sae STATE OF FLORIDA BE Bo AGENCY FOR HEALTH CARE ADMINISTRATION G5 yyy !9 . Pip a, STATE OF FLORIDA a oss AGENCY FOR HEALTH CARE OO RES ay ADMINISTRATION, BE Petitioner, vs. Case No. 2004010922 2004010923 MARIMAR MANOR, INC., d/b/a MARI MAR MANOR, mm AG OS DSq> 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 MARIMAR MANOR, INC., d/b/a MARI MAR MANOR, (hereinafter “Respondent”), pursuant to Section 120.569 and 120.57, Fla. Stat. (2004), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of $2,500.00 based upon the Respondent being cited with one uncorrected and four repeat State Class III deficiencies, pursuant to § 400.419(2)(c) Fla. Stat. (2004). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2004). 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 III, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 6-bed assisted living facility located at 8087 25" Avenue North, St. Petersburg, Florida 33710, and is licensed as an assisted living facility, license number 10015. 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. Pursuant to Section 400.4275(2) Fla. Stat. (2004), and Fla. Admin. Code R. 58A-5.019(3) and 58A-5.024(2)(a)3, the Respondent is required to maintain documentation of compliance with Level 1 background screening for all staff subject to screening requirements. 8. On 01/09/03, the Agency conducted a biennial state licensure survey at Respondent's facility. 9. Based on record review, personnel records did not contain documentation of Level | background screening compliance, for one of one staff reviewed, subject to said requirements. 10. Employee file review during the 01/09/03 survey revealed that C.S., hired as Caregiver in 10/02, had no documentation of having had a Level 1 background screening through the FDLE. 11. 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 Respondent for a State Class II deficiency. 12. The Agency provided Respondent with a mandatory correction date of 02/08/03. 13. The deficient practice was corrected by 02/06/03. 14. On 09/16/04 the Agency conducted a complaint investigation (CCR# 2004008459) at Respondent's facility. 15. Based on record review and interview, personnel records did not contain documentation of Level | background screening compliance for one staff member, subject to said requirements. 16. Review of employee files and interview with the Administrator confirmed that employee A.A hired on 07/24/04 had not received a Level 1 background screening prior to assisting residents with personal care. 17. 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 Respondent for a repeat State Class III deficiency. 18. The Agency provided Respondent with a mandatory correction date of 10/16/04. 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. (2004). COUNT IT 19, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20. Pursuant to Fla. Admin. Code R. 58A-5.024(2)(a) and Section 400.4275(4) Fla. Stat. (2004), personnel records must contain verification of freedom from communicable disease, including tuberculosis. 21. On 01/09/03, the Agency conducted a biennial state licensure survey at Respondent's facility. 22. Personnel files did not contain verification of freedom from communicable disease, including tuberculosis for one of two personnel files reviewed. 23. Review of personnel files during the 01/09/03 survey revealed that there was no statement regarding C.S.’s freedom from communicable disease, including tuberculosis. 24. 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 Respondent for a State Class If deficiency. 25. The Agency provided Respondent with a mandatory correction date of 02/08/03. 20. The deficient practice was corrected by 02/06/03. 27. On 09/16/04 the Agency conducted a complaint investigation (CCR# 2004008459) at Respondent’s facility. 28. Staff members A.A. and M.T. did not have documentation of freedom from communicable diseases, including tuberculosis. 29. 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 Respondent for a repeat State Class II deficiency. 30. The Agency provided Respondent with a mandatory correction date of 10/16/04. 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. (2004). COUNT Il 31. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 32. Pursuant to Fla, Admin. Code R. 58A-5.023(1)(b), peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. 33. On 01/09/03, the Agency conducted a biennial state licensure survey at Respondent's facility. 34. During the initial facility tour on the day of the 01/09/03 survey, the carpeting in the room of W.A. was observed to be badly soiled/smudged. 35. 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 Respondent for a State Class If deficiency. 36. The Agency provided Respondent with a mandatory correction date of 02/08/03. 37. The deficient practice was corrected by 02/06/03. 38. On 09/16/04 the Agency conducted a complaint investigation (CCR# 2004008459) at Respondents facility. 39, During the tour of the facility, torn, dirty carpeting at the exterior front entrance of the facility was observed. This presented a potential trip hazard to residents. 40. 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 Respondent for a repeat State Class III deficiency. 41. | The Agency provided Respondent with a mandatory correction date of 10/16/04. 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. (2004). COUNT IV 42. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 43. Pursuant to §§ 400.424(1) and 400.424(5) Fla. Stat. (2004), and Fla. Admin. Code R. 58A-5.024(3)(i) and 58A-5.025(1), the resident's record must include a copy of the resident's in contract with the facility, executed at or prior to admission, including any addendums to the contract. 44. On 01/09/03, the Agency conducted a biennial state licensure survey at Respondent's facility. 45. Threc of three resident records reviewed during the 01/09/03 survey revealed that the files for Residents # 1, # 2 and # 3 did not contain any contractual addendum addressing the 05/01 statutory change, whereby the facility is required to provide the resident with at least 45 days written notice of discharge. 46. Thus, residents/responsible parties were at risk of not being aware of their discharge- related rights. 47. 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 Respondent for a State Class III deficiency. 48. | The Agency provided Respondent with a mandatory correction date of 02/08/03. 49, The deficient practice was corrected by 02/06/03. 50. On 10/26/04 the Agency conducted a re-visit to the complaint investigation (CCR# 2004008459) at Respondent’s facility. Sl. Review of Resident # 4’s file and interview with the Administrator confirmed that this resident did not have an executed contract signed by the Administrator and the resident’s Power of Attomey. 52. 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 Respondent for a repeat State Class III deficiency. 53. The Agency provided Respondent with a mandatory correction date of 11/26/04. 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. (2004). COUNT V 54. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. Pursuant to § 400.441(1)(e) Fla. Stat. (2004), and Fla. Admin. Code R. 58A-5.024(1)(b), an up-to-date admission and discharge log must be maintained listing the names of all residents and each resident’s: 1) Date of admission; 2) Place from which the resident was admitted; 3) Admission with a stage 2 pressure sore, if applicable; 4) Date of discharge; 5) Reason for discharge; 6) The facility to which the resident is discharged or home address, or if the person is deceased, the date of death. 56. On 09/16/04, the Agency conducted a complaint investigation (CCR# 2004008459) at Respondent’s facility. 57. Review of facility files and interview with the Administrator confirmed that there was not an up-to-date admission/discharge log. 58. 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 Respondent for a State Class III deficiency. 59. The Agency provided Respondent with a mandatory correction date of 10/16/04. 60. On 10/26/04 the Agency conducted a re-visit to the complaint investigation (CCR# 2004008459) at Respondent’s facility. 61. Review of facility files and interview with the Administrator confirmed that the admission/discharge log was not current at the time of the re-visit on 10/26/04. 62. Resident # | and Resident # 2 were not on the admission/discharge log. 63. Resident # 3 was no longer a resident at the facility and the admission’discharge log did not indicate that the resident had been discharged to another facility. 64. 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 Respondent for an uncorrected State Class III deficiency. 65. The Agency provided Respondent with a mandatory correction date of 11/26/04. 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. (2004). Respectfully submitted this day of June 2005. PRD “Gerald L. Pickett Fla. Bar. No. 559334 Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330K. St. Petersburg, Florida 33701 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 The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, Florida 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. CERTIFICATE OF SERVICE LHEREBY CERTIFY, that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1729 on June Ll , 2005 to: Marilou Bacalan, Mari Mar Manor, c/o Mari Mar Manor 2, 493 8" Avenue North, St. Petersburg, Florida 33709, and by U.S. Certified Mail, Return Receipt No. wee 1010 0002 4667 1873 to: Marilou Bacalan, Mari Mar Manor, c/o Mari Mar Manor 2, 5024 7" jay North, St. Petersburg, Florida 33701. | / | Ze) LEW) erald L. Pickett, re Copies furnished to: Marilou Bacalan Marilou Bacalan Gerald L. Pickett Mari Mar Manor Mari Mar Manor Agency for Health Care c/o Mari Mar Manor 2 c/o Mari Mar Manor 2 Administration 493 8" Avenue North 5024 71" Street North 525 Mirror Lake Drive, 330K St. Petersburg, Florida 33709 St. Petersburg, Florida 33701 | St. Petersburg, Florida 33701 (U.S. Certified Mail) (U.S. Certified Mail) (Interoffice) 7 PAYMENT FORM SUL 19. py 3: 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. 2004010923 Mari Mar Manor 2004010922 Facility Name AHCA Case No.

Docket for Case No: 05-002593