STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Huss day i ‘hgh STATE OF FLORIDA AGENCY FOR Ips Ai HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2006000649 LONG SHADOW INN, INC., d/b/a LONG SHADOW INN, 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 LONG SHADOW INN, INC., d/b/a LONG SHADOW INN (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the sum of one thousand dollars ($1,000.00) based upon one cited State Class II deficiency pursuant to §400.419(2)(b), Fla. Stat. (2005), and the assessment of a survey of five hundred dollars ($500.00) in accord with §400.419(10), Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 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 41-bed assisted living facility located at 2275 Nebraska Avenue, Palm Harbor, Florida 34683, and is licensed as an assisted living facility, license number 8104. 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 facility is required to offer personal supervision, as appropriate for each resident, including. ..daily observation by designated 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. R. 58A-5.0182(1)(b), Fla. Admin. Code. 8. That on January 10, 2006, the Agency conducted a complaint investigation of the Respondent facility. 9. That based upon the review of records, observation, and interview, the Respondent facility failed to provide personal supervision appropriate for each resident including the daily observation by staff to assure general health, safety and well-being of a resident. Ne 10. That the Petitioner’s representatives observed resident number two (2) on January 10, 2006, and noted the existence of numerous small bruises or abrasions on the resident’s right arm. 11. That the Petitioner’s representative interviewed the family members of resident number two (2) and the Respondent’s administrator, none of which could identify the source or causation of the resident’s multiple bruises. 12. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number two (2) on January 10, 2006 and noted the following: a, That the resident’s health assessment dated April 13, 2005, completed by the resident’s physician, directed that precautions be taken to protect the resident from experiencing falls; b. That the resident had experienced documented falls on May 28, 2005, August 11, 2005, and October 22, 2005 for which x-rays were necessitated. 13. That absent from the Respondent’s records were the following: a. That there was no record indicating the implementation of any precautions to. prevent the resident from suffering further falls as had been directed by the resident’s health care provider; b. That there was no indication of the implementation of any supervision to monitor or protect the resident from future falls; c. That there was no record indicating the implementation of appropriate supervision for the resident even after the resident suffered from falls, each necessitating medical attention; d. That there was no record indicating the source of or noting the resident’s bruising; e. That there was no indication of daily observation of the resident in noting bruises; f. That there was no indication that the Respondent was aware of the resident’s bruising and its potential effect on the resident’s health, safety, and well-being. 14. That the Respondent failed to meet minimum resident care standards in its failure to: a. Provide personal supervision appropriate to a resident who has a medically indicated necessity to supervise the resident in order to prevent the resident from suffering falls; b. Designate staff to observe the resident’s activities; c. Maintain a daily awareness of the resident’s general health, safety, and physical well-being. 15. That the Respondent’s failures directly threatened the resident’s health and physical well- being. 16. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 17. The Agency provided Respondent with a mandatory correction date of February 10, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2005). COUNT II 18. The Agency re-alleges and incorporates paragraphs (1) through (5), and (7) through (18) as if fully set forth herein. 19. That as a result of the Agency’s complaint investigation on or about January 10, 2006, the Respondent was cited for one Class II deficiency which was the subject of the complaint. 20. That pursuant to Section 400.419(10), Florida Statutes (2005), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 400.428(3)(c), Florida Statutes (2005), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. | WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. (2005). Respectfully submitted this ZL day of February, 2006. Tho: / Walsh II Flé@ Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 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 (two pages) 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy ofthe foregoing has been served by U.S. Certified Mail, Return Receipt No. 7003 1010 0002 4667 1293 on February 2Z_, 2006 to Pat Fitzgerald, Esq., 1210— 66" Street North, St. Petersburg, FL 33710. Tho: AWW Alsh II Senior Attorney Copies furnished to: Pat Fitzgerald, Esq. Thomas J. Walsh, I Fitzgerald - Williams Agency for Health Care Admin. 1210 — 66" Street North 525 Mirror Lake Drive, 330G St. Petersburg, FL 33710 St. Petersburg, Florida 33701 (U.S. Certified Mail) (Interoffice) am fa ay LED PAYMENT FORM 0 Ses Let 6 APR 2) PH 4 anki ISioW oj Agency for Health Care Administration HEAR RATIVE Finance & Accounting ~ARIHGS 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. Long Shadow Inn 2006000649 a Facility Name AHCA No.

Docket for Case No: 06-001452