STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION I STATE OF FLORIDA, AGENCY FOR HEALTH CARE _. ADMINISTRATION, O71 ; S| ‘\ a : Petitioner, ; : vs. Case No. 2007000273 WESTWOOD MANOR, me = Ss Respondent. === s Tl / PRG |. as Sexes 2 | ADMINISTRATIVE COMPLAINT Ors g i COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION Ofjeinater Agency), by and through the undersigned counsel, and files this Administrative Complaint -against WESTWOOD MANOR (hereinafter Respondent) pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: _ NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of SEVEN THOUSAND FIVE HUNDRED DOLLARS ($7,500.00), based upon ten (10) uncorrected Class III deficiencies against the Respondent, pursuant to Sections 429. 19(2)(c),Florida Statutes (2006) and to assess a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20,42, 120.60 and 429.07, Florida Statutes (2006) . 2. Venue lies pursuant to Florida Administrative Code Rule 28-106.207. Page 1 of 36 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 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code, respectively. 4, Respondent operates a 30-bed assisted living facility located at 2339 Hoople Street, Fort Myers, Florida 33901.: Respondent is and was at all times material hereto a licensed facility, having been issued license number 8914. COUNTI The Respondent Failed To Ensure That All Medication In Its Labeled Container Is Taken To One (1) Of Three (3) Active Sampled Residents Who Receive Assistance With Self Administration Of Medications As Evidenced By Staff Removing Three (3) Medications . From Their Labeled Containers, Placing Them Into A Medication Cup, And Placing The Cup In The Drawer Of The Medication Cart For One (1) Resident Violating Section 429,256(3)(b), Florida Statutes (2006), And Rule 58A-5.0185(3)(c), Florida Administrative Code (2006) 5... The Agency re-alleges and incorporates paragraphs (1) through (4) as if fully set forth herein. 6. Pursuant to Florida law, assistance with self-administration of medication includes, in the presence of the resident, reading the label, opening the container, removing a prescribed amount of medication from the container, and closing the container. Section 429.256 (3)(b), Florida Statutes (2006), Staff shall observe the resident take the medication. Any concerns about the resident’s reaction to the medication shall be reported to the resident’s health care provider and documented in the resident’s record. Section 429.255, Florida Statutes (2006) and Rule 58A-5.0185 (3)(c), Florida Administrative Code (2006). 7, On or about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent’s facility that resulted in a Class III deficiency. The standard that. the Respondent shall Page 2 of 36 ensure that all medication in its labeled container is taken to residents who receive assistance with self administration of medications is not met. 8. Based upon interview it was determined the facility failed to assure that one (1) of four (4), resident’s, Resident number seven (7), receiving assistance with self administration of medications received medication in a properly dispensed and labeled container. 9. During a review of Resident number seven’s (7) Health Assessment Form 1823, Medications, and Medication Observation Record on August 29, 2006 it was noted the resident is receiving Lantus Insulin 50 units at hour of sleep and 8 units each morning, The resident is also to check their blood sugar twice a day and cover with Humulin on a sliding scale. 10. . On August 30, 2006 at about 10:23 a.m, a surveyor asks Resident number seven (7) if she draws up her own Insulin. The resident stated "the facility staff draws up the Insulin.". When asked which staff drew up the insulin she stated "all of them draw it up. he In an interview with the Administrator on August 30, 2006 at about 11:30 am. the administrator, when asked, stated, the resident draws up their own Insulin. When informed, the resident stated, that facility staff drew up the Insulin. The Administrator stated, that staff assists the residents by using "the hand over hand" method to assist the residents to draw up the Insulin. The Administrator was informed that the "hand over hand" method of assistance was not allowed... 12. For this. Class III deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. . 13. Agency surveyors conducted a Biennial Licensure Survey of the Respondent’s facility on or about November 15 through November 16, 2006. The standard that the Respondent shall ensure that all medication in its labeled container is taken to residents who receive assistance with self administration of medications was again not met. Page 3 of 36 14, On that date, based on observations, and staff interview, it was determined that the facility failed to ensure that all miedication in it’s labeled container is taken to 1 (Resident number ten (10) of 3 active sampled residents who receive assistance with self administration of medications as evidenced by staff removing three (3) medications from their labeled containers, placing them into a medication cup, and placing the cup in the drawer of the medication cart for Resident number ten (10). 15.. Observation on November 15, 2006 at approximately 3:00 p.m., during a medication review with the Assistant Administrator, a plastic medication cup was found in a drawer in the medication cart. The medication cup contained three (3) pills. The Assistant Administrator stated that these were for Resident number ten (10) and had been placed in the cup for 8:00 pm so it would be easier for whoever was giving the pills. 16. A review of the Resident’s Medication Observation Record revealed Resident number ten (10) was scheduled to receive Darvocet N-100, Naproxen 220mg and Diovan 80mg at 8:00 p.m. 17... An interview with the Assistant Administrator revealed that she did not know that ; medications could not be prepoured. 18, Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 19, Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 20. ‘For this Class i deficiency, the Agency provided the Respondent a mandated correction date of December 16, 2006. Page 4 of 36 WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($75 0.00) against Respondent, an assisted living facility _in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). . COUNT I The Respondent Failed To Maintain A Daily Up-To-Date Medication Observation Record For One Of Three Sampled Resident’s Medication Reviews Violating Rule 58A-5.0185(5)(b), Florida Administrative Code (2006) ; 21, The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. 22, Pursuant to Florida law, The facility shall maintain a daily medication observation record for each resident who receives assistance with self-administration of medications or medication administration. A Medication Observation Record must: include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The’ Medication Observation Record must be immediately updated each time the medication is offered or administered. Rule 58A-5.0185(5)(b), Florida Administrative Code (2006). 23. On or about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent’s facility that resulted in a Class III deficiency. 24, _ Based upon record review and interview it was determined the facility failed to maintain an accurate up to date Medication Observation Record for 2 of 4 resident records reviewed, Residents number four (4) and number nine (9). Page 5 of 36 25. During a medication review for Resident number four (4) it was observed the resident had a new order dated August 17, 2006 for Oxycodone 5 mg | tablet every 6 hours as needed . 26. The Administrator on August 29, 2006 at about 4:00 pm was asked for the medication and the Medication Observation Record for Resident number four (4). The medication was available but the medication had not been added to the resident's Medication Observation Record. 27. Resident number nine (9) was admitted on or about May 8, 2006. The resident's 1823 form had an order for Darvocet N100 1 tablet three times a day as needed. 28. During a medication review on August 29, 2006 at. about 4:00 p.m. a surveyor was provided with all of the resident's medications except for the Darvocet N100, The surveyor asked the owner where the Darvocet N100 was. 29. The surveyor reviewed the 1823 form with the owner and showed the owner where the Darvocet N100 had been included on the May 2006 Medication Observation Record but was not included on the June, July, or August 2006 Medication Observation Record's, 30. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 31. Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. 32, This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. | 33. Based on record review and staff interview the facility did not maintain a daily up-to-date Medication Observation Record for one Resident number eleven (11) of three sampled resident's medication reviews. Page 6 of 36 34. An observation on November 15, 2006 at approximately 3:00 p.m., during a medication review with the Assistant Administrator, a Flovent inhaler labeled for Resident eleven (11) to receive 2 puffs twice a day was in the medication cart. The Assistant Administrator confirmed that Resident number eleven (11) had been receiving the medication for a while. | 35. A review of the resident's Medication Observation Record revealed it did not include the Flovent inhaler. 36. An interview with the Assistant Administrator revealed that she did not know why the Flovent was not on the Medication Observation Record because the Resident is receiving the medication twice a day. 37. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 38, . Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 39. For this Class III uncorrected deficiency, the Agency provided the Respondent a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Page 7 of 36 COUNT III Respondent Failed to Ensure that Centrally Stored Medications were Accessible to Staff Responsible for Filling Pill Organizers, Assisting with Self-Administration or Administering Medication. Such Staff Must Have Ready Access to Keys to the Medication Storage Areas at All Times in Violation of Rule 58A-5.0185(6)(b) 3, Florida Administrative Code (2006) 40, The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein, 41. Pursuant to Florida law, if facility staff note deviations which could reasonably be attributed to the improper self-administration of medication, staff shall consult with the resident concerning any problems the resident may be experiencing with the medications; the need to permit the facility to aid the resident through the use of a pill organizer, provide assistance with self-administration of medications, or administer medications if such services are offered by the facility. The facility shall contact the resident's health care provider when observable health care changes occur that may be attributed to the resident’s medications, The facility shall document such contacts in the resident’s records .Rule 58A-5.0185(6)(b)3, Florida Administrative Code (2006). 42, On or about August 30, 2006, Agency surveyors conducted a complaint survey.of the Respondent’s facility that resulted in a Class III deficiency. 43, Based upon observation and interview it was determined the facility failed to assure that staff maintain control of keys to the medication storage cart. 44, On August 29, 2006 from 2:25 p.m. till 3:33 p.m. the keys to the drug storage cart were left on the top of the drug cart which was parked in front of the nurses’ station. The administrator was in charge of the medication keys. The administrator was in and out of the area _ for over an hour. The cart was left open and the keys were unattended. 45, On August 30, 2006 the keys were once again observed to be on top of the medication drug cart from 10:50 a.m. until about 11:05 am. The Administrator was in and out Page 8 of 36 of the area working on lunch preparation in the kitchen. The surveyor pointed out to the Administrator the medication cart was unlocked and the keys were on top of the drug storage cart unattended. 46. For this Class II deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 47. Agency surveyors conducted a biennial licensure survey of the Respondent's facility on or about November 15 through November 16, 2006. 48. Based upon observation and interview it was determined the facility failed to assure that staff maintain control of keys to the medication storage cart. 49. On November 15, 2006 at 8:00 a.m. during the initial tour observation revealed the keys to the drug storage cart were left on the top of the drug cart which was parked in front of the nurses station. The assistant administrator was in charge of the medication keys. The administrator was out of the area for over 15 minutes and the keys were unattended, 50. Such violations constitute the grounds for the imposed Class HI deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class Tor Class I violations. 51. Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 52. For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2006). Page 9 of 36 COUNT IV Respondent Failed To Provide Scheduled Activities At Least Five (5) Days A Week For A Total Of Not Less Than Ten (10) Hours Per Week, Not Including Television Viewing In Violation Of Rule 58A-5.0182(2)(c), Florida Administrative Code (2006) 53. The Agency re-alleges and incorporates paragraphs (1) through (4) as if fully set forth herein. 54, Pursuant to Florida law, scheduled activities shall be available at least six (6) days a week for a total of not less than twelve (12) hours per week, Watching television shall not be considered an activity for the purpose of meeting the twelve (12) hours per week of scheduled activities unless the television program is a special one-time event of special interest to residents of the facility. A facility whose residents choose to attend day programs conducted at adult day care centers, senior centers, mental health centers, or other day programs may count those attendance hours towards the required twelve (12) hours per week of scheduled activities. An activities calendar shall be posted in common areas where residents normally congregate. Rule 58A-5.0182(2)(c), Florida Administrative Code (2006). 55, On or about August 30, 2006, Agency surveyors conducted a complaint survey of , the Respondent’s facility that resulted in a Class III deficiency. 56. Based upon observations, and resident interviews, it was determined that the facility failed to ensure that scheduled activities were provided to the residents on a continual basis at least five days per week for a total of not less than ten hours per week. This is evidenced by the facility's failure to provide meaningful activities to the residents on a daily basis. 57, During a tour of the facility on August 29, 2006 at about 9:30 a.m. a surveyor asked residents about the activities program. 58. The following confidential responses were obtained. . Page 10 of 36 59. A resident at 9:40 a.m. stated there are no activities and the big TV is broken. 60. During an interview at about 9:45 am, the Administrator was asked about the big TV in the living room.. The Administrator stated it has been broken for about 2 to 3 weeks. The Administrator was asked ifthe small TV on top of the big TV worked. The administrator stated this TV worked. However, the remote was missing for this TV since about August 26, 2006 and the Administrator could not get this TV to work. 61. Two residents were asked, at about 10:00 a.m., about activities. They indicated there were no activities and the big TV was broken. One stated that the remote control to the small TV could not be located. 62. A resident, at about 10:55 am, was asked if there were any activities. The resident stated "who needs activities at our age?" Another resident stated the person who was supposed to provide some activities was out on leave. 63. A resident, during the noon meal at 12:40 p.m., was asked if there were any activities, The resident stated there were "no activities." 64, Another resident at about the same time, when asked, stated there were "no activities". This individual stated that after the surveyor entered the facility a staff member came by and asked if the resident "wanted to have activities today." 65. A review of the posted activities calendar for August 29, 2006 revealed the scheduled activity was "story telling". The surveyor did not observe any activities for residents on August 29, 2006. 66. On August 30, 2006 at about 4:00 p.m. the surveyor and the Administrator discussed the lack of meaningful activities for residents, The Administrator indicated when he offers activities no one seems to want to participate. Page 11 of 36 67. For this Class Ill deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 68. Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. 69. This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. 70. Based upon observations, and resident interviews, it was determined that the facility failed to ensure that scheduled activities are provided to the residents on a continual basis at least five days per week for a total of not less than ten hours per week. This is evidenced by the facility's failure to provide meaningful activities to the residents. 71, During the entrance tour on November 15, 2006 at about 8:00 a.m. two surveyors observed the monthly activity calendar posted on the wall was dated "October." 72. nan interview with the Administrator and Assistant Administrator on November 15, 2006 at about 9:15 a.m. two surveyors are informed that employee number six (6) is responsible for the activities program. However, surveyors are informed that employee number six (6) is out on leave and not on the schedule to work. 73, The surveyors are informed that Employee number two (2) has been substituting for Employee number six (6) but she is not working due to illness. 74, The surveyors are informed by the Administrator that activities are normally provided from 10:00 a.m. or 10:30 a.m. through 2:00 p.m. five (5) days a week. 75. In an interview with three (3) residents at 12:00 p.m. on November 15, 2006 a surveyor asks them about the activity program. The surveyor is informed that there are no activities and that the activity person is still out. Page 12 of 36 76. Surveyors observed that no activities were provided to residents on November 15, 2006. | 77. On November 16, 2006 at about 10:00 a.m., a surveyor speaks to a fourth resident about the activities program. The resident states that "the only activity is changing the month on the calendar." 78. On November 16, 2006, surveyors are in the facility until around 12:15 p.m. when they go to lunch. There are no activities during this time period. The surveyors re-enter the facility around 4:15 p.m, on November 16, 2006 after decision malcing in the Area 8 office building and see no signs of any resident activities. The monthly activity calendar still reads "October." 79, Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 80. Pursuant.to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 81. For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. ‘WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Page 13 of 36 | COUNT V Respondent Failed To Ensure Each Staff Member’s Personnel Record Contains A Copy Of The Original Employment Application With References In Violation of Section 429.275(4), Florida Statutes(2006) And Rule 58A-5.024(2)(a) Florida Administrative Code (2006) 82. | The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. . 83.. Pursuant to Florida law, the Agency may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance coverage, and reporting procedures, and specify documentation as necessary to implement the requirements of this section. Section 429,275(4), Florida Statutes (2006). Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. Rule 58A-5.024(2)(a), Florida Administrative Code (2006). 84. Onor about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent’s facility that resulted in a Class III deficiency. . 85. - Based upon interview it was determined the facility failed to assure that one (1) of three (3) employees, Employee number three (3), had a personnel record which contained a copy of the original employment application with references, 86. On August 30, 2006 at about 11:00 am a surveyor asked the administrator for ‘documentation that Employee number three (3) had a personnel record which contained a copy of the original employment application with references, 87. The Administrator, after review, stated he could not locate the required . documentation. The surveyor provided the Administrator an opportunity to locate missing ‘documentation. At about 5:00 p.m. on August 30, 2006 the surveyor exited the facility. The Page 14 of 36 Administrator was informed that if he could locate the missing documentation for Employee number three (3) to fax them to the office on August 31, 2006. 88... On September 1, 2006 at about 10:50 a.m. the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents, . 89. For this Class III deficiency, the Agency provided the Respondent a mandated correction date, of September 30, 2006. 90. . Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006, 91. . This isan uncorrected deficiency from the complaint investigation completed on August 30, 2006. 92. Based upon record review and interview it was determined the facility failed.to assure that two (2) of seven (7) employee records, Employees number one (1) and number four (4), reviewed contained a copy of the original employment application with references. 93, Employee number one (1) was hired on May 1, 2005 and is the Assistant Administrator. A review of her personnel file on November 15, 2006 at about 3:30 p.m. failed to _teveal any reference checks. . . | 94, The Assistant Administrator was provided an opportunity to locate the reference checks. She stated she was not responsible for making these checks and would not have made her own reference check. | 95. Employee number four (4) was hired on May 3, 2005. A review of employee number four’s (4) personnel file on November 15, 2006 at about 3:30 p.m. failed to reveal any reference checks. The Assistant Administrator was provided an opportunity to locate the reference checks. She stated she was not responsible for making these checks. Page 15 of 36 06. On November 16, 2006 at about 11:45 a.m., the administrator was provided an opportunity to locate the missing reference checks for Employees number one (1) and number four (4). 97. Atabout 4:30 p.m. on November 16, 2006, the Administrator was asked if he was able to locate the requested documentation for Employees number one (1) and number four (4). The Administrator indicated he did not have the requested documentation. 98. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 99, Pursuant to Section 400.419(2)(c), Florida Statutes, Class IIT violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 100. For this Class 1 uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). COUNT VI Respondent Failed To Ensure That Personnel Records Contain Verification Of Freedom From Communicable Disease Including Tuberculosis In Violation Of Section 429,275(4), Florida Statutes (2006) And Rule 58A-5.024(2)(a), Florida Administrative Code (2006) 101. The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. | 102. Pursuant to Florida law, the Agency may by rule clarify terms, establish requirements for financial records, accounting procedures, personnel procedures, insurance Page 16 of 36 coverage, and reporting procedures, and specify documentation as necessary to implement the requirements of this section. Section 429.275(4), Florida Statutes (2006). Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis, Rule 58A-5.024(2)(a), Florida Administrative Code (2006). 103, On or about August 30, 2006, Agency surveyors conducted’a complaint survey of the Respondent's facility that resulted in a Class II deficiency. _°104. Based upon interview it was determined the facility failed to assure that three (3) of three (3) employees, Employees number one (1), number two (2), and number three (3) had verification of freedom from communicable disease including tuberculosis in their personnel records. 105. On August 30, 2006 at about 11:00 a.m. a surveyor asked the administrator for documentation that Employees number one (1), number two (2), and number three Q had verification of freedom from communicable disease including tuberculosis in there personnel records. : 106. . The Administrator, after review, stated he could not locate the required documentation. The surveyor provided the Administrator an opportunity to locate missing documentation, At about 5:00 p.m. on August 30, 2006 the surveyor exited the facility. The Administrator was informed that if he could locate the missing documentation for Employees number one (1), number two (2), and number three (3) to fax them to the office on August 31, 2006. 107. On September 1, 2006 at about 10:50 a.m. the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents. Page 17 of 36 108. For this Class ITI deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 109, Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. 110, This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. 111. Based upon interview it was determined the facility failed to assure that four (4) of seven (7) employees, Employees number one (1), number two (2), number three (3), and number seven (7) had verification of freedom from communicable disease including tuberculosis in their personnel records. 112, Employee number one (1) was hired on May 1, 2005. During a review of Employee number one’s (1) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor observed the only item filled in was the date the Purified Protein Derivative (PPD) was given. This date was February 9, 2006. The "date checked" was blank as well as the results. The form was signed on February 16, 2006 by the Advanced Registered Nurse Practioner. 113. Employee number two (2) was hired on April 10, 2006. During a review of Employee number two’s (2) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor observed the Purified Protein Derivative (PPD) was given on September 21, 2006. The “date checked" was September 24, 2006. The - form did not contain any results of the Purified Protein Derivative test. 114. Employee number three (3) was hired on October 28, 2004. During a review of Employee number three’s (3) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor observed the date the Purified Protein Page 18 of 36 Derivative was given was September 21,2006. The "date checked" was September 24, 2006. The form did not contain any results of the Purified Protein Derivative test 115... Employee number seven (7) is the Administrator. A review of the Administrator's personnel file revealed a letter dated February 24, 1998 which stated the Administrator has a positive Purified Protein Derivative and a chest X-ray does not show active Tuberculosis. 116. On February 4, 2004, an Advanced Registered Nurse Practitioner ordered a chest X-ray for the Administrator. No results of the chest X-ray are present in the Administrator's file. 117. There are no other Tuberculosis test results in the Administrator's file. 118. -On November 16, 2006 at about 8:35 a.m., Employee number one (1) presented the surveyor with documents showing that Employees number one (1), number two (2), and number three (3) are free of Tuberculosis due to negative Purified Protein Derivative’s results. Refer to A0029 in AHICA State, complaint investigation, CCR# 2006-00986, for additional information concerning altered PPD test results, 119. On November 16, 2006 at about 11:45 a.m., the administrator was provided an opportunity to locate documentation that he was free from Tuberculosis. 120. At about 4:30 p.m. on November 16, 2006 the Administrator was asked if he was able to locate the requested Tuberculosis documentation for himself. The Administrator indicated he did not have the requested documentation. 121, Such violations constitute the grounds for the imposed Class Il deficiency in that: it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 122, Pursuant to Section 400.419(2)(c), Florida Statutes, Class HI violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. Page 19 of 36 123. — For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agericy intends to impose an administrative fine in the amount of SEVEN HUDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2006). f COUNT VII Respondent Failed to Provide Documentation That Newly Hired Staff Have Thirty (30) Days To Submit A Statement From A Health Care Provider, Based On An Examination Conducted Within The Last Six (6) Months, That The Person Does Not Have Any Signs Or Symptoms Of A Communicable Disease Including Tuberculosis In Violation Of Rule 58A- . 5.024(2)(a), Florida Administrative Code (2006) 124, The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein, . 125, Pursuant to Florida law, newly hired staff shall have 30 days to submit a statement from a health care provider, based on a examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis. Freedom from tuberculosis must be documented on an annual basis. A person with a positive tuberculosis test must submit a health care provider's statement that the person does not constitute a risk of communicating tuberculosis. Newly hired staff does not include an employee transferring from one facility to another that is under the same management or ownership, without a breal in service. If any staff member is later found to have, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator determines that such condition no longer exists. Rule 58A~-5.019(2)(a), Florida ‘Administrative Code, Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and verification of Page 20 of 36 freedom from communicable disease including tuberculosis, Rule 5 8A-5.024(2)(a), Florida Administrative Code (2006). 126. On or about August 30, 2006, Agency surveyors conducted a complaint survey of | “the Respondent's facility that resulted in a Class III deficiency. 127. . Based upon interview and record it was determined the facility failed to assure that two (2) of three (3) employees, Employee number one (1) and number three (3) submit a statement from a health care provider, based on an examination conducted within the last six (6) months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis within thirty (30) days of hire. 128. Employee number one (1) was hired on May 4, 20006 and Employee number three (3) was recently hired but the administrator could not tell the surveyor when they were hired. ) 129. The suryeyor could not locate any documentation that Employee number one (1) had submitted a statement within thirty (30) days of employment that they were free of communicable disease to include tuberculosis. 130. The surveyor provided the Administrator an opportunity to locate missing documentation. At about 5:00 pm on August 30, 2006 the surveyor exited the facility. The Administrator was informed that if he could locate the missing documentation for Employees number one (1) and number three (3) to fax them to the office on August 31, 2006. 131, On September 1, 2006 at about 10:50 a.m. the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents. 132. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. Page 21 of 36 133, Agency surveyors conducted a biennial licensure survey of the Respondent's facility on or about November 15 through November 16, 2006. 134, This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. . 135. Based upon interview and record it was determined the facility failed to assure that one (1) of seven (7) employees, Employee number two (2) submit a statement from a health care provider, based on an examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis within thirty (30) days of hire. 136. Employee number two (2) was hired on April 10, 2006. During a review of Employee number two’s (2) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor observed the Purified Protein Derivative was given on September 21,2006, The "date checked" was September 24, 2006. The form did not contain any results of the Purified Protein Derivative test. 137, The form was shown to the Assistant Administrator (AA) of the facility, by the surveyor, and asked what the results were of the Purified Protein Derivative test. Was Employee number two (2) positive or negative for possible TB? The Assistant Administrator acknowledged there were no results of the Purified Protein Derivative test documented. 138. On November 16, 2006 at about 8:35 a.m., the Assistant Administrator presented the surveyor with the same form. At the bottom of the form was "Purified Protein Derivative (-) on September 24, 2006" and initialed by the Advanced Registered Nurse Practioner (-) interpreted to mean negative). There was no indication that this was a late. entry. 139. On November 16, 2006 at about 8:35 a.m., the Assistant Administrator presented the surveyor with a document showing that employee number two (2) is free of TB due to Page 22 of 36 negative Purified Protein Derivative test results. Refer to A0029 in State Form, complaint investigation, CCR# 2006-009886, for additional information concerning altered PPD test results, 140. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations, 141. Pursuant to Section 400.419(2)¢c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation. 142. For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2006). | COUNT viII Respondent Failed To Provide That Freedom From Tuberculosis Must Be Documented On An Annual Basis. A Person With A False Positive Tuberculosis Test Must Submit A Health Care Provider’s Statement That The Person Does Not Constitute A Risk Of Communicating Tuberculosis In Violation Of Rule 58A-5.019(2)(a), Florida Administrative Code(2006) _ 143, The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. 144, Pursuant to Florida law, newly hired staff shall have 30 days to submit a statement from a health care provider, based on a examination conducted within the last six months, that the person does not have any signs or symptoms of a communicable disease including tuberculosis. Freedom from tuberculosis must be documented on an annual basis. A Page 23 of 36 person with a positive tuberculosis test must submit a health care provider’s statement that the person does not constitute a risk of communicating tuberculosis. Newly hired staff does not include an employee transferring from one facility to another that is under the same management or ownership, without a break in service, If any staff member is later found to have, or is suspected of having, a communicable disease, he/she shall be removed from duties until the administrator determines that such condition no longer exists. Rule 58A-5.019(2)(a), Florida Administrative Code (2006), 145. On or about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent’s facility that resulted in a Class III deficiency. 146, Based upon record review and interview it was determined the facility failed to. assure that one (1) of three (3) employees, Employee number two (2) provided documentation on an annual basis that they were free of tuberculosis. 147, Employee number two (2) was hired on November 1, 2004. During a review of the employee's personnel file the surveyor could not locate documentation of freedom from tuberculosis.on an annual basis, 148. The surveyor provided the Administrator an opportunity to locate missing documentation. At about 5:00 p.m. on August 30 2006 the surveyor exited the facility. The Administrator was informed that if he could locate the missing documentation for Employees number two (2) to fax it to the office on August 31, 2006. 149, On September 1, 2006 at about 10:50 am, the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents. 150. For this Class im deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. Page 24 of 36 _ 151. Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. 152. This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. 153. Based upon record review and interview it was determined the facility failed to document that 3 of 7 employee's personnel files, Employees number one () number three (3), and number seven 1(7) contained documentation of freedom from Tuberculosis (TB) on an annual basis. 154, Employee number one (1) was hired on May 1, 2005. During a review of Employee number ones (1) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor ‘observed the only item filled in was the date the Purified Protein Derivative was given. This date was February 9, 2006. The "date checked" was blank as well as the results. | 155. . Employee number three (3) was hired on October 28, 2004. During a review of Employee number three’s (3) personnel file for documentation of freedom from Tuberculosis on November 15, 2006 at about 3:30 p.m. the surveyor observed the date the Purified Protein Derivative was given was September 21, 2006. The "date checked" was September 24, 2006, The form did not contain any results of the PPD test, 156. Employee number seven (7) is the Administrator. A review of the Administrator's personnel file revealed a letter dated February 24, 1998 which stated the Administrator has a positive Purified Protein Derivative test and a chest X-ray does not show active TB. 157, On February 4, 2004, an Advanced Registered Nurse Practitioner ordered a chest X-ray for the Administrator. No results of the chest X-ray are present in the Administrator's file, 158. There are no other TB test results in the Administrator's file. Page 25 of 36 159. -On November 16, 2006 at about 8:35 a.m., the Assistant Administrator presented the surveyor with documents showing that Employees number one (1) and number three (3) are free of TB due to negative Purified Protein Derivative tests, 160. ‘ On November 16, 2006 at about 11:45 a.m. the administrator was provided an opportunity to locate documentation that he was. free from TB. | 161. At about 4:30 p.m. on November 16, 2006 the Administrator was asked if he was able to locate the requested TB documentation for himself. The Administrator indicated he did not have the requested documentation. 162. . Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 163. Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1, 000, 00 foreach violation. 164. For this Class III uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2006). Page 26 of 36 COUNT IX Respondent Failed To Provide That New Facility Staff Must Obtain An Initial Training On HIV/AIDS Within Thirty (30) Days Of Employment, Unless The New Staff Person Previously Completed The Initial Training And Has Maintained The Biennial Continuing Education Requirement. All Facility Employees Must Complete Biennially A Continuing Education Course On HIV And AIDS In Violation of Section 429.275(2), Florida Statutes (2006) and Rule 58A-5,0191(3), Rule 58A-5.024(2)(a)1 and Rule 58A-5.0191(11) Florida Administrative Code (2006) 165, The Agency re-alleges and incorporates paragraphs (1) through (4) above as if fully set forth herein. 166, Pursuant to Florida law, the administrator or owner of a facility shall maintain . personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule. Section 429.275(2), Florida Statutes (2006). Personnel records for each staff member shal! contain, ata. minimum, a copy of the original employment application with references furnished and verification of freedom from communicable disease including tuberculosis. Rule 58A- 5.024(2)(a), Florida Administrative Code (2006). All facility employees must complete biennially, a continuing education course on HIV and AIDS. New facility staff must obtain an initial training on HIV/AIDS within thirty (30) days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education requirement. Documentation of compliance must be maintained in accordance with subsection (11) of this rule. Section 381,0035, Florida Statutes (2006) and Rule 58A-5.0191(3), Florida Administrative Code. Except as otherwise noted, certificates of any training required by this rule shall be documented in the facility’s personnel files which documentation shall include the subject matter of the training program, the trainee’s name, the date of attendance, the training Page 27 of 36 provider’s name, signature and credentials, professional license number if applicable, and the number of hours of training. Section 429.52, Florida Statutes (2006) and Rule 5 BA-5.0191(1 1), Florida Administrative Code (2006). 167. On or about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent's facility that resulted in a Class III deficiency. 168, Based upon interview it was determined the facility failed to assure that 1 of 3 employees, Employee number three (3) received initial training on HIV/AIDS within thirty (30) days of employment, unless the new staff person previously completed the initial training and has maintained the biennial continuing education requirement. 169, On August 30, 2006 at about 11:00 a.m. a surveyor asked the administrator for documentation that Employee number three (3) had received the required HIV/AIDS training within thirty (30) days of employment. . 170. The Administrator, after review, stated he could not locate the required. documentation. The surveyor provided the Administrator an opportunity to locate missing documentation, At about 5:00 p.m. on August 30, 2006 the surveyor exited the facility. The Administrator was informed that if he could locate the missing documentation for Employee number three (3) to fax them to the office on August 31, 2006. 171., On September 1, 2006 at about 10:50 a.m. the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents. 172. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 173. Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. Page 28 of 36 - 174. This is an uncorrected deficiency from the complaint investigation completed on August 30, 2006. 175. Based upon record review and interview it was determined the facility failed to assure that five (5) of seven (7) new staff, Employees number one (1), number three (3), number four (4), number five (5), and number six (6) obtain initial training on HIV/AIDS within thirty (30) days of employment and two (2) of seven (7) staff members, Employees number two (2) and number seven (7) employed for over two (2) years complete biennially, a continuing education course on HIV and AIDS. | 176. During an employee record review on November 15, 2006 at about 3:30 pm.a _ surveyor asked Employee number one (1), the Assistant Administrator (AA) about the training certificates for HIV/AIDS for Employee number one (1) who was hired on May 1, 2005, Employee number two (2) who was hired on April 10, 2006, Employee number three (3) who was hired on October 28, 2004, Employee number four (4) who was hired on May 3, 2005, employee number five (5) who was hired on September 26, 2006, and Employee number six (6) who was hired on April 10, 2006, 177, The certificates were either signed by the Assistant Administrator or the Administrator, The surveyor informed the Assistant Administrator that they were not qualified to teach HIV/AIDS. The Assistant Administrator indicated she thought since she had attended Assisted Living Facility Core Training that this qualified her to teach HIV/AIDS, _ 178. On November 16, 2006 at about 9:30 a.m., a surveyor was reviewing the employee file of Employee number seven (7), the Administrator, and could not locate any training certificates for HIV/AIDS. Page 29 of 36 179. On November 16, 2006 at about 11:45 a.m., the administrator was provided an opportunity to locate documentation that hé had received the required HIV/AIDS continuing education. . 180. At about 4:30 p.m. on November 16, 2006, the Administrator was asked if he was able to locate the requested HIV/AIDS continuing education documentation for himself. The Administrator indicated he did not have the requested documentation. 181. Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 182. Pursuant to Section 400.419(2)(c), Florida Statutes, Class III violations are subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation, 183. For this Class II uncorrected deficiency, the Agency provided the Respondent with a mandatory correction date of December 16, 2006. WHEREFORE, the Agency intends to i impose an administrative fine in the amount of SEVEN HUNDRED FIFTY DOLLARS ($750,00) against Respondent, an assisted living Feollity in the State of Florida, pursuant to Section 429. 19(2)(c), Florida Statutes (2006). COUNT X ; Respondent Failed To Ensure That Personnel Records Contain Documentation Of Compliance With Level One (1) Background Screening For All Statf Subject To Screening Requirements In Violation Of Section 429. 273(2), Florida Statutes(2006), Rule 58A- 5.019(3), and Rule 58A-024(2)(a) 3, Florida Administrative Code (2006) 184. The Agency re-alleges and incorporates paragraphs (1) through (4) as if fully set forth herein. 185. Pursuant to Florida law, Personnel records for each staff member shall contain, at a minimum, a copy of the original employment application with references furnished and Page 30 of 36 verification of freedom from communicable disease including tuberculosis. Rule 58A- 5.024(2)(a), Florida Administrative Code (2006). The administrator or owner of a facility shal] maintain personnel records for each staff member which contain, ata Pah documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule, Section 429.275(2), Florida Statutes (2006), 186. Onor about August 30, 2006, Agency surveyors conducted a complaint survey of the Respondent’s facility that resulted in a Class tt deficiency, 187. Based upon interview and record it was determined the facility failed to assure that two (2) of three (3) employees personnel records, Employees number one (1) and number three (3) contain documentation of compliance with level one (1) background screening for all staff subject to screening requirements. 188. . Employee number one (1) was hired on May 4, 2006 and Employee number three (3) was recently hired’ but the administrator could not tell the surveyor when they were hired. 189, The surveyor could not locate any documentation that Employee number one (1) had the required level one (1) background screening. There were no personnel records for Employee number three (3).. The Administrator indicated Employee number three (3) was recently hired. 190. The surveyor provided the Administrator an opportunity to locate missing documentation. At about 5:00 p.m. on August 30, 2006 the surveyor exited the facility. The Administrator was informed that if he could locate the missing documentation for Employees number one (1) and number three (3) to fax them to the office on August 31, 2006. Page 31 of 36 191. On September 1, 2006 at about 10:50 a.m. the surveyor spoke with the Administrator. The Administrator stated he could not locate the requested documents, 192. For this Class III deficiency, the Agency provided the Respondent a mandated correction date of September 30, 2006. 193. Agency surveyors conducted a biennial licensure survey of the Respondent’s facility on or about November 15 through November 16, 2006. 194, This is an uncorrected deficiency from the complaint investigation completed on - August 30, 2006. 195. . Based upon interview and record it was determined the facility failed to assure that 2 of 7 employees personnel records, Employees number two (2) and number five (5) contain documentation of compliance with level one (1) background screening for all staff subject to screening requirements, . 196, . Employee number two (2) was hired on April 10, 2006 and Employee number five (5) was hired on September 26, 2006, Both employees provide direct care assistance to residents. During a review of their employee personnel files for compliance level 1 background screening requirements the surveyor could not locate documentation that Employees number two (2) and number five (5) had clear background checks. 197. These findings were reviewed with the Assistant Administrator on November 15, 2006 at about 3:30 p.m. The Assistant Administrator was provided an opportunity to locate the missing documentation. 198. On November 16, 2006 at about 11:45 a.m., the administrator was provided an opportunity to locate the missing background screening documentation for Employees number two (2) and number five (5). Page 32 of 36 199. .At about 4:30 p.m, on November 16, 2006, the Administrator was asked if he was able to locate the requested background screening documentation for Employees number-two (2) and number five (5). The Administrator indicated he did not have the requested documentation. 200, Such violations constitute the grounds for the imposed Class III deficiency in that it indirectly or potentially threatened the physical or emotional health, safety or security of the facility’s residents, other than Class I or Class II violations. 201. Pursuant to Section 400.419(2)(c), Florida Statutes, Class IIT violations are - subject to an administrative fine of not less than $500.00 and not exceeding $1,000.00 for each violation, , 202. For this Class IIT uncorrected deficiency, the Agency provided the Respondent . with a mandatory correction date of December 16, 2006. | WHEREFORE, the Agency intends to impose an administrative fine in the amount of _ SEVEN HUNDRED FIFTY DOLLARS ($750.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2006). COUNT XI (Assessment of Survey Fee) 203. The Agency re-alleges and incorporates by reference paragraphs 1 through 4 and the allegations in Count I through Count X. 204, The Agency received a complaint about the Respondent. 205. In response to the complaint, the Agency conducted a complaint survey of the Respondent and its Facility on November 15, 2006. 206. As a result of the Agency’s complaint survey, the Respondent was cited for ten (10) uncorrected deficiencies for the complaint. 207. The basis for the deficiency alleged in this Administrative Complaint relates to Page 33 of 36 the complaint against the Respondent and its Facility. 208. Pursuant to Section 429,19(10), Florida Statutes (2006), the Agency 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 investigation that resulted in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under Section 429,.28(3)(c), Florida Statutes (2006), to verify the correction of the violations. 209. — In this case, the Agency is authorized to seek a survey fee of $500.00. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assess a survey fee against the Respondent in the amount of FIVE HUNDRED - DOLLARS ($500.00) pursuant to Section 429.19(10), Florida Statutes (2006), 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 against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of SEVEN THOUSAND FIVE HUNDRED DOLLARS ($7,500.00). 3. Assess a survey fee against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). Page 34 of 36 4. Order any other relief that this Court deems just and appropriate. Respectfully submitted this aA day of October, 2007. Andrea M. Lang, ea Attorney or ae Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel . 2295 Victoria Avenue, Room 346C * Fort Myers, Florida 33901 Telephone: (239) 338-3203 NOTICE THE RESPONDENT IS NOTIF TED THAT IT/HE/SHE HAS THE RIGHT TO REQUES’ T AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. IF THE RESPONDENT WANTS TO HIRE AN ATT ORNEY, IT/HE/SHE HAS THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN TIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE aTiACHED ELECTION OF RIGHTS FORM. THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE. MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DELIVERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BUILDING 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. Page 35 of 36 CERTIFICATE OF SERVICE SEAN Ss I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7006 0810 0005 8950 3468 on October 4 __, 2007 to: Peter Kramer, Administrator, Westwood Manor, 2339 Hoople Street, Fort Myers, Florida 33901. Copies furnished to: - Andrea M. Lang, Senior Attorney Florida Bar No.0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 _ Office: (239) 338-3203 Fax: (239) 338-2699 John F. Gilroy II, P.A. Counsel for Respondent : 1435 East Piedmont Drive, Suite 215 Tallahassee, Florida 32308 -| (U.S. Mail) Andrea M, Lang, Senior Attorney Office of the General Counsel ‘9995 Victoria Avenue, Room 346C. Fort Myers, Florida 33901 (Interoffice Mail) Peter Kramer, Administrator Westwood Manor 2339 Hoople Street Fort Myers, Florida 33901 (U.S. Certified Mail) Kriste J. Mennella Field Office Manager 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) Page 36 of 36 Agency for Health Care Administration Agency for Health Care Administration i = Complete items'1,2, and 3. Also complete ° item 4 If Restricted Delivery Is desired. ; Mf Print your name and address on the reverse | so that we.can return.the card to you. ! @ Attach this.card to tha back of the mailplece, : or on the front if space permits, ES 1. Article Addressed to: oe. TE Peter ra mes, Adrinssfr for. | Wes tuned dnaner : | 2339 Hoaple Street Fart myers, Florida, 3390/ D, Is delivery address different from ttem1? (1 Yes If YES, enter delivery address below: .. CJ No 8, Service Type i Certified Mall “1 Express Mail GI Registered (2 Return Receipt for Merchandise 1 insured Mall ~=— £1 G.0.D, 4. Restricted Delivery? (Extra Fea) “7006 paio o005 ‘aq50 34ba | 1PS Form 3811, February 2004 +, Domestic Retum Recelpt 2, Articia Number | (Transtar from service label) i 102585-02-M-1 S40

Docket for Case No: 07-005152