STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, F Case No. 2004003818 VS. CLEARVIEW MANOR, INC., ~ 5. Lon d/b/a CLEARVIEW MANOR, [ a ‘) ( so 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 CLEARVIEW MANOR, INC. d/b/a CLEARVIEW MANOR. (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION This is an action to revoke the license of the Respondent Clearview Manner, Inc., d/b/a Clearview Manner pursuant to the provisions of §400.414(1)(e), Fla. Stat. (2003), or in the alternative to impose an administrative fine in the amount of two thousand five hundred dollars ($2,500.00) based upon five cited State Class III uncorrected or repeat deficiencies, pursuant to §400.419(2)(c), Fla. Stat. (2003). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. 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 HI, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 15-bed assisted living facility located at 1080 S. Clearview Avenue, Tampa, Florida 33629, and is licensed as an assisted living facility, license number 9643. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, a three day supply of non-perishable food, based on the number of weekly meals the facility has contracted with residents to serve, shall be on hand at all times. Fla. Admin. Code R. 58A-5.020(2)(h). 8. That on November 24, 2003, the Petitioner Agency conducted an appraisal visit of the Respondent facility. 9. That based upon a review of the facility food supply by the Petitioner’s representatives on the day of this visit, the facility did not ensure that a three day supply of non-perishable food, based upon the weekly meals the facility has contracted to serve, was on-hand at all times, in violation of law. 10. That on the day of this visit, the facility census was fifteen residents who receive three meals per day. 11. That the calculation of the required amount of non-perishable food for three days was determined to be as follows: Protein-270 oz. Vegetables-540 oz. Fruit-360 oz. Dairy-720 oz 12. That a review of the non-perishable food supply on hand revealed it to be inadequate in that there was no source of non-perishable protein maintained by the Respondent facility on the day of the Petitioner’s survey. 13. That observation further reflected that the Respondent facility was utilizing the noted non-perishable food supply in the preparation of daily meals. Having done so, the Respondent facility illustrated that it did not maintain a non-perishable food supply specifically set aside for emergencies at all times as required by law. 14. 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. 15. That the Agency provided the Respondent with a mandatory correction date of December 24, 2003. 16. That on February 26, 2004, the Petitioner Agency conducted a re-visit to the appraisal survey of November 24, 2003, at the Respondent facility. 17. That based upon a review of the non-perishable food supply and staff interview, the Respondent facility did not ensure that a three day supply of non-perishable food, based upon the weekly meals the facility has contracted to serve, was on-hand at all times in violation of law. 18. That on Petitioner’s noted that on February 26, 2004, the Respondent facility census was seventeen (17) residents, who were to be provided three meals per day. 19. That the licensed capacity of the facility is fifteen (15) residents who were to be provided three meals per day. 20. That a calculation of the required amount of non-perishable food for three days for a capacity of fifteen (15) was determined to be as follows: Protein-270 oz. Vegetables-540 oz. Fruit-360 oz. Dairy-720 oz 21. That the Petitioner’s representative observed the non-perishable food supply maintained by the Respondent facility at approximately 10:30 a.m. on February 26, 2004. No source of protein was located in said non-perishable food supply. 22. That the Petitioner’s representative interviewed the Respondent’s administrator on February 26, 2004. 23. That the Respondent’s administrator confirmed that the Petitioner’s representative had observed the non-perishable food supply maintained by the Respondent facility. 24. 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. 25. That the Agency provided Respondent with a mandatory correction date of March 26, 2004. 26. That the same constitutes the second time the Respondent was cited for said violation and, as such, constitutes an uncorrected or repeat deficiency pursuant to §400.419(2)(c), Fla. Stat. (2003). 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 II 27. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28. That pursuant to Florida law, the facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Fla. Admin. Code R. 58A-5.023(1)(b). 29. That on November 24, 2003, the Petitioner Agency conducted an appraisal survey of the Respondent facility. 30. That based upon observation, the facility did not ensure that the physical structure was maintained in good repair in violation of law. 31. That the Petitioner’s representative toured the Respondent facility on November 24, 2003. 32. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That the exterior wood on the front of the main house was mildewed and the wood was damaged from moisture; b. That the walls and moldings of the living room in the main house were dirty, stained and/or marred; c. That the walls of bedrooms and bathrooms in house “B” and “C” were dirty, cracked, scraped and/or marred; d. That floors in the hallway of house “B” was painted cement and not covered by any floor covering; e. That floors in bedroom one of house “B” and bedroom one of house “C” were painted cement and not covered by any floor covering; f. That the bathroom in house “C” did not have any floor covering. It was a painted cement floor and not subject to effective cleaning; g. That broken or missing tiles were observed in hallways and bedrooms of houses “B” and “C;” h. That in the bathroom of house “C,” a portion of the wall was torn out to repair a water pipe. Another area of the wall in this bathroom was damaged from moisture; i. That the floor of the porch in the main house was partially un-tiled and remained rough cement; j. That there was a hole in the shower wall around the control mechanism; k. That the hallway of house “B” was moldy; 1. That the bathroom shower was in the process of repairs in house “B” and was not usable. 33. 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. 34, That the Agency provided Respondent with a mandatory correction date of December 24, 2003. 35. That on February 26, 2004, the Petitioner Agency conducted a re-visit to the appraisal survey of Respondent. 36. That based upon observation, the facility did not ensure that the physical structure was maintained in good repair in violation of law. 37. That the Petitioner’s representative toured the Respondent facility on February 26, 2004. 38, That the Petitioner’s representative observed the following in and about the Respondent facility: a. That the exterior wood on the front of the main house was mildewed and the wood was damaged from moisture; b. That the walls of bedrooms and bathrooms in houses “B” and “C” were dirty, cracked, scraped and/or marred; c. That broken or missing tiles were observed in hallways and bedrooms of houses “B” and “C;” d. That in the bathroom of house “C”, an area of the wall was damaged from moisture; e. That the floor of the porch in the main house lacked tile in part, revealing rough cement. 39. 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. 40. That the Agency provided Respondent with a mandatory correction date of March 26, 2004. 4l. That the same constitutes the second time the Respondent was cited for said violation and, as such, constitutes an uncorrected or repeat deficiency pursuant to §400.419(2)(c), Fla. Stat. (2003). 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 42. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 43. That pursuant to Florida law, peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. Fla. Admin. Code R. 58A-5.023(1)(b) 44. — That on November 24, 2003, the Petitioner Agency conducted an appraisal survey of the Respondent facility. 45. That based upon observation, the facility did not ensure that missing and broken floor tiles were repaired or replaced in violation of law. 46. That the Petitioner’s representative toured the Respondent facility on November 24, 2003. 47. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That room three of house “B” had missing and torn floor covering; b. That the hall floor in house “B” had broken and torn linoleum tiles: c. That room one in house “C” had broken and torn tiles; d. That the floor tiles in the hallway of house “C” were broken and missing: e. That room “3” in house “C” had broken and missing floor tiles. 48. 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. 49. That the Agency provided Respondent with a mandatory correction date of December 24, 2003. 50. That on February 26, 2004, the Petitioner Agency conducted a re-visit to the appraisal survey of November 24. 2003 at the Respondent facility. 51. That based upon observation, the facility did not ensure that missing or broken floor tiles were repaired or replaced in violation of law. 52. That the Petitioner's representative toured the Respondent facility on February 26, 2004. 53. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That room three of house “B” had missing and torn floor coverings; b. That the hall floor in house “B” had broken and torn linoleum tiles; c. That room one in house “C” had torn and broken floor tiles; d. That the floor tiles in the hallway of house “C” were broken and missing e. That room three in house “C” had broken and missing floor tiles. 54. 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. 55. That the Agency provided Respondent with a mandatory correction date of March 26, 2004. 56. That the same constitutes the second time the Respondent was cited for said violation and, as such, constitutes an uncorrected or repeat deficiency pursuant to §400.419(2)(c), Fla. Stat. (2003). 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 57. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. That pursuant to Florida law, windows, doors, plumbing and appliances shall be functional and in good working order. Rule 58A-023(1)(b), Fla. Admin. Code. 59. That on November 24, 2003, the Petitioner Agency conducted an appraisal survey of the Respondent facility. 60. That based upon observation, the facility did not ensure that all windows, doors, and plumbing of the Respondent facility were in good working order, thereby violating Florida law. 61. That the Petitioner’s representative toured the Respondent facility on November 24. 2003. 62. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That the sink in bedroom one of the main house was not secure to the wall; b. That there were gaps around the bedroom door for room number one of the main house; c. That the outlet cover plate was not secure in room number three of house “B”; d. That the toilet tank did not have a cover in the bathroom of house “B”; e. That there were gaps between the structure and the air conditioning units located in bedrooms one and two of house “B”; f. That the air conditioning unit in room number one of house “B” was not securely installed; g. That the window screen in the bathroom of house “B” was loose. 63. 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. 64. That the Agency provided Respondent with a mandatory correction date of December 24, 2003. 65. That on February 26, 2004, the Petitioner Agency conducted a re-visit to the appraisal survey of Respondent. 66. That based upon observation, the facility did not ensure that all windows, doors, and plumbing of the Respondent facility were in good working order, thereby violating Florida law. 67. That the Petitioner’s representative toured the Respondent facility on February 26, 2004. 68. That the Petitioner’s representative observed gaps between the structure and the bedroom door for bedroom number one of the main house. 69. 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. 70. That the Agency provided Respondent with a mandatory correction date of March 26, 2004. 11 71. That the same constitutes the second time the Respondent was cited for said violation and, as such, constitutes an uncorrected or repeat deficiency pursuant to §400.419(2)(c), Fla. Stat. (2003). 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 72. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 73. That pursuant to Florida law, all furmiture and furnishings shall be clean, functional, free- of-odors, and in good repair. Fla. Admin. Code R. 58A-5.023(1)(b). 74. That on November 24, 2003, the Petitioner Agency conducted an appraisal survey of the Respondent facility. 75. That based upon observation, the facility did not ensure that all furniture and furnishings were clean and in good repair, thereby violating Florida law. 76. That the Petitioner’s representative toured the Respondent facility on November 24, 2003. 77. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That the carpeting in room number two of house “B” was badly stained and dirty; b. That the ceiling light fixtures and fans in room three of house “B” were dusty and grimy; c. That there were no protective globes on ceiling light fixtures in rooms two and three of house “C” and in the hallway of the main house; d. That the air conditioning and heating units were missing covers and were laden with dust in room three of house “B” and rooms one and two of house “C”; e. That the floors were dirty and littered with debris in room one of the main house, and in rooms one and three of house “C”; f. That the walls were dirty, marred, and scraped in bedrooms and common areas throughout all three resident houses. 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 State Class III deficiency. 79, That the Agency provided Respondent with a mandatory correction date of December 24, 2003. 80. That on February 26, 2004, the Petitioner Agency conducted a re-visit to the appraisal survey of Respondent. 81. That based upon observation, the facility did not ensure that all furniture and furnishings were clean and in good repair, thereby violating Florida law. 82. That the Petitioner’s representative toured the Respondent facility on February 26, 2004. 83. That the Petitioner’s representative observed the following in and about the Respondent facility: a. That ceiling light fixtures and fans were dusty and grimy in room three of house “B”: b. That there were no protective globes on ceiling light fixtures in rooms two and three of house “C” and in the hallway of the main house; c. That the air conditioning and heating units were laden with dust in room three of house “B” and in rooms one and two of house “C”; d. That floors were dirty and littered with debris in rooms one and three of house “Cr; e. That the walls were dirty, marred, and scraped in bedrooms and common areas through out all three houses. 84. 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. 85. That the Agency provided Respondent with a mandatory correction date of March 26, 2004. 86. That the same constitutes the second time the Respondent was cited for said violation and, as such, constitutes an uncorrected or repeat deficiency pursuant to §400.419(2)(c), Fla. Stat. (2003). 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 VI 87. The Agency re-alleges and incorporates paragraphs (1) through (5), (7) through (26), (28) through (41), (43) through (56), (58) through (71), and (73) through (86) as if fully set forth herein. 88. That pursuant to Florida law, the Petitioner Agency for health Care Administration may revoke the license of an assisted living facility for a citation of five or more class III deficiencies 14 that have been cited on a single survey and have not been corrected within the times specified. Section 400.414(1 )(e) Fla. Stat. (2003). 89. That the Respondent was cited with five (5) uncorrected class ITI deficiencies in Petitioner’s re-visit to the appraisal survey of November 24, 2003 conducted on February 26, 2004. 90. That the Petitioner Agency intends to revoke the license of the Respondent as a result of five uncorrected class III deficiencies in the Petitioner’s re-visit to the appraisal survey of November 24, 2003 conducted on February 26, 2004. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration intends to revoke the license of the Respondent Clearview Manor, Inc., an Assisted Living Facility in the State of Florida, pursuant to the provisions of Chapter 400, Florida Statutes. Respectfully submitted this % day of March, 2005. Low Il, Esq. Tho Fla. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration §25 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. 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 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. In CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0002 4667 0753 on March . 2005 to Kevin S. Kladakis, Registered Agent, Clearview Manor, Inc., 4008 Sevilla Street, Tampa, FL 33629 and by U.S. Certified Mail, Return Receipt No. 7003 1010 0002 4667 0760 to Deetra Taylor, Administrator, Clearview Manor, 1080 S. Clearview Avenue, Tampa, FL 33629. J. Walsh IT, Esquire 7 Copies furnished to: Kevin S. Kladakis Deetra Taylor, Administrator Thomas J. Walsh, II Registered Agent Clearview Manor Agency for Health Care Admin. Clearview Manor 1080 S. Clearview Avenue 525 Mirror Lake Drive, 330G 4008 Sevilla Street Tampa, FL 33629 St. Petersburg, FL 33701 Tampa, FL 33629 (U.S. Certified Mail) (Interoffice) (U.S. Certified Mail) _ - 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. CLEARVIEW MANOR 2004003818 Facility Name AHCA No.

Docket for Case No: 05-002032