STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005001089 Vv. Return Receipt Requested: 7002 2410 0001 4234 4226 S.0.S. HEALTHCARE, INC., d/b/a 7002 2410 0001 4234 4233 A LOVING CARE INN, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA"), by and through the undersigned counsel, and files this Administrative Complaint against S.J.S. Healthcare, Inc., d/b/a A Loving Care Inn (hereinafter “A Loving Care Inn”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Section 400.419, Florida Statutes (2004), for the protection of the public health, safety and welfare and $500.00 survey fee pursuant to Section 400.419(10), and 400.428(3)(c), Fla. Stat. (2004) JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Broward County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code. 5. A Loving Care Inn operates a 60-bed assisted living facility located at 604 North 62™ Avenue, Hollywood, Florida 33024. A Loving Care Inn is licensed as an assisted living facility license number AL6653, with an expiration date of January 11, 2006. A Loving Care Inn was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I A LOVING CARE INN FAILED TO CONTACT THE RESIDENT’S HEALTH CARE PROVIDER AND OTHER APPROPRIATE PARTY IF THE RESIDENT EXHIBITS A SIGNIFICANT CHANGE Rule 58A-5.0182(1) (da), Florida Administrative Code (RESIDENT CARE STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted = on 01/10/2005 and based on record review and interview, the facility failed to contact the resident's health care provider and other appropriate party such as the resident's family if the resident exhibits a significant change. 8. During a review of Resident #1's record and interviews with the Administrator and resident's representative, it was revealed that the resident: (a) On 11/8/04 fell out of bed and sustained a head injury and scalp laceration. A progress note was found in the resident's file that stated he/she was "OK with a bump on his head". There was no documentation that the resident's representative (power of attorney) and physician were notified at the time of the injury of this change in condition. The following day, 11/9/04, he/she was seen by the physician at the facility and was diagnosis with head trauma and scalp lacerations. {(b) On 12/07/04 the resident was found to be itching and again was seen by the physician at the facility without the resident's representative being notified of this change in condition. The physician at the facility diagnosed this itching to be poison ivy and prescribed medication. The facility did not notify the resident's representative until the pharmacy called regarding the prescribed medications. The resident was taken to his primary care physician by his representative on 12/10/04 due to his/her severe itching and scabbing and referred to a dermatologist. On 01/03/05 the resident's representative took the resident to the dermatologist and the skin condition was confirmed to be scabies. 9. Based on the foregoing, A Loving Care Inn violated 58A- 5.0182(1) (d), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $1,000.00 against A Loving Care Inn on Count I for one Class II violation. Cc. Assess a survey fee of $500.00 against A Loving Care Inn, pursuant to Sections 400.419(10), and 400.428(3)(c), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right ‘to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. Ail requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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. Nels E. Rodney Assistant General Coblinsel Agency for Health Care Administration 8350 N. W. 52™4 Terrace Suite 103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Stephen A. Sugar, Administrator, 604 North 62"? Avenue, Hollywood, Florida 33024, and to Sam _ Sugar, Registered Agent, 604 North 62°47 Avenue, Hollywood, Florida 33021 _, 2005. e¥sorn E. Rodtfey

Docket for Case No: 05-000924