that the staff member received the required training on August 1, 2003, in excess of six months from the staff member’s employment. 98. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class IIT deficiency. 99. That the Agency provided the Respondent with a mandatory correction date of May 21, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2003). COUNT V 100. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 101. That pursuant to Florida law, every facility shall maintain, as public information available for public inspection under such conditions as the agency shall prescribe, records containing copies of all inspection reports pertaining to the facility that have been issued by the agency to the facility. Copies of inspection reports shall be retained in the records for 5 years from the date the reports are filed or issued. Section 400.435(1) Fla. Stat.(2003). Agency reports which pertain to any agency survey, inspection, monitoring visit, or complaint investigation shall be available to residents and the public. Fla. Admin. Code R. 58A-5.024(4)(c). 102. That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of Respondent. 103. That based upon observations made during the tour of the facility, the facility failed to have agency surveys available to the public. 104. That during the tour of the facility, the Petitioner’s representative observed that the last page of the last ECC (Extended Congregate Care) survey was posted in a glass frame. 105. That the Biennial survey was not available to the public. 106. That the Agency determined that the above constitutes the grounds for the imposition of an uncorrected Class IV deficiency in that it does not threaten the health, safety, or security of residents of the facility. 107. That the Agency provided Respondent with a mandatory correction date of May 21, 2004. 108. That on June 3, 2004, the Agency conducted a follow-up survey at the Respondent facility. 109. That based upon review of facility records review and interview, it was determined that the facility failed to ensure that the most recent Agency for Health Care Administration (AHCA) inspection was available to residents and the public. 110. That Petitioner’s representative, in preparing for the survey of June 3, 2004, noted that a Biennial inspection had been conducted by the Agency of Respondent’s facility on April 20, 2004. The Respondent's residence Director had executed said report on May 7, 2004 to include the plan of correction. 111. That Petitioner's representative reviewed the State inspection book located in a sitting room off of the main entrance of the Respondent facility. 112. That the most recent survey report contained therein was dated May 21, 2002. 113. That Petitioner’s representative interviewed the Respondent’s residence director. 114. That the Respondent’s residence director indicated that the June 2004 survey was not included in the publicly available record as the director belicved that the same should not be made available until such time as the plan of correction was completed. 115. That the Agency determined that the above constitutes the grounds for the imposition of an uncorrected Class IV deficiency in that it does not threaten the health, safety, or security of residents of the facility. 116. That the Agency provided Respondent with a mandatory correction date of July 3, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $100.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(1)(d), Fla. Stat. (2003). COUNT VI 117. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 118. That pursuant to Florida law, for facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider’s order or prescription label. Fla. Admin. Code R. 58A-5.0185(4)(a). 119. That on April 20, 2004, the Agency conducted a Biennial Licensure Survey of Respondent’s facility. 120. That based upon a review of records and interview with staff, the facility did not ensure medication was administered as ordered by the physician for one of five resident's reviewed. 121. That Petitioner’s representative reviewed the records, including but not limited to the medication observation records (hereinafter MOR) and medication labels, for resident number two. 122. That resident number two’s records reflect the following: a. That the resident was admitted to the facility on February 9, 2004; b. That the Department of Elder Affairs Assisted Living Facility Form completed by residents number two’s physician and dated February 13, 2004, indicated that the resident was to receive Fosamax 70 mg once a week; c. That no further physicians order was located; d. That resident number two’s record contained an order for Tylenol PM dated April 17, 2004, to be administered one tablet one hour before sleep. 123. That a review of the medications in the resident’s medication drawer revealed two boxes whose label indicated they contained Fosamax 10 mg tablets. 124. That the pharmacy label indicated the medication was to be administered as | tablet every day. 125. That the pharmacy label also had a hand written note indicating "give 1 a wk (week) 7 (with a circle around it) 10 mg = 70 mg". 126. That no Tylenol PM was located in the resident’s medication drawer. 127. That a review of resident number two’s MOR for this resident revealed the following: a. "Fosamax 70 mg tablet take 1 tablet once a week with 8 ounces of water 30 minutes before a meal-sit up for 30 min{minutes) after."; 18 b. That the documentation indicated the medication was to be given weekly; c. That the MOR had been documented as the medication having been administered on April 2, 9, and 16, 2004, with two further doses at 7 day intervals scheduled during April, 2004; d. That there was no documentation which would indicate that resident number two had received any Tylenol as prescribed. 128. That resident number two’s chart reflected that the Fosamax had been administered once a week since the resident’s admission. 129. That the physician’s directive and the directive contained on the resident’s medication container differed in administration. 130. That the Petitioner’s representative interviewed the Respondent’s administrative staff and nurse. 131. That the Respondent’s administrative staff indicated that resident number two had filled prescriptions immediately prior to the resident’s admission and that those medications were being utilized until gone at which time medications would be provided by the facility's pharmacy. 132. That the Respondent’s nurse who was administering medications on the date of survey indicated that she was uncertain of how the Fosamax was being administered and that the container label indicated daily. 133. That the Fosamax weekly dose is formulated differently than the daily dose and they should not be utilized interchangeably. 134. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class III deficiency. 135. That the Agency provided Respondent with a mandatory correction date of May 22, 2004. 136. That on June 3, 2004, the Agency conducted a follow-up survey of Respondent. 137. That based upon a review of records and interview with staff, the facility did not ensure medication was administered as ordered by the physician for one of four resident's reviewed. 138. That Petitioner’s representative reviewed the records, including but not limited to the medication observation records (hereinafter MOR), for resident number six. 139. That resident number six’s clinical record contained the following: a. That the resident was admitted to the facility on May 6, 2004; b. That a physicians order dated May 7, 2004 prescribed Senna S (Senokot) 8.6-50 mg., one tablet by mouth nightly at bedtime; c. That a facsimile from the resident’s physician dated May 24, 2004 reads “D/C (discontinue) Tylenol, Compazine, Roxanol, Senokot, change to PRN (as needed) nighttime O2 (oxygen), change to PRN Meclizine 25 mg (milligrams) p.o. (by mouth) TID (three times per day) routine.” 140. That a review of resident number six’s medicine observation record (hereinafter MOR) reflects as follows: a. That in the month of May, resident number six was offered, but refused, Senokot eleven of seventeen opportunities; b. That resident number six was administered Senokot on June 1, 2004 and June 2, 2004. 20 141. That Petitioner’s representative interviewed the Respondent’s administrative staff on June 3, 2004. 142. That staff indicated that they were unaware of the fact that resident number six had routinely received Senokot after the resident’s prescription had been changed. 143. That the Agency determined that this deficient practice was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for an uncorrected State Class II] deficiency. 144. That the Agency provided Respondent with a mandatory correction date July 3, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2003). Respectfully submitted this ze day of December, 2004. f as J. Walsh, II a. Bar. No. 566365 Senior Attorney Agency for Health Care Administration §25 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. 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. 21 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7003-1010-0003 4303 8371 on December 7 7 __, 2004 to: CT Corporation System, Registered Agent, Alterra Sterling House of Cape Coral, 1200 South Pine Island Road, Plantation, FL 33324 and U.S. Mail to Staci D. Leask, Administrator, Alterra Sterling House of Cape Coral, 1416 Country Club Road, Cape Coral, Florida 33990. Thorpds “Walsh, II, Esq. Copies furnished to: CT Corporation System Registered Agent Alterra Sterling House of Cape Coral 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Staci D. Leask Administrator Alterra Sterling House of Cape Coral 1416 Country Club Road Cape Coral, FL 33990 (U.S. Mail) Thomas J. Walsh, II, Esq. Agency for Health Care Administration $25 Mirror Lake Dr., 330G St. Petersburg, FL 33701 (Interoffice) 22 PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , Which represents payment of the Administrative Fine imposed by AHCA. Alterra Sterling House of Cape Coral 2004004203/ 2004006049 ee Facility Name AHCA No.

Docket for Case No: 05-000701