STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004011447 AHCA No.: 2005001293 v. Return Receipt Requested: 7002 2410 0001 4234 2680 COLCHRIST CARE, LLC d/b/a COLCHRIS 7002 2410 0001 4234 2697 CARE, 7002 2410 0001 4234 2703 Respondent. ) ( S 2) O23 a ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Colchrist Care, LLC d/b/a Colchris Care (hereinafter “Colchris Care”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,964.00 [$1,500.00 fine + $464.00 survey fee] pursuant to Sections 400.414 and 400.419, Florida Statutes for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, and Chapter 28-106, Florida Administrative Code. 3. Venue lies in Broward County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. 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 (2005) and Chapter 58A-5 Florida Administrative Code. 5. Colchris Care operates a 6-bed assisted living facility located at 601 N. W. gsth Way, Pembroke Pines, Florida 33024. Colchris Care is licensed as an assisted living facility under license number 10163. Colchris Care 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 COLCHRIS CARE FAILED TO ENSURE THAT ALL RESIDENTS MET THE CONTINUED RESIDENCY CRITERIA. RULE 58A-5.0181(1)(c) and (d), FLORIDA ADMINISTRATIVE CODE, (ADMISSION CRITERIA STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs through (5) as if fully set forth herein. 7. Colchris Care was cited with one (1) Class II deficiency and one (1) Class III deficiency due to a complaint investigation conducted on December 8, 2004. 8. A complaint investigation was conducted on December 8, 2004. Based on interview and record review, it was determined that the facility failed to ensure that all residents met the continued residency criteria. The findings are as follows: 9. During a review of Resident #3's record, it was revealed that the resident was admitted to the facility on 07/07/02 with the diagnosis of Alzheimer's, Diabetes ASHD, CAD, HTN, and history of a seizure disorder. During an interview with a facility staff member, it was reported that Resident #3 required assistance from facility staff with consumption of his/her meals, including set-up and cuing. However, the staff member also reported that the resident required "total" help with the remainder of his/her ADL's including: wheeling the resident around the facility in his/her wheelchair, as the resident was unable to ambulate and/or self propel him/herself, bathing, grooming, dressing, and toileting (i.e. changing his/her incontinence briefs). The Administrator reported that over the last couple of months, the resident showed evidence of a rapid decline in function from requiring only supervision and/or assistance with ADL's, to requiring "tota." help with his/her ADL's. It was also reported that Resident #3 required total help with transferring. During an observation, it was observed that the resident required total help with an attempt to transfer and was also non-weight bearing. 10. During another interview, the Administrator reported that over the last couple of months, the resident showed evidence of a rapid decline in function from requiring only supervision with transferring, to requiring "total" help with transferring. After further investigation and interviews, the Administrator acknowledged that Resident #3 was inappropriate for the ALF and no longer met the continued residency criteria. 11. Based on the foregoing facts, Colchris Care violated Rule 58A-5.0181(1)(c) and (dj), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. COUNT II COLCHRIS CARE FAILED TO HAVE A SATISFACTORY FIRE INSPECTION. SECTION 400.441(1) (a), FLORIDA STATUTES RULE 58A-5.024(1) (m), FLORIDA ADMINISTRATIVE CODE (FACILITY RECORDS STANDARDS) CLASS III VIOLATION 12. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. A complaint investigation was conducted on December 8, 2004. Based on interview and record review, it was determined that the facility failed to have a satisfactory fire inspection. The findings are as follows: 14. During a review of the facility records, it was revealed that the local fire department conducted an annual fire safety inspection at the facility on 11/03/04. Further review of the records and interview with the Administrator revealed that the facility received an unsatisfactory fire safety inspection report on this date, including citations involving documentation of fire drills, wheelchair entrance and exit ramps, fire sprinkler system, etc. The Administrator was interviewed and reported that a follow-up inspection had not been conducted to ensure compliance by the local fire department, as of the date of the Petitioner’s complaint investigation. 15. The mandated date of correction was designated as January 8, 2005. 16. A revisit survey was conducted on January 27, 2005. Based on interview and record review, it was determined that the facility still failed to have a satisfactory fire inspection. The findings are as follows 17. The Administrator was interviewed on 01/28/05 again and reported that a follow-up inspection had still not been conducted, as of the date of the revisit, to ensure compliance by the local fire department. This is an uncorrected deficiency from the survey of December 8, 2004. 18. Based on the foregoing facts, Colchris Care violated Section 400.441(1) (a), Florida Statutes and Rule S58A- 5.024(1) (m), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $464.00 has been assessed in this case. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Colchris Care on Counts I and II. 2. Assess an administrative fine of $1,500.00 against Colchris Care on Counts I and II for the violations cited above. 3. Assess a survey fee of $464.00 against Colchris Care pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. 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. 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, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. « Julien>—Esq. Assigtant Ge al Counsel ageficy for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 B. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice 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 Colin Jackson, Administrator, Colchris Care, 601 N. W. 85 Way, Pembroke Pines, Florida 33024; Colchrist Care, LLC, P. O. Box 210425, Royal Palm Beach, Florida 33421; Aubin W. Robinson, 505 Royal Palm Beach Blvd., Royal Palm Beach, Florida 33411 on this A~ day of [Neawl— , 2005. Beret Margarpt [Julieyt, YEsq.

Docket for Case No: 05-002029