STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR f) vy ‘a O HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2008008311 CINDI J. THOMPSON, d/b/a KENDALL PLACE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“Agency”) and files this Administrative Complaint against CINDI J. THOMPSON, d/b/a KENDALL PLACE (“Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility and to impose an administrative fine in the sum of two thousand seven hundred dollars ($2,700.00) based upon two (2) uncorrected State Class IV deficiencies and five (5) uncorrected State Class III deficiencies. This action is taken pursuant to Sections 429.19(2)(c), 429.19(2)(d), and 429.14(1)(e), Florida Statutes (2007). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, and 120.60, and Chapters 429, Part I, and 408, Part II, Florida Statutes (2007). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted living facilities, pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 5-bed assisted living facility located at 6506 Tebbetts Drive, Orlando, Florida 32818, and is licensed as an assisted living facility, license number 10699. 5. At all times material to the allegations of this complaint, Respondent was a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 7. Rule 58A-5.021(2), Florida Administrative Code, requires: (2) ACCOUNTING PROCEDURES. The facility shall maintain written business records using generally accepted accounting principles as defined in Rule 61H1- 20.007, F.A.C., which accurately reflect the facility’s assets and liabilities and income and expenses. Income from residents shall be identified by resident name in supporting documents, and income and expenses from other sources, such as from day care or interest on facility funds, shall be separately identified. 8. Rule 58A-5.024, Florida Administrative Code, requires: (4) RECORD INSPECTION. (a) All records required by this rule chapter shall be available for inspection at all times by staff of the agency, the department, the district long-term care ombudsman council, and the advocacy center for persons with disabilities. (d) The facility shall ensure the availability of records for inspection. 9. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 9.1. Based on facility record review and interview the facility failed to maintain written business records that accurately reflect assets and liabilities, income and expenses and identify income from residents by resident name and source. 9.2. The assets and liability report available for review on 3/18/08 at approximately 11:30 AM revealed that the most recent report available was dated 4/8/06 and listed only the facility expenses; however, it did not list income from residents. 9.3. On March 18, 2008, the administrator designee told the Agency Surveyor that no other documentation was available, that the administrator was out of town, and that maybe the administrator had it with her. 10. The Agency determined that the above constitutes the grounds for the imposition of a Class IV deficiency pursuant to Section 429.19(2)(d), Florida Statutes (2007) in that it does not threaten the health, safety, or security of residents of the facility. 11. The Agency provided Respondent with a mandatory correction date of April 3, 2008. 12. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 12.1. Based on facility records review and interview the facility failed to maintain written business records that accurately reflect assets and liabilities, income and expenses and identify income from residents by resident name and source. 12.2. Facility financial records review on 5/7/08 at approximately 12:30 PM revealed that the records for 2005, 2006, and 2007 listed the facility's expenses but did not list the income from residents. 12.3. On May 7, 2008, the administrator told the Agency surveyor that the 2008 financial records were not available yet, that she had them at home and was working on them, and that she did not know that the income from residents had to be listed. 13. The Agency determined that the above constitutes the grounds for the imposition of an uncorrected State Class IV deficiency in that it does not threaten the health, safety, or security of residents of the facility. 14. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 15. The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $100.00, or in such greater amount as this tribunal may determine, against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(d), Florida Statutes (2007). COUNT II 16. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and paragraph eight (8), as if fully set forth in this count. 17. Section 429.275(3), Florida Statutes (2007), requires: (3) The administrator or owner of a facility shall maintain liability insurance coverage that is in force at all times. 18. Rule 58A-5.021(8), Florida Administrative Code, defines: (8) LIABILITY INSURANCE. Pursuant to Section 429.275, F.S., facilities shall maintain liability insurance coverage, as defined in Section 624.605, F.S., in force at all times. On the renewal date of the facility’s policy or whenever a facility changes policies, the facility shall file documentation of continued coverage with the AHCA central office. Such documentation shall be issued by the insurance company and shall include the name of the facility, the street address of the facility, that it is an assisted living facility, its licensed capacity, and the dates of coverage. 19. Rule 58A-5.024(1)(g), Florida Administrative Code, defines: (1) FACILITY RECORDS. Facility records shall include: (g) The facility’s liability insurance policy required under Rule 58A-5.021, F.A.C. 20. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 20.1. Based on facility record review and interview the facility failed to ensure that liability insurance coverage was maintained at all times. 20.2. The insurance policy provided to the Agency surveyor for review on 3/18/08 at approximately 11:45 AM revealed that the policy expired on 6/20/07. 20.3. On March 18, 2008, the administrator designee told the Agency surveyor that no other documentation was available, that the administrator was out of town, and that maybe the administrator had it with her. 21. | The Agency determined that the above failure to make available for Agency surveyor review a current and in force liability insurance policy constitutes the grounds for the imposition of a Class IV deficiency pursuant to Section 429.19(2)(d), Florida Statutes (2007), in that it does not threaten the health, safety, or security of residents of the facility. 22. The Agency provided Respondent with a mandatory correction date of March 19, 2008. 23. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 23.1. Based on facility record review and interview the facility failed to ensure that liability insurance coverage was maintained at all times. 23.2. The administrator stated on 5/7/08 at approximately 11 AM that the prior liability insurance had lapsed. Therefore, she had to apply as a new costumer and it was taking some time. Therefore a liability insurance policy was not available for review by the Agency surveyor. 24. The Agency determined that the above failure to make available for Agency surveyor review a current and in force liability insurance policy constitutes the grounds for the imposition of an uncorrected State Class IV deficiency in that it does not threaten the health, safety, or security of residents of the facility. 25. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 26. The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $100.00, or in such greater amount as this tribunal may determine, against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(d), Florida Statutes (2007). COUNT Ill (Hi=206) 27. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and paragraph eight (8), as if fully set forth in this count. 28. 29. 30. Rule 58A-5.024(1)(i), Florida Administrative Code, defines: (1) FACILITY RECORDS. Facility records shall include: (i) The admission package presented to new or prospective residents (less the resident’s contract) described in Rule 58A-5.0182, F.A.C. Rule 58A-5.0182(6), Florida Administrative Code, describes: (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A- 5.0181, F.A.C. (e) The facility shall have a written statement of its house rules and procedures which shall be included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. The rules and procedures shall address the facility’s policies with respect to such issues, for example, as resident responsibilities, the facility’s alcohol and tobacco policy, medication storage, the delivery of services to residents by third party providers, resident elopement, and other administrative and housekeeping practices, schedules, and requirements. Rule 58A-5.0181(3), Florida Administrative Code, defines: (3) ADMISSION PACKAGE. (a) The facility shall make available to potential residents a written statement(s) which includes the following information listed below. A copy of the facility resident contract or facility brochure containing all the required information shall meet this requirement: 1. The facility’s residency criteria; 2. The daily, weekly or monthly charge to reside in the facility and the services, supplies, and accommodations provide by the facility for that rate; 3. Personal care services that the facility is prepared to provide to residents and additional costs to the resident, if any; 4. Nursing services that the facility is prepared to provide to residents and additional costs to the resident, if any; 5. Food service and the ability of the facility to accommodate special diets; 6. The availability of transportation and additional costs to the resident, if any; 7. Any other special services that are provided by the facility and additional cost if any; 8. Social and leisure activities generally offered by the facility; 9. Any services that the facility does not provide but will arrange for the resident and additional cost, if any; 10. A statement of facility rules and regulations that residents must follow as described in Rule 58A-5.0182, F.A.C.; 11. A statement of the facility policy concerning Do Not Resuscitate Orders pursuant to Section 429.255, F.S., and Advance Directives pursuant to Chapter 765, F.S. 12. If the facility also has an extended congregate care program, the ECC program’s residency criteria; and a description of the additional personal, supportive, and nursing services provided by the program; additional costs; and any limitations, if any, on where ECC residents must reside based on the policies and procedures described in Rule 58A-5.030, F.A.C.; 13. If the facility advertises that it provides special care for persons with Alzheimer’s disease and related disorders, a written description of those special services as required under Section 429.177, F.S.; and 14. A copy of the facility’s resident elopement response policies and procedures. (b) Prior to or at the time of admission the resident, responsible party, guardian, or attorney in fact, if applicable, shall be provided with the following: 1. A copy of the resident’s contract which meets the requirements of Rule 58A-5.025, F.A.C.; 2. A copy of the facility statement described in paragraph (a) if one has not already been provided; 3. A copy of the resident’s bill of rights as required by Rule 58A-5.0182, F.A.C.; and 4. A Long-Term Care Ombudsman Council brochure which includes the telephone number and address of the district council. (c) Documents required by this subsection shall be in English. If the resident is not able to read, or does not understand English and translated documents are not available, the facility must explain its policies to a family member or friend of the resident or another individual who can communicate the information to the resident. 31. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 31.1. Based on record review and interview the facility failed to ensure that it maintained for review an admission package with all required components to be presented to new or prospective residents. 31.2. -The administrator designee stated on 3/18/08 at approximately 10:30 AM that an admission packet was not available for review by the Agency surveyor. 32. The Agency determined that this deficient practice of failing to have available for review an admission package containing the required materials was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the residents, and cited Respondent for a State Class III deficiency. 33. | The Agency provided Respondent with a mandatory correction date of March 28, 2008. 34. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 34.1. Based on record review and interview, the facility failed to maintain for review an admission package that included the facility's Do Not Resuscitate policy to be presented to new and prospective residents. 34.2. Review of facility records on 5/7/08 at approximately 11:00 AM revealed that the admission packet did not include a statement of the facility's policy concerning Do Not Resuscitate Orders pursuant to Section 429.255, F.S. 34.3. The administrator stated on said date and time that she was not aware that the Do Not Resuscitate policy needed to be in such detail. 35. The Agency determined that this deficient practice of failing to have available for review an admission package containing the required materials was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 36. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 37. The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT IV 38. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 39. — Rule 58A-5.0185(7)(c), Florida Administrative Code, defines: (c) If the directions for use are “as needed” or “as directed,” the health care provider shall be contacted and requested to provide revised instructions. For an “as needed” prescription, the circumstances under which it would be appropriate for the resident to request the medication and any limitations shall be specified; for example, “as needed for pain, not to exceed 4 tablets per day.” The revised instructions, including the date they were obtained from the health care provider and the signature of the staff who obtained them, shall be noted in the medication record, or a revised label shall be obtained from the pharmacist. 40. | From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 40.1. Based on observation, record review and interview the facility failed to ensure that when medication directions for use were "as needed" or "as directed," the health care provider was contacted and requested to provide revised instructions; for one of seven sampled residents, “Resident #4.” 10 40.2. Observation during the medication review on 3/13/08 at approximately 1:15 PM revealed Vistaril (hydroxyzine) (anti-anxiety) 25 mg to be taken one, twice daily, as needed with an RX label dated 11/8/07. Record review for Resident #4 revealed, on March 13, 2008, at approximately 2:30 PM, that there were no revised orders for use that included the circumstances under which it would be appropriate for the resident to request the medication and any limitations. 40.3. The administrator designee told the Agency surveyor on March 13, 2008, at approximately 1:30 PM, that no revised orders were available. 41. The Agency determined that this deficient practice of failing to obtain clarification of “as needed” or “as directed” medication orders was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 42. The Agency provided Respondent with a mandatory correction date of March 19, 2008. 43. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 43.1. Based on observation, record review and interview the facility failed to ensure that when medication directions for use were "as needed" or "as directed," the health care provider was contacted and requested to provide revised instructions; for one of seven sampled residents, “Resident #4.” 43.2. Observation during the medication review on 5/7/08 at approximately 1:15 PM revealed Vistaril 25 mg (hydroxyzine, for anxiety) to be taken one, twice daily, as needed with an RX label dated 11/8/07. Record review for Resident #4 revealed that 11 there were no revised orders for use that included the circumstances under which it would be appropriate for the resident to request the medication and any limitations. 43.3. The administrator designee stated on May 7, 2008, at approximately 1:30 PM that no clarification orders were available, and that the resident did not really use the medication. 44. The Agency determined that this deficient practice of failing to obtain clarification of “as needed” or “as directed” medication orders was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 45. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 46. | The Agency provided Respondent with a mandatory correction date of May 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT V 47. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 48. Rule 58A-5.0182(8)(b), Florida Administrative Code, requires: (b) Facility Resident Elopement Response Policies and Procedures. The facility shall develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures shall include: 12 1. An immediate staff search of the facility and premises; 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities; 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to subparagraph (8)(b)1.; and 4. The continued care of all residents within the facility in the event of an elopement. 49. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 49.1. Based on interview and review of the facility's elopement response policy, the facility failed to create detailed written policies and procedures for responding to a resident elopement. 49.2. Review of the facility's elopement response policy and procedures on 3/18/08 at approximately 11:45 AM revealed that the policy did not address: 1. An immediate staff search of the facility and premises; 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities; 3. The identification of staff responsible for contacting law enforcement, the resident's family, guardian, health care surrogate, and case manager if the resident is not located; and 4. The continued care of all residents within the facility in the event of an elopement. 49.3. On March 18, 2008, the administrator designee told the Agency surveyor that no other documentation was available, that the administrator was out of town, and that maybe the administrator had it with her. 50. | The Agency determined that this deficient practice of failing to have a complete resident elopement policy was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a 13 State Class III deficiency. 51. The Agency provided Respondent with a mandatory correction date of March 28, 2008. 52. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 52.1. Based on interview and review of the facility's elopement response policy, the facility failed to create detailed written policies and procedures for responding to a resident elopement. 52.2. Review of the facility's elopement response policy and procedures on 5/7/08 at approximately 12:45 PM revealed that the document indicated that it was an "elopement drill" and did not address: 1. An immediate staff search of the facility and premises; 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities; 3. The identification of staff responsible for contacting law enforcement, the resident's family, guardian, health care surrogate, and case manager if the resident is not located; and 4. The continued care of all residents within the facility in the event of an elopement. 52.3. On May 7, 2008, the administrator stated she did not realize that the policy needed to be more detailed. 53. The Agency determined that this deficient practice of failing to have a complete resident elopement policy was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 14 54. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 55. | The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT VI 56. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 57. Rule 58A-5.023(1)(b), Florida Administrative Code, defines: (b) The facility’s physical structure, including the interior and exterior walls, floors, roof and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. Windows, doors, plumbing, and appliances shall be functional and in good working order. All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed. 58. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 58.1. Based on observations and interviews the facility failed to ensure that all rugs and carpets were clean. 58.2. During the facility tour on 3/13/08 at approximately 9:45 AM, the Agency surveyor observed that the carpet in the room of Residents #3 and #7 was very soiled: dark color spots, stains covered the rug. The carpet in the room of Residents #6 and #7 15 had multiple stains or spots. 58.3. The administrator designee stated to the Agency Surveyor at approximately 11 AM that they had discussed getting the carpets clean. 59. The Agency determined that this deficient practice of failing to maintain a clean facility was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 60. The Agency provided Respondent with a mandatory correction date of March 28, 2008. 61. On May 7, 2007, the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 61.1. Based on observations and interviews the facility failed to ensure that all rugs and carpets were clean. 61.2. During the facility tour on 5/7/08 at approximately 11:45 PM, the Agency surveyor noted that the carpet in the room of Residents #3 and #7 was still very soiled with dark colored spots, and stains covered the rug. The carpet in the room of Residents #6 and #7 had multiple stains or spots. The carpet in the room of Residents #6 and #7 had multiple discolored areas. 61.3. The administrator told the Agency surveyor that a staff member had tried to clean the carpet with a broom and bleach and discolored the carpet. She added that the carpet had been professionally cleaned but they had not done a good job. She stated that to replace the carpet would be very costly. 62. The Agency determined that this deficient practice of failing to maintain a clean facility was related to the personal care of the resident that indirectly or potentially threatened the 16 health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 63. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 64. The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT VII 65. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth in this count. 66. Rule 58A-5.019(2)(a), Florida Administrative Code, defines: (a) 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. Freedém 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 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.: 67. From March 13, 2008, through March 18, 2008, the Agency conducted a Complaint Survey (CCR #2008002591) of the Respondent facility: 17 67.1. Based on personnel record review and interview, the facility failed to ensure that one of three sampled staff, “Staff #2,” had obtained a physicians statement that annually documented freedom from tuberculosis (TB). 67.2. Personnel record review on 3/18/08 at approximately 2:45 PM for Staff #2, hired in August 2005, revealed that the staff member had no annual documentation of freedom from TB. 68. The administrator designee told the Agency surveyor that no other documentation was available, that the administrator was out of town, and that maybe the administrator had additional documents with her. 69. The Agency determined that this deficient practice of failure to obtain annual documentation of freedom from tuberculosis was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for a State Class III deficiency. 70. The Agency provided Respondent with a mandatory correction date of March 28, 2008. 71. On May 7, 2008 the Agency conducted a re-visit to the Complaint Survey (CCR #2008002591) of the Respondent. 71.1. Based on personnel record review and interview, the facility failed to ensure that two of three sampled staff, Staff #1 and Staff #2, obtained a healthcare provider's statement that annually documented freedom from tuberculosis (TB). 71.2. Individual personnel record review on 5/7/08 at approximately 1:45 PM revealed that: a. Staff #1, the owner/administrator last had a TB test dated 4/10/07. 18 b. Staff #2, hired in August 2005, last had a freedom from communicable diseases statement including TB dated 4/19/07. 72. Continued review revealed that neither Staff #1 nor Staff #2 had received a test within one year of the date of the survey showing freedom from TB. 73. The administrator stated that Staff #2 and she were scheduled for a TB test on 5/8/09. 74. The Agency determined that this deficient practice of failure to obtain annual documentation of freedom from tuberculosis was related to the personal care of the resident that indirectly or potentially threatened the health, safety, or security of the resident and cited Respondent for an uncorrected State Class III deficiency. 75. The violation identified on March 18, 2008, being uncorrected on the May 7, 2008, survey, the May 7, 2008, violation constitutes an “uncorrected” deficiency as defined by law. 76. The Agency provided Respondent with a mandatory correction date of May 21, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2007). COUNT VI0 77. The Agency re-alleges and incorporates the above Counts I through VII, as if fully recited in this count. 78. The Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2007) for the citation of one (1) or more cited Class I deficiencies, or three (3) or more cited Class II deficiencies. Section 429.14(1)(e), Florida Statutes (2007). 19 79. Onan Agency complaint survey completed May 7, 2008, the Respondent has been cited with five (5) uncorrected Class [II deficiencies, which constitute grounds for revocation. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to § 429.14(1)(e), Florida Statutes (2007). m _ ; ames H. Harris, Esq. . Bar. No. 817775 Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, 330H St. Petersburg, FL 33701 727-552-1435 Facsimile: 727-552-1440 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308; Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7007 1490 0001 6908 7353 on July 24-2008 to Cindi Thompson, Owner/Administrator, Kendall Place, 6506 Tebbetts Drive, Orlando, FL 32818, and 20 by regular U.S. Mail to her attorneys, John F. Gilroy, II, P-A., 1695 Metropolitan Circle, Suite 2, Tallahassee, Florida 32308-8722. Assistant General Counsel Copies furnished to: Cindi Thompson Doris Spivey and Joel Libby Owner/Administrator Agency for Health Care Admin. Kendall Place Hurston South Tower 6506 Tebbetts Drive 400 W. Robinson St., Suite S309 Orlando, Florida 32818 Orlando, FL 32801 (U.S. Certified Mail) (U.S. Mail) James H. Harris, Esq. John F. Gilroy, II, P.A. Agency for Health Care Admin. 1695 Metropolitan Circle 525 Mirror Lake Drive, 330H Suite 2 St. Petersburg, Florida 33701 Tallahassee, Florida 32308-8722 (Interoffice) (U.S. Mail) 21 SENDER: COMPLETE ™ Complete items 1, 2, ater 3. ASO complete : item 4 if Restricted Delivery Is desired. _ ™ Print your name and address on the reverse So that we can return the card to you. ™ Attach this card to the back of the mailpiece, Or on the front if Space permits. 1. Article Addressed to: x IU B. Recelved by (rinted Name) Cindi Thompson Owner/Administrator -Kendall Place 6506 Tebbetts Drive : o Mall Orlando, Florida 32818 DGartes adie Pace tor Merchandise O insured Mail CO c.0.p. 4. Restricted Delivery? (Extra Fee) 2. Article Ni H ZI (Transfer 7007 14450 ono1 6908 7353 200800 F3 1 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 08-004890