Lithubt A O4-462 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ‘AHCA No.: 2009004030 cael Return Receipt Requested;, v. 7009 0080 0000 0586 6461 7009 0080 0000 0586 6478 GRAND COURT VILLAGE INC. d/b/a GRAND COURT VILLAGE I, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Grand Court Village Inc. d/b/a Grand Court village I (hereinafter “Grand Court village I”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2008), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $4,500.00 pursuant to Section 429.19, Florida Statutes (2008), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fliorida Statutes (2008), and Chapter 28-106, Florida Administrative Code (2008). 3. Venue lies pursuant to Section 120.57, Florida Statutes (2008), and Rule 28-106.207, Florida Administrative Code (2008). PARTIES 4, AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, 'Part I, Florida Statutes (2008), and Chapter 58A-5 Florida Administrative Code (2008). 5. Grand Court Village I operates a 125-bed’ assisted living facility located at 295 S. W. 4*® Avenue, Pompano Beach, Florida 33060. Grand Court Village I is licensed as an assisted living facility under license number 5464. Grand Court Village I was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I GRAND COURT VILLAGE I FAILED TO ENSURE THAT THE STATEWIDE TOLL FREE FLORIDA ABUSE HOTLINE NUMBER WAS POSTED IN FULL VIEW IN AN ACCESSIBLE AREA OF THE FACILITY. RULE 58A-5.0182(6) (d), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Grand Court Village I was cited with nine (9%) Class III deficiencies as a result of licensure surveys that were conducted on January 21, 2009 and February 25, 2009. 8. A licensure survey was conducted on January 21, 2009. Based on observation during the tour of the facility and interview with the Administrator on the day of the survey at approximately 10:00 AM, it was determined that the facility failed to ensure the Statewide toll free Florida Abuse Hotline number was posted in full view in a freely accessible area of the facility. The findings include the following. 9. During a tour of the facility with tne Administrator, it was noted that the facility did not have the statewide toll free Florida Abuse Hotline number posted in full view in a freely accessible area of the facility. 10. This was confirmed by the Administrator on 1/21/09 at approximately 11:00 AM. il. The mandated date of correction was designated as February 21, 2009. 12. A revisit survey was conducted on February 25, 2009. Based on observation during the tour of the facility and interview with the Administrator on the day of the survey at approximately 10:00 AM, it was determined that the facility failed to ensure the Statewide toll free Florida Abuse Hotline number was posted in full view in a freely accessible area of the facility. The findings include the following. 13. During a tour of the facility with the Administrator, it was noted that the facility did not have the Statewide toll free Florida Abuse Hotline number posted in full view in a freely accessible area of the facility. 14. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 15. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.0182(6)(d), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.(2)(c), Florida Statutes. COUNT II GRAND COURT VILLAGE I FAILED TO DESIGNATE IN WRITING THE PERSON WHO IS RESPONSIBLE FOR TOTAL FOOD SERVICES AND DAY-TO-DAY SUPERVISION OF FOOD SERVICES. RULE 58A-5.020(1) (a), FLORIDA ADMINISTRATIVE CODE (NUTRITION AND DIETARY STANDARDS) CLASS III VIOLATION 16. AHCA re-alleges and incorporates paragraphs (1) tnrough (5) as if fully set forth herein. 17. A licensure survey was conducted on January 21, 2009. Based on record review and interview, it was determined that the facility failed to designate in writing the person who is responsible for the total food services and day-to-day supervision of food services. The findings include the following. 18. During an interview conducted on 1/21/09 at approximately 12 PM, the Administrator reported that Employee #9 (the chef) is responsible for the facility's food service. During a review of Employee #9 personnel file and the facility's records, it was noted that the files lacked written documentation regarding the person that the facility had designated in writing to he responsible for the facility's food service, as requested. 19. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 20. The mandated date of correction was designated as February 21, 2009. 21. A revisit survey was conducted on February 25, 2009. Based on interview and record review, it was determined that the facility failed to provide documentation of a designee in writing who responsible for total food services and the day-to- day supervision of food services staff. Tne findings include the following. 22. During an interview with the Administrator on 02/25/09 at approximately 1:00 PM, it was reported that Employee #6, is responsible for total food services and the day-to-day supervision of food services staff. During a review of Employee #6'S personnel record, it was noted that the file lacked documentation of the designees' responsibilities. During a further interview, the Administrator reported that the documentation was unavailable for review, as of the day of the revisit survey. This is an uncorrected deficiency from the survey of January 21, 2009. 23. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.020(1) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2) (c), Florida Statutes. COUNT III GRAND COURT VILLAGE I FAILED TO PROVIDE THERAPEUTIC DIETS AS ORDERED BY THE RESIDENTS’ HEALTH CARE PROVIDER. RULE 58A-5.020(2) (e), FLORIDA ADMINISTRATIVE CODE (NUTRITION & DIETARY STANDARDS) CLASS III VIOLATION 24. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. A licensure survey was conducted on January 21, 2009. Based on observation and interview with the food service aides, the chef, and the Administrator, it was determined that the facility was not providing desserts and beverages for residents on therapeutic diets as ordered by the residents’ health care provider. The findings include the following. 26. During the lunch meal on 1/21/09, the facility's dining room staff was observed to have served canned vanilla pudding to all of the diabetic residents, including Resident #1, that was prescribed a diabetic diet. The facility had did not have available sugar free desserts in storage for an alternative. 27. Upon interview, the kitchen and servers did not have a list of residents on special diets and were not familiar with the residents' currently prescribed diets. 28. During an interview at approximately 4:30 PM, the Administrator acknowledged the findings. 29. The mandated date of correction was designated as February 21, 2009. 30. A revisit survey was conducted on February 25, 2009. Based on observation and interview with the food service aides, the chef, and the Administrator of the facility, it was determined that the facility was not providing desserts and beverages for residents on therapeutic diets as ordered by the residents’ health care provider. The findings include the following. 31. On the day of the survey, at the lunch meal, the facility's dining room staff was observed to have served ice cream cake to some of the diabetic residents, including Resident #1, that was prescribed a diabetic diet. The facility staff serving the residents did not have knowledge of which residents were prescribed special diets. 32. Resident #3 was prescribed a mechanical soft diet on 1/23/09. The resident was served a regular diet of hot dogs on a bun with sauerkraut, French fries, and baked beans. 33. Resident #4 was prescribed a mechanical soft diet on 1/26/09. The resident was served a regular diet of hot dogs on a bun with sauerkraut, French fries, and baked beans. 34. Resident #6 was prescribed a low carb diet on 1/29/09. The resident was served a regular diet of hot dogs on a bun with sauerkraut, French fries, and baked beans. 35. The facility staff when interviewed stated the resident refuses to follow his/her diet which was given to the chef on 1/22/09. The facility had no documentation that this resident refuses his/her therapeutic diet and the residents’ health care provider was notified. 36. Upon interview, the chef (kitchen) and servers did not have an accurate list of residents on special diets and were not familiar with the residents' currently prescribed diets. 37. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 38. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.020(2)(e), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2)(c), Florida Statutes. COUNT _IV GRAND COURT VILLAGE I FAILED TO ENSURE THAT STAFF HAD SUBMITTED A STATEMENT FROM A HEALTH CARE PROVIDER STATING THE EMPLOYEE DID NOT HAVE SIGNS OR SYMPTOMS OF COMMUNICABLE DISEASE, INCLUDING TUBERCULOSIS. RULE 58A-5.019(2) (a), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORD STANDARDS) CLASS III VIOLATION 39. AHCA xre-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 40. A licensure survey was conducted on January 21, 2009. Based on interview and record review, it was determined that the facility failed to provide documentation from a health care provider that a newly hired employee does not have signs or symptoms of a communicable disease, including tuberculosis, for 1 out of 9 sampled employees (Employee #3). The findings include the following. 41. Based on record review of sampled employees' files and an interview with the Administrator, it was determined that 1 newly hired employee's personnel file (Employee #8) lacked documentation of verification by a health care provider indicating that the staff member was free from any signs or symptoms of a communicable disease including tuberculosis as required. Employee #8 had been hired on 01/26/2008. 10 42. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 43. The mandated date of correction was designated as February 21, 2009. 44. A revisit survey was conducted on February 25, 2009. Based on record review and interview, it was determined tnat the facility failed to ensure that all employee files contained documentation indicating that all newly hired staff members do not have any signs or symptoms of a communicable disease including tuberculosis, within 30 days of hire, for 2 out of 6 sampled employees (Employee #'s 1 and 5). The findings include the following. | 45. Upon interview with the Administrator on 02/25/09 at approximately 11:00 AM, it was reported that Employee #1 (hired in 07/08) and 6 (hired in 12/08) both provide personal care services for the residents residing at the facility. During a further review of the record, it was noted.that the employee files lacked documentation of a statement from a health care provider, based on an examination conducted within the last six months, that the employees do not have any signs or symptoms of a communicable disease including tuberculosis. 46. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 47. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.019(2) (a), Florida Administrative Code, and Rule 58A-5.024(1) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2) (c), Florida Statutes. COUNT Vv GRAND COURT VILLAGE I FAILED TO PROVIDE DOCUMENTATION OF FREEDOM FROM TUBERCULOSIS SIGNED BY A PHYSICIAN ON AN ANNUAL BASIS. RULE 58A-5.019(2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORD STANDARDS) CLASS III VIOLATION 48. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 49. A licensure survey was conducted on January 21, 2009. Based on record review and interview, it was determined that the facility failed to provide documentation of freedom from tuberculosis signed by a physician on an annual basis, for 3 out of 9 sampled employees (Employee #1, #2 & #4). The findings include the following. 12 50. During the Staff Records Standards portion of the survey conducted on 01/21/09 at approximately 1 PM, personnel files were reviewed with the Human Resource Employee and the Administrator. Upon review of Employee #1, #2 and #4 personnel records, it was revealed that the employees' personnel files lacked documentation of freedom from tuberculosis that was signed and dated by a physician on an annual basis, as required. Documentation of freedom from tuberculosis last documented on the following dates: Employee #1: 10/11/07; Employee’ #2: 11/11/07; Employee #4: 01/17/07. Sl. The Administrator of the facility was interviewed on the day of the survey (during an exit. conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 52. The mandated date of correction was designated as January 21, 2009. 53. A revisit survey was conducted on February 25, 2009. Based on record review and interview, it was determined that the facility failed to provide documentation of freedom from tuberculosis signed by a physician on an annual basis, for 1 out of 6 sampled employees (Employee #3). The findings include the following. 54. Upon interview with the Administrator on 02/25/09 at approximately 11:00 AM, it was reported that Employee #3 (hired 13 in 08/07) provides personal care services for the residents residing at the facility. 55. Upon review cf Employee #3's personnel record, it was noted that the file lacked documentation of freedom from tuberculosis that was signed and dated by a physician on an annual basis, as required. 56. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 57. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.019(2)(a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2) (c), Florida Statutes. COUNT_VI GRAND COURT VILLAGE I FAILED TO ENSURE THAT ALL APPLICABLE EMPLOYEE PERSONNEL FILES CONTAIN DOCUMENTATION VERIFYING THAT EMPLOYEE RECEIVED TRAINING PRIOR TO PROVIDING ASSISTANCE WITH SELF-ADMINISTERED MEDICATION. SECTION 429.256, FLORIDA STATUTES SECTION 429.52(5), FLORIDA STATUTES RULE 58A-5.0191(5), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)1., FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 58. AHCA re-alleges and incorporates paragraphs (1) 14 through (5) as if fully set forth herein. 59. A licensure survey was conducted on January 21, 2009. Based on interview and record review, it was determined that the facility failed to ensure that all applicable employee personnel files contain documentation verifying that the employee received training prior to providing assistance with self-administered medication, for 1 out of 9 sampled employees (Employee #8). The findings include the following. 60. During the Staff Records Standards portion of the survey conducted on 01/21/09 at approximately 1 PM, an interview with the Administrator revealed that 2 out of 9 sampled employees provide residents with assistance with their self- administered medications. 61. During a review of sampled employees' personnel -records, it was noted that 1 out of 9 sampled employees' (Employee #8) personnel file lacked documentation verifying that the employee had received a minimum of 4 hours of training prior to assuming this responsibility, as required. During a further interview with the Administrator and the Human Resource employee, the above information was requested, no documentation was provided. 62. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at 15 approximately 4:30 PM, and after investigation, confirmed the findings. 63. The mandated date of correction was designated as February 21, 2009. 64. A revisit survey was conducted on February 25, 2009. Based on interview and record review, it was determined that the facility failed to ensure that all applicable personnel files contain documentation verifying that the employee(s) received training prior to providing assistance with self-administered medication for 2 out of 6 sampled employees (Employee #'s 4 and 5). The findings include the following. 65. Upon interview with the Administrator on 02/25/09 at approximately 10:00 AM, it was reported that Employee #4 (hired in 08/06) and 5 (hired in 12/08) both provide the residents with assistance with self-administered medications. 66. During a review of Employee #4 and #5's personnel records, it was revealed that the file lacked documentation indicating that the employees completed a minimum of 4 hours of training in assisting residents with self-administered medications, prior to assuming this responsibility, as required. 67. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 16 68. Based on the foregoing facts, Grand Court Village I violated Section 429.256, Florida Statutes, Section 429.52(5), Florida Statutes, Rule 58A-5.0191(5), Florida Administrative Code, and Rule 58A-5.024(2)(a)l., Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant te Section 429.19(2) (c), Florida Statutes. COUNT VII GRAND COURT VILLAGE I FAILED TO ENSURE THAT STAFF MEMBERS WHO PROVIDE ASSISTANCE WITH SELF-ADMINISTERED MEDICATION RECEIVE THE REQUIRED CONTINUING EDUCATION TRAINING. SECTION 429.256, FLORIDA STATUTES RULE 58A-5.0191(5) (c), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.024(2) (a)1., FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 69. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 70. A licensure survey was conducted on January 21, 2009. Based on record review and interview, it was determined that the facility failed to ensure that staff members, who provide assistance with self-administered medications obtained annually a minimum of 2 hours of continuing education training on providing assistance with self-administration of medications and 17 safe medication practices in an ALF, for 1 out of 9 sampled employees (Employee #6). The findings include the following. 71. During the Staff Records Standards portion of the survey conducted on 02/21/09 at approximately 1 PM, an interview with the Administrator revealed that 2 out of 9 sampled employees provide residents with assistance with their self- administered medications. During a review of sampled employees' personnel records, it was noted that 1 out of 9 sampled employees' (Employee #6) personnel file lacked documentation verifying that each employee had attended a minimum of 2 hours cf continuing education training on providing assistance with self-administration of medications and safe medication practices in an ALF. The last documented training on medication assistance for the above employee was on 03/03/06. During a further interview with the Administrator and the Human Resource employee, the above information was requested, no documentation was provided. 72. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 73. The mandated date of correction was designated as February 21, 2009. 18 74. A revisit survey was conducted on February 25, 2609. Based on interview and record review, it was determined that the facility failed to ensure that unlicensed persons who provide residents with assistance with self-administered medications, obtain 2 hours of continuing education on an annual basis for 1 out of 6 sampled employees (Employee #4). The findings include the following. 75. Upon interview, during the biennial re-licensure survey conducted at approximately 9:45 AM, the Administrator reported that Employee #4 (hired in 08/06) provides the residents with assistance with self-administered medications. 76. During a review of Employee H's, personnel record it was revealed that the file lacked documentation indicating that the employee completed a minimum of 2 hours of continuing education training on providing assistance with self- administered medications and safe medication practices in an ALF, on an annual basis, as required. 77. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 78. Based on the foregoing facts, Grand Court Village I violated Section 429.256, Florida Statutes, Rule 58A- 5.0191(5) (c), Florida Administrative Code, and Rule 58A- 5.024(2) (aj)1., Florida Administrative Code, herein classified as 19 an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2)(c), Florida Statutes. COUNT VIII GRAND COURT VILLAGE I FAILED TO ENSURE THAT A COPY OF EMPLOYEE JOB DESCRIPTIONS ARE INCLUDED IN EACH EMPLOYEES PERSONNEL FILE. SECTION 429.275(4), FLORIDA STATUTES RULE 58A-5.019(2) (e)1., FLORIDA ADMINISTRATIVE CODE Rule 58A-5.024(2) (a)4., FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 79. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 80. A licensure survey was conducted on January 21,2009. Based on record review and interview, it was determined that the facility failed to ensure that a written copy of employee job descriptions are included in each employee's personnel file, for 3 out of 9 sampled employee personnel files (Employee #3, #4 & #5). The findings include the following. 81. During the Staff Records Standards portion of the survey conducted on 01/21/09 at approximately 1 PM, employee files were reviewed with the Human Resource Employee. During an interview with the Administrator, it was reported that the facility's resident census totaled 80, as of the day of the biennial re-licensure. During a review of Employee #3, #4 & #5 20 personnel files, it was noted that all three records lacked documentation of a job description. 82. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 83. The mandated date of correction was designated as February 21, 2009. 84. A revisits survey was conducted on February 25, 2009. Based on record review and interview, it was determined that the facility failed to ensure that all personnel files contained documentation of a job description for 5 out of 6 sampled employees (Employee #'s 1, 3, 4, 5, and 6). The findings include the following. 85. Upon review of the facility's personnel records, it was revealed that the Employee #1, 3, 4, 5 and 6's files lacked decumentation of a job description reflecting their current position, as required. 86. During an interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 2121, 2009. 87. Based on the foregoing facts, Grand Court Village lI violated Section 429.275(4), Florida Statutes, Rule 58A- 5.019(2)(e)1, Florida Administrative Code, and Rule 58A- 21 5.024(2) (a)4., Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2)(c), Florida Statutes. COUNT IX GRAND COURT VILLAGE I FAILED TO PROVIDE DOCUMENTATION OF THE FACILITY’S DIRECT CARE STAFF AND THE ADMINISTRATOR’ S PARTICIPATION IN RESIDENT ELOPEMENT DRILLS. RULE 58A-5.0024(2) (a)5, FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 88. AHCA re-alleges and incorporates paragraphs {1) through (5) as if fully set forth herein. 89. A licensure survey was conducted on January 21 2009. Based on an interview, the facility failed to provide documentation of the facility's direct care staff and the Administrator's participation in resident elopement drills, for 6 out of 9 sampled employees (Employee #1, #3, #4, #5, #8 & #9). The findings include the following. 90. During the Staff Records Standards portion of the survey, sampled employees' files were reviewed for documentation of participation in a resident elopement drill. It was noted that 6 out of 9 sampled employees’ files lacked documentation of participation in a resident elopement drill. During an interview 22 with the Administrator and the Human Resource Employee at approximately 2 PM, it was reported that the facility did not have documentation of the facility's staff member (Employee #1, #3, #4, #5, #8 & #9) participation in resident elopement drills. 91. The Administrator of the facility was interviewed on the day of the survey (during an exit conference) at approximately 4:30 PM, and after investigation, confirmed the findings. 92. The mandated date of correction was designated as February 21, 2009. 93. A revisit survey was conducted on February 25, 2009. Based on interview, it was determined that the facility failed to provide documentation of all applicable staff participation in resident elopement drills for 4 out of 6 sampled employees (Employee #'s 1, 3, 4 and 5). The findings include the following. 94. Upon interview with the Administrator conducted on 02/25/09 at approximately 10:00 AM, it was reported that Employee #'s 1, 3, 4 and 5 all provide direct care for the residents residing at the facility. 95. During a further interview, the Administrator reported that documentation confirming that Employee #'s 1, 3, 4 and 5 all participated in resident elopement drill(s) was unavailable, as required. 23 96. During a further interview, conducted at approximately 3:00 PM, the Administrator confirmed the findings. This is an uncorrected deficiency from the survey of January 21, 2009. 97. Based on the foregoing facts, Grand Court Village I violated Rule 58A-5.024(2)(a)5, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00 pursuant to Section 429.19(2)(c), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Grand Court Village I on Counts I through IX. 2. Assess an administrative fine of $4,500.00 against Grand Court Village I on Counts I through IX for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. 24 Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2008). 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 the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER 2, Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 25 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Gwen M. Duncan, Administrator, Grand Court Village I, 295 S.W. 4% Avenue, Pompano Beach, Florida 33060; Arturo Godinez, Registered Agent, 295 S¢ qth Avenue, Pompano . 3,5 Beach, Florida 33060 on this 3?” day of 2009. Obl C02, Bh capa, urdes A. Naranjo, Esq. 7 26 so that we can retum the card to you. @ Attach this card to the back of the mailpiece, | q c & i c ' oron the front if space permits. i +. Article Addressed to: j Postage | $ . Centitied Fee fuer ut . d ayiciw D. Is delivery address different from item 1? If YES, enter delivery address belo} 7005 0080 GOO0 0546 G4bL ~ cena laa ss Krona Cours Vilage T (Enaaiservont Reed} 44 Sa 4 Guenu 3. Service Type 1 Certified Mail © Express Mall : Total Postage & Fees | $ Paomsetomer Beach, Fleude 3%bo Cl Registered 1 Return Receipt for Merchandise TI Insured Mail OCOD. : 4 Restricted Delivery? (Extra Fee) Oh yes 7009 go80 ooo0 0546 b4bL Tee 80h 4030 “Transfer fram service label) wat \ T fy PS Form 3811, February 2004 Domestic Return Receipt (3 min Company = 0289SO2M1BH0 Sei Grune Athos Certified fee 25 Sw 4 th ? venus te h, Peach so Rae . f yy 50 | _ moon Lorrdar 33060 Postage 1s wm rt a: a = e ao] ts wo in a a ae CS dnaabia Runees o | ve eg Oo co ca S nage ro [Sere a CO | Steer ~ = Cortitied Mai 6] CO Registered & “a O Insured Mail " 4. Rest oe 04 060 Oo00 O58 &478

Docket for Case No: 09-004620

Orders for Case No: 09-004620