| Division of Administrative Hearings STATE OF FLORIDA AGENCY FOR HEALTH CARE ‘Boos | | E ) STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Daten Petitioner, AHCA NO.: 2006011002 v. JABOT’S ASSISTED LIVING, INC., 0 7 | > ( by Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through undersigned counsel, and files this Administrative Complaint against Jabot’s Assisted Living, Inc.,(hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of one- thousand five hundred dollars ($1,500), based upon the Respondent being cited for three (3) repeat Class III deficiencies pursuant to Sections 429.24(1) and (5), 429.26(4) and (5), and 429.52(4) Florida Statutes (2006). JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), Chapter 429, Part I, Florida Statutes (2006), and Chapter 28-106, Florida Administrative Code (2006). 3. Venue lies in Clay County, pursuant to Rule 28-106.207, Florida Administrative Code (2006). PARTIES 4. The State of Florida, Agency for Health Care Administration (““AHCA”) is the enforcing authority with regard to assisted living facility licensure pursuant to Chapter 429, Part I, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code (2006). 5. Respondent is an assisted living facility located at 2031 Sussex Drive, Orange Park, Florida 32073. Respondent was, at all times material hereto, a licensed assisted living facility, License number 8373, under Chapter 429, Florida Statutes (2006), and Chapter 58A-5, Florida Administrative Code (2006). COUNTI FACILITY’S RECORDS DID NOT INCLUDE A COPY OF THE RESIDENT’S ‘CONTRACT WITH THE FACILITY IN CONTRAVENTION OF SECTION 429.24(1) AND (5), FLORIDA STATUTES (2006) AND RULE 58A-5.024(3)(i) AND 58A-5.025(1), FLORIDA ADMINISTRATIVE CODE (2006). AN ADMINISTRATIVE FINE OF $500 IS WARRANTED. CLASS If DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about October 10, 2006, AHCA conducted a biennial survey of the facility. oo 8. Based on employee record review and an interview with the administrator on October 10, 2006, the facility failed to include a copy of the resident's contract with the facility, executed at or prior to admission, including any addendums to the contract. The findings include: A review of resident records revealed a copy of the first page of the contract. No other parts of the contract were contained in the record, including a signature for the residents' approval. An interview with the administrator at 2:00 PM revealed that she has never had this available for review. 9. This class I] deficiency was originally cited on 10/7/04, corrected on 11/12/04, and recited on 10/10/06. 10.‘ The findings listed above constitute a violation of Section 429,24(1) and (5), Florida Statutes (2006) and Rule 58A-5.024(3)(i) and 58A-5.025(1), Florida - Administrative Code (2006). 11. The above constitutes a Class III violation for which a fine of $500.00 is statutorily authorized pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT I. FACILITY FAILED TO ENSURE THAT ALL RESIDENTS HAD A COMPLETED MEDICAL EXAMINATION REPORT WITHIN 60 DAYS PRIOR TO ADMISSION, BUT NO LATER THAN 30.DAYS AFTER ADMISSION, IN CONTRAVENTION OF SECTION 429.26(4) AND (5) FLORIDA STATUTES (2006) AND RULE 58A-5.0181(2)(a), FLORIDA ADMINISTRATIVE CODE (2006). _AN ADMINISTRATIVE FINE OF $500 IS WARRANTED. CLASS Til DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 13. On or about October 10, 2006, AHCA conducted a biennial survey of the facility. 14. Based on resident’s record review for one of three sampled (Resident #1), it was determined that the facility failed to ensure that all residents were examined by a health care provider and a medical examination report was provided to the administrator within 60 days prior to the residents’ admission to the facility, but no later than 30 days after admission. This was confirmed by facility staff interview. The findings include: A Resident’s record review on 10/10/06 at 10 a.m. revealed that for one of three sampled residents (#1) there was a health assessment (1823) dated 8/26/05. This resident according to facility provided information was admitted on 12/8/05. This was confirmed by facility staff interview on 10/10/06 at 10:30 a.m. 15. This class III deficiency was originally cited on 10/7/04, corrected on 11/12/04, and recited on 10/10/06. 16... The findings listed above constitute a violation of Section 429.26(4) and (5) Florida Statutes (2006) and Rule 58A-5.0181(2)(a), Florida Administrative Code (2006). 17. The above constitutes a Class II violation for which a fine of $500.00 is statutorily authorized pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT I RESPONDENT’S ADMINISTRATOR FAILED TO PARTICIPATE IN 12 HOURS OF CONTINUING EDUCATION IN TOPICS RELATED TO ASSISTED LIVING EVERY 2 YEARS IN CONTRAVENTION OF SECTION 429.52(4) FLORIDA STATUTES (2006) AND RULE 58A-5.0191(1)(C), FLORIDA ADMINISTRATIVE CODE (2006). AN ADMINISTRATIVE FINE OF $500 IS WARRANTED. CLASS I DEFICIENCY 18. .AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. On or about October 10, 2006, AHCA conducted a biennial survey of the facility. 20. Based on employee record review and an interview with the adnninistrator on October 10, 2006, the Respondent failed to ensure that the administrator completed 12 hours of continuing education during the last two years. The findings include: A review of the employee records for the administrator revealed no continuing education during the last two years. In an interview with the administrator at 2:00 PM, on October 10, 2006, the administrator was unable to provide documentation of continuing education. Failure to maintain continuing education requirements renders the administrator a new administrator who must retake core training and pass the competency test. ” 21. This class III deficiency was original cited on 10/7/04, corrected on - 11/12/04, and recited on 10/10/06. 22. The findings listed above constitute a violation of Section 429.52(4), Florida Statutes (2006) and Rule 58A-5.0191(1)(c), Florida Administrative Code (2006). 23. The above constitutes a Class II violation for which a fine of $500.00 is statutorily authorized pursuant to Section 429.19(2)(c), Florida Statutes (2006). CLAIM FOR RELIEF WHEREFORE, the Siate of Florida, Agency for Health Care Administration, respectfully requests that the Court order the following relief against Respondent: (A) Make factual and legal findings in favor of the Agency on Counts I, Il and IT; (B) Recommend administrative fines against Respondent in the amount of five hundred ($500) dollars for Count I, in the amount of five hundred ($500) dollars for Count I, and in the amount of five hundred ($500) dollars for Count III, for a total of one-thousand, five hundred dollars ($1,500), pursuant to Section 429.19(2)(c), Florida Statutes (2006); (C) Assess attorney’s fees and costs; and (D) Grant all other general and equitable relief allowed by law. 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. 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. Reshéctfully s : Bart O. Moore \ Florida Bar # 0768715 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE J HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 7371, to Administrator Lucile Colvin, 5 Widener Way, Orange Park, FL 32073 and by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 7388, to Owner Jabot’s Assisted Living, Inc., 2031 Sussex Drive, Orange Park, FL 32073, on this a! “doy of frum 2007. / Moore, Esquire Copy furnished to: Nancy K. Marsh Field Office Manager

Docket for Case No: 07-001263