STATE OF FLORIDA , 7 4p AGENCY FOR HEALTH CARE ADMINISTRATION Oy STATE OF FLORIDA, 405 i Sig AGENCY FOR HEALTH CARE cop ip. ADMINISTRATION hep : AHCA No.: 2007001637 Petitioner, Return Receipt Requested: v. 7002 2410 0001 4235 5550 7002 2410 0001 4235 5567 COUNT AND COUNTESS DE HOERNLE ALZHEIMER'S PAVILION, INC. d/b/a q O DEHOERNLE ALZHEIMER'S PAVILION, () | - | ¥ INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration {(“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Count and Countess de Hoernle Alzheimer’s Pavilion, Inc. d/b/a Dehoernle Alzheimer’s Pavilion, Inc. (hereinafter “Dehoernle Alzheimer’s Pavilion”), pursuant to Chapter 429, Part I and Section 120.60, Florida Statutes (2006), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $1,000.00 pursuant to Section 429.19(2)(c), Florida Statutes for the protection of the public health, safety and welfare pursuant to 429.28(3) (c), Florida Statutes. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to ‘Sections 120.569 and 120.57 Florida Statutes, 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 429, Part I, Florida Statutes (2006), and Chapter 58A-5 Florida Administrative Code. 5. Dehoernle Alzheimer’s Pavilion operates a 46-bed 2™ Avenue, assisted living facility located at 325 N.W. Deerfield Beach, Florida 33441. Dehoernle Alzheimer’s. Pavilion is licensed as an assisted living facility. under license number 8415. Dehoernle Alzheimer’s Pavilion 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 DEHOERNLE ALZHEIMER’S PAVILION FAILED TO ENSURE THAT A SAFE ENVIRONMENT WAS PROVIDED FOR THE RESIDENTS Rules 58A-5.023(1) (a), and 58A-5.0185(6) (a), Florida Administrative Code (PHYSICAL PLANT STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the re-licensure survey conducted on 12/07/06, and based on observation and interview with the Director of Social Services and the Administrator, the facility failed to ensure that the facility is maintained for the safe care of all residents. 8. During the initial tour of the facility on 12/7/06 at approximately 10:30 AM, in which, the surveyor was accompanied by the Director of Social Services, the surveyor observed: {a) Large quantities of personal care items located in 2/3 of the resident rooms. The residents have all been diagnosed with Dementia and the facility is secured at all times. The doors of the resident rooms were noted to be unlocked and/or open. The following over-the-counter items were visible and/or unsecured and accessible to other residents. Bottles of Perineal Wash Solution Perishield Cream Bottles of mouth wash Bottles of Shampoo Bottles of Wound Cleanser Container of medicated powder (b) Room #16 had two disposable razors in the unsecured medicine cabinet. (c) The toilet seats in approximately 1/3 of the resident rooms were extremely loose. 9. The items/situations noted above create a potential hazard for the residents. 10. The Administrator was interviewed on the day of the survey at approximately 4:00 PM and confirmed the findings. ' Correction date given: 01/07/07. 11. During the follow-up conducted on 01/12/07 at approximately 11:45 AM and accompanied by Administrator, the surveyor and the Administrator observed: (a) Large quantities of personal care items were observed in 2/3 of the resident rooms. The residents have all been diagnosed with Dementia and the facility is secured at all times. The doors of the resident rooms were noted to be unlocked and/or open. The following over-the-counter items were visible and/or unsecured and accessible to other residents. Bottles of Perineal Wash Solution Perishield Cream Bottles of mouth wash Bottles of Shampoo Bottle of Peroximint solution Denture cleaning tablets Container of medicated powder (b) Room #2 had two disposable razors in the unsecured medicine cabinet. 12. The items/situations noted above create a potential threat for the residents. 13. The Administrator was interviewed on the day of the survey at approximately 2:00 PM and confirmed the findings. This is an uncorrected deficiency from the 12/07/06 survey. 14.. Based on the foregoing, Dehoernle Alzheimer’s Pavilion violated Rules 58A-5.023(1) (a), and 58A-5.0185(6) (a), Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT II DEHOERNLE ALZHEIMER'S PAVILION FAILED TO ENSURE THAT ALL PERSONNEL RECORDS REVIEWED CONTAINED ANNUAL VERIFICATION OF FREEDOM FROM TUBERCULOSIS Rule 58A-5.019(2) (a), Florida Administrative Code (STAFF RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 15. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16. During the re-licensure survey. conducted on 12/07/06, and based on record review and interview with the Administrator on the day of the survey at approximately 3:00 PM, the facility failed to ensure that one of the six personnel records reviewed contained annual verification of freedom from tuberculosis. 17. During the review of the staff records, it was noted that Employee's #4 record did not contain an annual statement from a health care provider that the employee was free from tuberculosis. The latest statement available had expired 7/06. The Administrator was interviewed and, after investigation, confirmed the findings. Mandated Date of Correction: 1/7/07 18. During the follow-up conducted on 01/12/07, and pased on record review and interview with the Administrator on the day of the survey at approximately 2:00 PM, the facility failed to ensure that two of the five personnel records reviewed contained annual verification of freedom from tuberculosis. 19. During the review of the staff records, it was noted that Employee's #1 and 2 records did not contain an annual statement from a health care provider that the employee was free from tuberculosis.. The Administrator was interviewed and, after investigation, confirmed the findings. This is an uncorrected deficiency from the 12/7/06 survey report. 20. Based on the foregoing, Dehoernle Alzheimer’s Pavilion violated Rule 58A-5.019(2) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. 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 Dehoernle Alzheimer’s Pavilion on Counts I and II. 2. Assess an administrative fine of $1,000.00 against Dehoernle Alzheimer’s Pavilion on Counts I and II for the violations cited above. 3. 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 (2006). Specific options for administrative action are set out in the attached Election of Rights form. 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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THE MATTER , ssistant General Counsel Agency for Health Care Administration Spokane Bldg., Suite 103 8350 N. W. 52™ Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (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 Alicia Schindler, Administrator, Dehocernle Alzheimer’s Pavilion, Inc., 325 N.W. 2™¢ Avenue, Deerfield Beach, Florida 33441, and to Stephen Cypen, Miami Beach, Registered Agent, 825 Arthur Godfrey Florida 33140 on this 4 day otf. Vf STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION o. » RE: Count and Countess De Hoernle Alzheimer’s Pavilion, Inv. CASE NO: 2007004637 wk d/b/a Dehoernle Alzheimer’s Pavililion ¢ ELECTION OF RIGHTS Se ne es) This Election of Rights form is attached to a proposed action by the Agency for He Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the-date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. : OPTION TWO (2) I admit to the allegations of facts contained in the Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC JER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY mpiete items 1, 2, and 3. Also complete n 4 if Restricted Delivery is desired. nt your name and address on the reverse that we can return the card to you. ach this card to the back of the mailpiece, on the front if space permits.. 3. Servipe Type trCertied Mail 1 Express Mail i Oi Registered return Receipt for Merchandise Cl insured Mail 01 C.0.D. 4. Restricted Delivery? (Extra Fee) rticle Number H ‘anster from service label) 7O02 2410 0001 4235 55b? =orm 3811, August 2001 Domestic Return Receipt 2ACPRI-09-2-0985 | i

Docket for Case No: 07-001890