STATE OF FLORIDA i AGENCY FOR HEALTH CARE ADMINISTRATION 87 Boy . STATE OF FLORIDA, 8 PH 4: @g AGENCY FOR HEALTH CARE ADMINISTRATION, . Petitioner, 0! , S| 0 4 v. Case Nos. 2007007583 GOLD KEY DEVELOPMENT, INC., D/b/a CARRIAGE INN, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration, (hereinafter “the Agency”), by and through the undersigned counsel, and files this administrative complaint against the Respondent, GOLD KEY DEVELOPMENT, INC., d/b/a CARRIAGE ’ INN, (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the license of an assisted living facility pursuant to Subsection 429.14(1)(e)2, Florida Statutes (2006), Subsection 408.815(1)(c), Florida Statutes (2006), and Subsection 408.815(1)(d), Florida Statutes (2006), or altematively, to impose an administrative fine in the amount of four thousand five hundred dollars ($4,500.00), pursuant to Subsections 429.19(2)(b)-(c), Florida Statutes (2006), based upon the facility committing nine uncorrected Class II violations. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to sections 120.569 and 120.57, Florida Statutes (2006). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2006). 3. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules, governing assisted living facilities. Ch. 408, Part II, and Ch. 429, Part I, Fla. Stat. (2006); Rule 58A-5, Fla. Admin. Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine in the manner provided in Chapter 120, Florida Statutes. §§ 408.813, 408.815, 429.14, Fla. Stat. (2006). 5. The Respondent was issued a license by the Agency (License Number 10146) to operate a 35-bed assisted living facility located at 3409 W. 19" Street, Panama City, Florida 32405, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules governing assisted living facilities. COUNT I REVOCATION OF LICENSE The Respondent Was Cited For Nine Uncorrected Class III Deficiencies In Violation Of F.S. 429.14(1)(e)3 6. The Agency re-alleges and incorporates by reference paragraphs 1 through 5. 7. Under Florida law, the Agency may deny, revoke, or suspend license issued under Chapter 429, Part I, Florida Statues, or impose an administrative fine in the manner provided under Chapter 120, Florida Statutes, for, any action enumerated in Subsection 429.14(1)(a)-{n), Florida Statutes. The Respondent is being cited for nine uncorrected Class III deficiencies. § 429.14(1)(e)3, Fla. Stat. (2006). 8. The Agency re-alleges and incorporates by reference the allegations in Counts II through X. 9. On or about May 22, 2007, the Agency conducted a follow-up survey to the complaint survey conducted April 6, 2007 of the Respondent and its Facility. 10. __— As a result of this follow-up survey, the Agency cited the Respondent for nine uncorrected Class III deficiencies in violation of Section 429.14(1)(e)3, Florida Statutes (2006). 11. The Respondent was cited for and committed nine uncorrected Class TI deficiencies in violation of Section 429.14(1)(e)3, Florida Statutes (2006). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to revoke the license of the Respondent to operate the above- referenced assisted living facility. COUNT II The Respondent Failed To Ensure That Medical Examination For Residents In The Facility Had The Required Documented Information On The DOEA Form Health Assessment 1823 In Violation Of Section 429.26(4), Fla. Stat. (2006) And Fla. Admin. Code R. 58A- §.0181(2)(a)7 Uncorrected Class III Violation 12. The Agency re-alleges and incorporates paragraphs 1 through 5. 13. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 14. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 15. Based on observation, interview and record review the facility failed to ensure the medical examination for residents in the facility had documented information on the DOEA form Health Assessment 1823 addressing the following: a. Whether the individual will require any assistance with the administration of medication; b. A statement that in the opinion of the examining physician, physician assistant, or ARNP, on the day the examination is conducted, the individual's needs can be met in an assisted living facility for 1 of 4 (#7) sampled residents And to ensure that the medical examination on the DOEA form Health Assessment 1823 had been conducted and a copy available in the medical record for 3 of 4 (#4, #5, #8) sampled residents. The surveyor’s findings were: 16. 1, A record review of the facility's residents was conducted on 05/21/2007. During this review it was revealed that sampled resident #7 did not have the following required documentation: a. Whether the individual will require any assistance with the administration of medication, and did not have the statement checked yes or no. b. That in the opinion of the examining physician, physician assistant, or ARNP, on the day the examination is conducted, the individual's needs can be met in an assisted living facility Yes/No. 2. A record review of the facility's residents was conducted on 05-21-2007. During this review it was revealed that the medical record for sampled residents #4, #5, and #8 did not contain a copy of the DOEA form Health Assessment 1823. 3. In an interview with the assistant supervisor at approximately 1:00 pm on 05- 21-2007 it was confirmed that the health assessment forms 1823 for all facility residents had been requested from the physicians since the last complaint survey. The health assessment forms had not been received for sampled residents #4, #5, #7 and #8. The Agency gave a mandatory correction date of June 21, 2007. The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429,19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT II The Facility’s Administrator Failed To Ensure That Any Information That Is Not Contained In The Resident’s Medical Examination Report Must Be Obtained Within 30 Days After Admission Using AHCA Form 1823. In Violation Of F.A.C. 58A-5.0181(2)(c) ~ Uncorrected Class III Violation 17. The Agency re-alleges and incorporates paragraphs 1 through 5. 18. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 19. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 20. Based on record review and interview the administrator failed to ensure any information that is not contained in the resident's medical examination report must be obtained within 30 days after admission using AHCA Form 1823 for 4 of 4 (#4, #5, #7 & #8) sampled residents. The surveyor’s findings were: 1. A record review of the facility's residents was conducted on 05/21/2007. During this review it was revealed that sampled resident #7's DOEA 1823 Health Assessment was conducted on 06/15/2006 and did not have the following documentation as required entered onto the form with in 30 days by the administrator: a. Whether the individual will require any assistance with the administration of medication, and did not have the statement checked yes or no. b. That in the opinion of the examining physician, physician assistant, or ARNP, on the day the examination is conducted, the individual's needs can be met in an assisted living facility was not checked either Yes/No. 2. Also during these record reviews it was revealed that there was no documentation for sampled residents #4, #5, and #8 to show DOEA 1823 Health Assessment had been completed. 3. In an interview with the assistant supervisor it was confirmed that the DOEA 1823 health assessment forms for sampled residents #4, #5, #7, #8 had not been up-dated since the previous complaint survey on 04-06-2007. The forms had been requested from the physicians but had not been returned to the facility. The Agency gave a mandatory correction date of June 21, 2007. 21... The Agency shall impose an administrative fine for a cited uncorrected Class IIT violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429.19(2)(c), Florida Statutes (2006).. A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT IV The Facility’s Owner/Administrator Failed To Assess And Monitor Residents For The Continued Appropriateness Of Placement Of A Resident In The Facility For Five of Fifteen Residents In Violation of § 429.26(1), Fla. Stat. (2006) and F.A.C. 58A-5.0181(4) Uncorrected Class II deficiency 22. The Agency re-alleges and incorporates paragraphs 1 through 5. 23. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 24. The facility was found to be out of substantial compliance with S8A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, AO808 and A1105. 25. Based on record review and interview the facility's owner/administrator failed to assess and monitor residents for the continued appropriateness of placement of a resident in the facility for 5 of 15 (#4, #5, #6, #7 & #8) sampled residents. The surveyor’s findings were: 1. During a tour of the facility it was noted that there was no licensed nursing personnel/staff at the facility. During interviews with the Administrator and the Supervisor, the Supervisor stated, "The Licensed Practical Nurse (LPN) walked out on 03/22/2007 and we have not had any nurse work in the facility since then." The administrator also stated, “we won't hire any more nurses after this." The facility did not have a licensed nurse working at the facility between 03/22/2007 and the day of this complaint survey. 2. A review of the resident's records was conducted on 04/06/2007. During these record reviews it was revealed that the following residents were documented on the DOEA Form 1823 in the questioning statement - Does the individual need help with their medications (Yes/No)?, and if Yes please describe; to require "Nursing" Staff to "Administer" medications in lieu of unlicensed staff "Assisting" with medications: Sampled resident #4 ("Nursing Staff needs to dispense medications") Sampled resident #5 ("Nursing Staff needs to administer medications") Sampled resident #6 (Left Blank) Sampled resident #7 ("Needs to be given medications" Note: additional hand. written in other ink that the original -."Error, Yes box checked and after the above statement, "Needs to be given medications," "self administers," was written in. There was no new or updated DOEA 1823 for this resident. There was no documentation for this alteration of the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.") Sampled resident #8 ("Licensed Nurse to Administer" Note: the word "Administer was scratched out using a different ink and the words "assist if needed later with medications” was written in. There was no documentation in the resident's chart to show there had been a change in the resident's status. There was no documentation for this alteration in the original DOEA 1823 form in the resident's chart. The facility (Administrator/Supervisor) could not produce any documentation to show this change in the resident's status. The Administrator did state, "The nurse that walked out set us up for this.”) 3. An interview with the facility's administrator was conducted on 04/06/2007. The administrator could not show any documentation where any of the above resident's were re-evaluated by the physician (Physician's Assistant/Advanced Registered Nurse Practioner) and no longer needed to have their medications administered. The administrator also stated, “After today they all will be medication assist only residents." The administrator also could no show where the resident had been assessed/evaluated for further residency continuance at the facility. 4. Also during the tour it was observed that sampled resident #2 had 8 Insulin (pre-filled by a Licensed Practical Nurse/LPN no longer at the facility or employed by the facility). The syringes were filled with a clear liquid stored in the facility's medication room. There was no name (who they were for), date drawn up/filled, type insulin, amount of insulin to be in each syringe, or any other identification to the 8 pre-filled syringes. The facility supervisor stated, "They belong to sampled resident #2 and were drawn up by the LPN who walked out." 5. An interview with sampled resident #2 was conducted on 04/06/2007. During this interview the resident acknowledged that the facility did not allow him to draw up his own insulin or have his medication (insulin and oral medications) in his room to self administer but that the facility staff (Aid & Supervisor) would bring the pre-filled (see item #1 above) medication (insulin) to his/her room when the scheduled time for administration was. 6. An interview with the facility's supervisor was conducted on 04/06/2007. During this interview the supervisor acknowledged that the previous employee (an LPN), no longer working at the facility, had pre-drawn insulin in syringes for sampled resident #2 and they were stored in the facility's medication room (Note: Syringes were unlabeled with any name, date or substance in them). The supervisor also acknowledged that there had been no licensed (physician, nurse, physician's assistant, registered nurse Practioner) person in the facility to assist in or administer medications to residents since the LPN left the facility on 03/22/2007. The supervisor also acknowledged that the staff Aids were taking the pre-filled insulin syringes to sampled resident #2 every evening at the scheduled time and that the resident was not drawing up his/her own medication as per the self administration process and there was no one to verify that the correct amount of insulin was in each syringe. 7, There were no assessments that the facility could produce to show that the above residents met continued residency requirements. The Agency gave a mandatory correction date of June 21, 2007. 26.. | The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429,19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. ‘ WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT V The Respondent's Facility Failed To Have At Least One Staff Member Who Is Trained In First Aid And CPR In The Facility At All Times In Violation Of F.A.C. 58A-5.019(4)(a)4 Uncorrected Class III Violation 27. The Agency re-alleges and incorporates paragraphs | through 5. 28 On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 29. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, 0524, A0702, A0807, A0808 and A1105. 30. Based on observation and interview the facility failed to have at least one staff member who is trained in First Aid and CPR, as provided under Rule 58A-5.0191, in the facility at all times when residents are in the facility. The surveyor’s findings were: 1. A review of the facility's personnel records was conducted on 05/21/2007. During this review it was revealed that there was no staff member in the facility certified in ist Aid at or during any portion of the survey until after the notification of the AHCA Field Office was conducted. 2. Interviews were conducted on 05/21/2007 during the survey with the 3 staff members and administrator. During these interviews the Administrator, Assistant Supervisor, Aid & Cook acknowledged they did not have a 1st Aid certification. The resident Aid at the facility was the only individual that thought he/she may have a 1st Aid certification but did not produce documentation to show this during or after the survey. A call from the assistant supervisor to the only staff member certified in 1st Aid was conducted to have the Aid come to the facility. The Aid arrived at the facility at approximately 2:15 PM Central Standard Time, The assistant supervisor called a certified 1st Aid instructor. The instructor came to the facility to provide a Ist aid class for facility staff members and the administrator. The Agency gave a mandatory correction date of June 21, 2007. 31. | The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429,19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT VI The Respondent’s Facility Failed To Monitor The Quantity And Quality Of Resident Diets By Failing To Ensure All Regular And Therapeutic Menus To Be Used By The Facility Are Reviewed By A Registered Dietitian, Licensed Dietitian/Nutritionist, Or By A Dietetic Technician Supervised By A Registered Dietitian Or Licensed Dietitian/Nutritionist; Failed To Ensure The Meals Were Commensurate With The Nutritional Standards, And Failed To Ensure The Served Meal Portion Sizes Were In Accordance With The Certified Meal Menu In Violation Of F.A.C. 58A-5.0182(1)(a) Uncorrected Class II Violation 10 32, The Agency re-alleges and incorporates paragraphs 1 through 5. 33. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 34. The facility was found to be out of substantial compliance with S8A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 35. Based on observation, record review, and interview the facility failed to monitor the quantity and quality of resident diets in accordance with rule S8A-5,020 by failing to ensure all regular and therapeutic menus to be used by the facility are reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or licensed dietitian/nutritionist; failed to ensure the meals were commensurate with the nutritional standards; failed to ensure served meal portion sizes were in accordance with the certified meal menu. The surveyor’s findings were: 1. A tour of the facility was conducted on 05/21/2007. During this tour it was observed that the facility menu was posted on a bulletin board in the kitchen. It was further revealed that the date the menu was faxed to the facility from the Registered Dietitian (RD) was 01/27/2004. There was no documentation on the menu to show that it had been reviewed or updated and signed off by an RD since that time, and the facility could provide no further. 2. In an interview with the assistant supervisor at approximately 11:55 PM Central Standard Time on 05/21/2007 it was confirmed that the menus had not been up-dated and did not contain portion sizes but that an appointment was scheduled with an RD on 05/21/2007 to receive the up-dated menus. However before the surveyors left the facility, the assistant supervisor was not able to contact the RD to get a copy of the up-dated menus. The Agency gave a mandatory correction date of June 21, 2007. 36. The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429.19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, , respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT VII The Respondent’s Facility Failed To Ensure All Regular And Therapeutic Menus Are Reviewed Annually By A Registered Dietitian, Licensed Dietitian/Nutritionist, Or By A Dietitian Technician Supervised By A Registered Dietitian/Nutritionist To Ensure The Meals Are Commensurate With The Nutritional Standards In Violation Of F.A.C. 58A-5.020(2)e Uncorrected Class II Violation 37. The Agency re-alleges and incorporates paragraphs 1 through 5. 38. | On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 39, The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 40. Based on observation and interview the facility failed to ensure all regular and therapeutic menus to be used by the facility are reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician supervised by a registered dietitian or hcensed dietitian/nutritionist to ensure the meals are commensurate with the nutritional standards, The surveyor’s findings were: 1. A tour of the facility was conducted on 04/06/2007. During this tour it was noted observed that the only meal menu was posted on a bulletin board in the kitchen away from resident view. It was further revealed that the date the menu 12 was faxed to the facility from the Registered Dietitian (RD) was 01/27/2004. There was no documentation on the menu to show that it had been reviewed or updated and signed off by an RD since that time and the facility could provide no further documentation to show this had been done. 2. An observation of the lunch meal was conducted on 04/06/2007. The menu posted in the kitchen documented the meal was to be: Fish Cheese Grits Com Peas Tomatoes Bread Pound Cake (Note: over the peas & Tomatoes was hand written - "Baked Beans" Tea, Water, Coffee The observed meal served to the residents was: Fried Fish Baked Beans Fired Corn Meal Balls (Hush-Puppies) Cole Slaw Apple Crisp Tea, Water, Coffee 3. Further review of the facility's menu reviewed that there had been inked in changes since it was originally produced and there was no documentation that these changes had been approved by any RD for the facility. 4. An interview with the facility's cook was conducted on 04/06/2007. During this interview the cook acknowledged that he/she had no documentation to show that the menus had ever been updated per the annual review/update requirement. The cook also acknowledged that if there was a substitution to the meal menu he/she made the chose of the substitution predicated on what was available at the facility. The cook acknowledged that he/she did not have the training to ascertain if the substitution was of equal nutritional value to the item being substituted for, and did not keep a record or other documentation of any substituted menu meal item. The cook also acknowledged that he/she did not post the menu changes for the residents to review at any time. The Agency gave a mandatory correction date of June 21, 2007. 41. The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an arnount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429.19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the 13 correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT VII The Respondent’s Facility Failed To Ensure That The Menus Contained Portion Sizes In Violation Of F.A.C. 58A-5.020(2)(c) Uncorrected Class III Deficiency 42. The Agency re-alleges and incorporates paragraphs 1 through 5. 43, On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 44. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 45. Based on observation and interview the facility failed to ensure that the menus contained portion sizes. The surveyors’ findings were: 1. A tour of the facility was conducted on 05/21/2007. During this tour it was observed that the menu posted-was on a bulletin board in the kitchen did not contain portion sizes. 2, In an interview with the assistant supervisor at approximately 11:55 PM Central Standard Time it was confirmed that the menus did not contain portion sizes. The Agency gave a mandatory correction date of June 21, 2007. 46. The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth 14 in Section 429.19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT IX The Respondents Facility Failed To Ensure All Menus Were Dated And Planned At Least One Week In Advance For Both Regular And Therapeutic Diets In Violation Of F.A.C. 58A-5.020(2)(d) Uncorrected Class HI Deficiency 47. The Agency re-alleges and incorporates paragraphs 1 through 5. 48. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Respondent and its Facility. 49. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and A1105. 50. Based on observation and interview the facility failed to ensure all menus to be served were dated and planned at least one week in advance for both regular and therapeutic diets. The surveyors’ findings were: 1. In an interview with the assistant supervisor at 11:55 PM Central Standard Time that the menu had not been up-dated. An appointment had been scheduled with an RD on 05-21-2007 to receive the up-dated menus. However the menus were not available before the surveyors left the facility. The Agency gave a mandatory correction date of June 21, 2007. The Agency gave a mandatory correction date of June 21, 2007. 51. The Agency shall impose an administrative fine for a cited uncorrected Class III 15 violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429.19(2)(c), Florida Statutes (2006), A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). COUNT X The Respondent’s Facility Failed To Have Documentation Of Current Certification In An Approved First Aid Course In At Least One Personnel Record For Staff On Duty At All Times In Violation Of F.A.C. 58A-5.0191(4) Uncorrected Class III Deficiency 52. The Agency re-alleges and incorporates paragraphs 1 through 5. 53. On or about May 22, 2007, the Agency conducted a follow-up to the complaint survey on April 6, 2007 of the Resporident and its Facility. 54. The facility was found to be out of substantial compliance with 58A-5 F.A.C. and the following citations were not cleared: A0417, A0420, A0524, A0702, A0807, A0808 and Al1105, 55. Based on record review and interview the facility failed to have documentation of current certification in an approved First Aid course in at least 1 personnel record for staff on duty at the facility, as provided under Rule 58A-5.0191 at all times when residents are in the facility. The surveyors’ findings were: 1. An initial tour of the facility was conducted on 05/21/2007. During this tour it was noted that there was 3 staff members and the administrator in the facility upon the survey team arrival (Supervisor, Cook, & Aid). 16 2. A review of the facility's personnel records was conducted on 05/21/2007. During this review it was revealed that there was no staff member in the facility certified in 1st Aid. 3. Interviews were conducted during the survey on 05/21/2007 of the 3 staff members and administrator. During these interviews the Administrator, Assistant Supervisor, & Cook acknowledged they did not have Ist Aid certification. The resident Aid was the only individual that thought he/she may have a 1st Aid certification but did not produce documentation to show this during or after the survey. 4. A call from the assistant supervisor to a resident Aid certified in 1st Aid was conducted. The certified Aid arrived at the facility at approximately 2:15 PM Central Standard Time. At approximately 2:30 PM Central Standard Time, a certified 1st Aid instructor arrived at the facility to provide 1st Aid instruction to the facility staff members. The Agency gave a mandatory correction date of June 21, 2007. 56. The Agency shall impose an administrative fine for a cited uncorrected Class III violation in an amount not less than $500 and not exceeding $1,000 for each violation as set forth in Section 429.19(2)(c), Florida Statutes (2006). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of five hundred dollars ($500). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency as set forth above. 2. Revoke the license of the Respondent to operate the above-referenced assisted 17 living facility. 3. Secondarily, in the alternative to license revocation, impose an administrative fine against the Respondent in the total amount of four thousand five hundred dollars ($4,500). 4. Enter any other relief that this Court deems just and appropriate. 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, (850) 922-5873. If you want to hire an attomey, 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. fel this & day of September, 2007. Respectfully submitted O. Moore Florida Bar # 0768715 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the Administrative Complaint and Election of Rights form have been served to: Administrator and Registered Agent, Jane A. Jones, 3409 West 19" Street, Panama City, Florida 32405, by U.S. Certified Mail, Retum Receipt Requested (7004 2890 0000 5526 7773), and to Owner Gold Key Development, Inc., 3409 West 19” Street, Panama City, Florida 32405, by U.S. Certified Mail, Retum Receipt Requested (7004 2890 0000 5526 7780), on this & A *e**_ day of September, 2007. Bart O. Moore Copy fumished to: Barbara Alford, FOM ‘U.S. Postal Servicer: CERTIFIED MAIL. RECEIPT. (Domestic Mail Only;-No Insurance Coverage Provided) isi i coma For-delivery information visit our website at www.usps.ci OFFICIAL USE fs jeturn Recelpt Fee (endorsement Required) Restricted Delivery Fee {Endorsement Required) 7004 2890 O000 552@b 7773 : g Ss) eee. ON Se coosooeee aro bara” ecac Sethe M rv i N r cy 00, Jt 2002 See Reverse for Instructions PS Form 3800, June . t SENDER: complete THIS SECTION | § Complete items 1, 2, and 3. Also complete F item 4 If Restricted Delivery is desired. ; & Print your name and address on the reverse i So that we can return the card to you. + Mt Attach this card to the back of the mailpiece, or on the front if space permits, 1. Article Addressed to: COMPLETE THIS SECTION ON DELIVERY D, Is delivery address different from item 17° Ct Yes If YES, enter delivery address below: CJ No E) Certified Mail C2 Express Mall OD Registered 1 Retum Receipt for Merchandise ONSET ERR Que 7 ; “. SG ee O insured Mat 1 C.0D. “Gurney hy aie RWS 4. Restricted Delivery? (Exdra Fea) J" 3004 2890 000 S526 7773 ' PS Form 3811, February 2004 D Yes ! Domestic Return Receipt 102595-02-M-1540 - U.S. Postal Service: CERTIFIED MAIL... RECEIPT (Domestic Mail Only! No Insurance Coverage Provided) : For delivery information visit our website-at WWW.USPS:COM» | OFFICIAL USE | Postage | $ omar | Postmark Fistum Receipt Fee Here {Endorsement Required) Restricted Detivery Fee {Endorsement Required) ranromessren|§ | 7004 2890 Oo000 552h 7780 BS Form 3800, dune 2002 See Reverse for instructions. SENDER: Come.ere THIS SECTION COMPLETE THIS SECTION ON DELIVERY ' @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Oelivery-is desired, ' @ Print your name and address on the reverse H So that we can return the Card to you. : MM Attach this card to the back of the mailpiece, Or on the front if Space permits. | 1. Article Addressed to: C. Dateot Delivery A Loflfs erent from item 1? [1 Yes {f YES, enter delivery address below: DI No 3. pe Type Certified Mail 1 Express Mail CO Registered © D Retum Receipt for Merchandise. O insured Mat «= C.0,D. 4, Restricted Delivery? (Extra Fee) O Yes 8 7004 2859 0000 ssa, 7780 . PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 07-005104