STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs, Case No. 2010004740 LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Petitioner”, “Agency”, or “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE (hereinafter “Respondent” or “Facility”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2010), and alleges: NATURE OF THE ACTION This is an action to REVOKE the license of Respondent as an assisted living facility in the State-of Florida pursuant to §§ 408.815 and 429.14, Fla, Stat, (2010) based upon the Agency’s determination of systematic records falsification and misrepresentation conducted by Respondent, in violation of § 429.49, Fla, Stat. (2010). . . JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Section § 20.42, Section § 120.60 and Chapters 408, Part Il, and 429, Part I, Fla. Stat. (2010). Filed January 5, 2011 4:24 PM Division of Administrative Hearings 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 the Chapters 408, Part II, and 429, Part J, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates a 44-bed assisted living facility (hereafter “ALF”) located at 907 B. Orange Ave., Eustis, FL 32726, and is licensed as an ALF, license number 6622. 5. Respondent was at all times material hereto a licensed facility under the licensing _ authority of the Agency, and was required to.comply with all applicable rules and statutes. COUNT J (Tag 029) 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein, 7. That based upon the review of records, Respondent failed to ensure that no medical or other assisted living facility record was fraudulently altered, defaced, or falsified, the same being contrary to law. 8. That pursuant to the Assisted Living Facilities Act: “(2) The purpose of this act is to promote the availability of appropriate services for elderly persons and adults with disabilities in the least restrictive and most homelike environment, to encourage the development of facilities that promote the dignity, individuality, privacy, and decisionmaking ability of such persons, to provide for the health, safety, and welfare of residents of assisted living facilities in the state, to promote continued improvement of such facilities, to encourage the development of innovative and affordable facilities particularly for. persons with low to moderate incomes, to ensure that all agencies of the state cooperate in the protection of such residents, and to ensure that needed economic, social, mental health, health, and leisure services ate made available to residents of such facilities through the efforts of the Agency for Health Care Administration, the Department of Elderly Affairs, the Department of Children and Family Services, the Department of Health, assisted living facilities, and other Page 2 of 17 community agencies. To the maximum extent possible, appropriate community- based programs must be available to state-supported residents to augment the services provided in assisted living facilities. The Legislature recognizes that assisted living facilities are an important part of the continuum of long-term care in the state. In support of the goal of aging in place, the Legislature further recognizes that assisted living facilities should be operated and regulated as residential environments with supportive services and not as medical or nursing _ facilities. The services available in these facilities, either directly or through contract or agreement, are intended to help residents remain as independent as possible. Regulations governing these facilities must be sufficiently flexible to allow facilities to adopt policies that enable residents to age in place when resources are available to meet their needs and accommodate their preferences. (3) The principle that a license issued under this part is a public trust anda privilege and is not an entitlement should guide the finder of fact or trier of law at any administrative proceeding or in a court action initiated by the Agency for Health Care Administration to enforce this part.” See § 429,01(2)-(3), Fla. Stat. (2010) (emphasis added). 9. That pursuant to Florida law, the Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health - Care Licensing Procedures Act, the authorizing statutes or applicable rules. See §§ 408.815, 429.14, 429.19, 429.49, Fla. Stat. (2010). 10. | That pursuant to Florida Jaw, “ ‘Client’ ) means any person receiving services from a provider listed in s. 408.802.” § 408.803(6), Fla. Stat. (2010) 11. That pursuant to Florida law, “ ‘Provider’ means any activity, service, agency, or facility regulated by the agency and listed in s. 408.802.” § 408.803(11), Fla. Stat. (2010) 12. That pursuant to Florida law, the provisions of this part apply to the provision of services that require licensure as defined in this part and to the following entities licensed, registered, or certified by. the agency, as described in chapters 112, 383, 390, 394, 395, 400, 429, 440, 483, and 765: Assisted living facilities, as provided under part I of chapter 429. See § 408.802(14), Fla. Stat, (2010) Page 3 of 17 13. 14. That specifically, Florida law provides that: (1) In addition to, the requirements of part II of chapter 408, the agency may deny, revoke, and suspend any license issued under this. part and impose an administrative fine in the manner provided in chapter 120 against a licensee of an assisted living facility for a violation of any provision of this part, part II of chapter 408, or applicable rules, or for any of the following actions by a licensee of an assisted living facility, forthe actions of any person subject to level 2 background screening under s, 408.809, or for the actions of any facility employee: (a) An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. RK : (f) A determination that a person subject to level 2 background screening under s. 408.809 does not meet the screening standards of s. 435.04 or that the facility is retaining an employee subject to level 1 background screening standards under s. 429.174 who does not meet the screening standards of s. 435.03 and for whom exemptions from disqualification have not been provided by the agency. (g) A determination that an employee, volunteer, administrator, or owner, or person who otherwise has access to the residents of a facility does not meet the criteria specified in s. 435.03(2), and the owner or administrator has not taken action to remove the person, Exemptions from disqualification may be granted as set forth in s. 435.07, No administrative action may be taken against the facility if the person is granted an exemption. * OK * () Any ‘act constituting a ground upon which application for a license may be denied. See § 429.14, Fla. Stat. (2010) That specifically, Florida law provides that: Jn addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: (a) False. represéntation of a material fact in the license application or omission of any material fact from the application. (b) An intentional or negligent act materially affecting the health or safety of a client of the provider. (c).A violation of this part, authorizing statutes, or applicable rules. (d) A demonstrated pattern of deficient performance. (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Page 4 of [7 Medicaid program, the Medicaid program of any other state, or the Medicare program. See § 408.815(1), Fla. Stat. (2010) 15. That pursuant to Florida law, “(1) Any person who fraudulently alters, defaces, or falsifies any medical or other record of an assisted living facility, or causes or procures any such offense to be committed, commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083. (2) A conviction under subsection (1) is also grounds for restriction, suspension, or termination of license privileges.” See § 429,49(1-2), Fla. Stat. (2010). 16. That pursuant to Florida law, records requirements for ALFs require that, inter alia, “[alll 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.” Fla. Admin, Code R. 58A-5,024(4)(a). 17. That pursuant to Florida law, records requirements for ALF's require that, inter alia, “{t]he facility shall ensure the availability of records for inspection.” Fla. Admin. Code R. 58A- 5.024(4)(d). 18. That pursuant to Florida law, personnel records requirements for ALFs require that, inter alia, “[t}he 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.” See § 429.275(2), Fla. Stat. (2010). 19, That pursuant to Florida law, background soréening requirements for ALFs require that, inter alia, “[alll staff who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S., and meet the screening standards of Section 435.03, F.S. A packet containing background screening forms and Page 5 of 17 instructions may be obtained from the Agency Background Screening Unit, 2727 Mahan Drive, Tallahassee, FI, 32308; telephone (850) 410-3400. Within ten (10) days of an individual’s employment, the facility shall submit the following to the Agency Background Screening Unit: 1. A completed Level 1 Criminal History Request, ANCA Form 3110-0002, July 2005, which is incorporated by xeference and may be obtained in the screening packet referenced in paragraph | (3)(a) of this rule.” Fla, Admin. Code R. 58A-5.019(3)(a)(1). 20. That the screening requirements and exemptions of § 429.174, Fla. Stat. (2010) are as follows: “The owner or administrator of an assisted living facility must conduct level 1 background screening, as set forth in chapter 435, on all employees hired on or after October 1, 1998, who perform personal services as defined in s. 429.02(16). The agency may exempt an individual from employment disqualification as set forth in chapter 435. Such persons shall be considered as having met this requirement if: (1) Proof of compliance with level 1 screening requirements obtained to meet any professional license requirements in this state is provided and accompanied, under penalty of perjury, by a copy of the person's current professional license and an affidavit of current compliance with the background screening requirements. (2) The person required to be screened has been continuously employed in the same type of occupation for which the person is seeking employment without a breach in service which exceeds 180 days, and proof of compliance with the level 1 screening requirement which is no more than 2 years old is provided. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person scréened. Upon request, a copy of screening results shall be provided by the employer retaining documentation of the screening to the person screened. (3) The. person required to be screened-is employed by a corporation or business entity or related ‘corporation. or business entity that owns, operates, or manages more than one facility or agency licensed under this chapter, and for whom a level 1 screening was conducted by the corporation. or business entity as a condition of initial or continued “ employment.” Page 6 of 17 21. “{pjersonnel 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. In addition, records shall contain the following, as applicable: 3. Documentation of compliance with level 1 background screening for all staff subject to screening requirements as required under Rule 58A-5.019, F.A.C.” Fla. Admin. Code That pursuant to Florida law, staff records requirements for ALFs require that, inter alia, R. 58A-5.024(2)(a)(3). 22. 23. after October 1, 1998, and subject to level 1 background screening as required under Rule 58A- That the screening requirements of § 435.03, Fla. Stat. (2010) are as follows: “(1) All employees required by law to be screened pursuant to this section must undergo background screening as a condition of employment and continued employment which includes, but need not be limited to, employment history checks and statewide criminal correspondence checks through the Department of Law Enforcement, a check of the Dru Sjodin National Sex Offender Public Website, and may include local criminal records checks through local law enforcement agencies. (2) Any person required by law to be screened pursuant to this section must not have an atrest awaiting final disposition, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under s. 435.04(2) or similar law ‘of another jurisdiction. (3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.” That the following seven (7) people were employees of Respondent, were all hired on or 95.019, FAC. Employee No. 1: Regina Morrison — Employee No. 2: Evelyn Azier Driver Employee No. 3: Vernita Edwards ._Employee No. 4: Tina Dick Employee No. 5: Tonya Adams. PROS Page 7 of 17 f Employee No. 6: Latoya Reshond Gaston; and g. Employee No. 7: Stacey Gray 24, That pursuant to a medicaid contract review, a review of the Level I and Level II background checks of the Respondent’s employees prompted a cross-check with the Agency’s Background Screening Unit (hereafter “ABSU”). 25, That according to the ABSU, some of the purported background screenings were never in fact condiicted by the ABSU, despite being on Agency letterhead, and both the font and format used on said purported background screenings were not consistent with the ABSU font and format. 26. That in one (1) instance, ABSU sent the Respondent a certified letter declaring a particular employee in question ineligible due to a prior conviction.' However, the Respondent submitted background screening documentation, purportedly from the ABSU, showing the inelligible employee as “OK” (See page 9, | 27(g), Employee No. 7 referenced herein below)’. 27. That with respect to the following seven (7) employees of Respondent, the following determinations were made based upon personnel record review: a. ere No. 1 (Regina Morrison): i. Application has her as a CNA but there is no record of any CNA certificate in the file or on the DOH website; and ii, No background screening is/was on file or submitted by Respondent. b. Employee No. 2 (Evelyn Azier Driver): i. Application has her listed as a cook; and ii. No background screenings is/was on file or submitted by the Respondent. ' See Composite Exhibit “A”, attached hereto and incorporated herein by this reference. 2 See Exhibit “B”, attached hereto and incorporated herein by this reference, Page 8 of 17 c, Employee No. 3 (Vernita Edwards): i. Is a Direct Care Staff; and ii. No background screening is/was on file or submitted by the Respondent. d. Employee No. 4 (Tina Dick)’: i. Application has her listed as a cook; ii, The ABSU document submitted by the provider is in different format and font as used by the AHCA background screening Unit; and iii. The screening ‘unit confirmed that no background screening for this employee has ever been conducted by the ABSU on behalf of any Respondent. 2 Employee No. 5 (Tonya Adams)'; i. Application has her listed as Direct Care Staff. Application has her listed as a cook, ii. The ABSU document submitted by the Respondent is in different format and font as used by the ABSU. iii, The screening unit confirmed that no background screening for this employee has ever been conducted by the ABSU on behalf of any licensed health care provider. Employee No. 6 (Latoya Reshond Gaston)’: i. Application does not have position listed, but is Direct Care Staff; ii, Application has name as Latoya Reshond Gaston; mh iii, The background on file and submitted by Respondent has her as Latoya Reshond without the last name Gaston; iv. The ABSU stated the document they reviewed does not have their format and that no screening has ever been conducted by them under the name Latoya Reshond and there is no backgtound screening for Latoya Reshond Gaston; and v. The format used on the background screening is not that of the ABSU. g. Employee No. 7 (Stacey Gray): i. Application does not list position title but is Direct Care Staff; ii. Background screening in file and submitted by Respondent states. that the screening is “OK”; , iti, A review by the ABSU determined that it is not their format and a copy of the original background screening was faxed to the MPI investigator; * See Exhibit “C*, attached hereto and incorporated herein by this reference, * See Exhibit “D”, attached hereto and incorporated herein by this reference. 5 See Exhibit “E”, attached hereto and incorporated herein by this reference. Page 9 of 17 iv. A letter of disqualification and a copy of the criminal history report (original screening document) was transmitted via certified mailed. on 8/01/05 to the Respondent and stated that the prospective employee was not eligible based on a 1986 conviction out of Lake County Florida for Aggravated Assault with a weapon, F.S. 784.045, Case No. 86595CF Disp Date 07/31/1986 to 3 years probation; and v. This employee was an active employee at the Respondent’s facility at the time of records review. 28. That based upon interview and record review, the Respondent falsified and/or altered background screenings of Respondent’s employees and failed or refused to conduct background screenings on Respondent’s employees who were all required to have such screenings, contrary to law, 29, That the above facts show, inter alia, that Respondent undertook to systematically and fraudulently alter multiple background screening records of Respondent’s employees, which is a deficient practice placing residents at potentially great risk of not receiving proper care and seriously affecting the health, safety, or welfare of Respondent’s residents. - 30. That the above facts show, inter alia, that Respondent committed intentional and/or negligent acts that materially affected the health or safety of Respondent’s clients/residents. 31. That the Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2010) for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility and any act constituting a ground upon which application for licensure may be denied. Section 429.14(1)(a) and (k), Florida Statutes (2010). An applicant must demonstrate compliance with the requirements in this part, authorizing statutes, and applicable rules during an inspection pursuant to s.408.81 1, as required by authorizing statutes. Section 408.806(7)(a), Florida Statutes (2010). 32. That Florida law provides that in addition to the grounds provided in authorizing statutes, grounds that may be used by the agency for denying and revoking a license... include any of the Page 10 of 17 following actions by a controlling interest: (6) An intentional or negligent act materially affecting the health or safety of a client of the provider, (c) A violation of this part, authorizing statutes, or applicable rules, and (d) A demonstrated pattern of deficient performance. See § 408.815(1)(b) and (d), Fla. Stat. (2010). 27. That Respondent had at all material times hereto a continuing duty to maintain its operations in accord with the minimum requirements of law and to provide care and services at mandated minimum standards. 28. That Respondent has violated the provision of Chapter 429, Part I, Fla. Stat. (2010), and Chapter 58A-5, Florida Administrative Code. 29. That Respondent has been cited with falsification of multiple employee background screenings, 30. That Respondent’s acts and omissions constitute not only a knowing and fraudulent pattern of illegal activity but also intentional and negligent acts seriously affecting the health, safety, or welfare of residents. 31. That the above reflect grounds for which the Agency may revoke Respondent’s licensure to operate and assisted living facility in the State of Florida. 32. That Respondent has a duty to maintain its operations in accord with the minimum standards of law and its actions and/or inactions as described with particularity herein constitute intentional or negligent acts which are in violation of the mandates of law and materially affected the health or safety of residents. 33. That based thereon, individually and collectively, the Agency seeks the revocation of the Respondent’s licensure as an assisted living facility. . 34, That with respect to Respondent, the Agency has independent grounds to revoke based on a demonstrated pattern of deficient performance, ‘pursuant to § 408.815(d), Fla. Stat. (2010), as Page 11 of 17 evidenced by the following survey deficiency history: Historical Deficiency Analysis since 08/07/07 # Deficiency Tag Citations Survey Description. 07/08/10! 3 An unannounced complaint survey, in response to CCR# 2010006791 was conducted on July 8, 2010, 09/03/09" 12 An unannounced Limited Nursing Service Survey was conducted in conjunction with the Biennial Licensure survey on September 2-3, 2009. Deficiencies were identified during the course of the survey. 03/27/08" 3 Unannounced complaint investigations, CCR# 2008003586 and CCR# 2008003633 were conducted on 03/27/08. Deficiencies were identified at the time of the survey. 08/07/07" 10 The Biennial Licensure survey was conducted on 8/6- 7/07 to determine the facility compliance with Chapter 429, Part I, Florida Statutes and Chapter 58A-5, Florida Administrative Code. 09/12/07" 1 During the 09/12/07 follow-up to the 08/07/07 Biennial Licensure Survey, the following deficiencies were corrected: A 1119, A223, A 327, A 505, A 610, A 628, A 632, A 700, and A 1104. The facility continued to be deficient at A 615, resulting in a recite for non-compliance. Total: 29 6 See Exhibit “F", attached hereto and incorporated herein by this reference, 7 See Exhibit “G”, attached hereto and incorporated herein by this reference. 5 See Exhibit “H”, attached hereto and incorporated herein by this reference. ? See Exhibit “I”, attached hereto and incorporated herein by this reference. " See Exhibit “J”, attached hereto and incorporated heréin by this reference. Page 12 of 17 35. That as additional grounds evidencing a demonstrated pattern of deficient performance, the following Final Orders have been filed against Respondent: a, Case No. 2007000215"! (dated 04/16/07); b. Case No. 2005009267/05-4578" (dated 03/30/06); ¢, Case No. 2005003581/05-2320'3 (dated 01/17/06); and d. Case No. 2007012301" (dated 03/28/08). 36. “Pattern” is defined as, “frequent or widespread incidence”!, “a regular, mainly unvarying way of acting or doing”!®, “a combination of qualities, acts, tendencies, etc., forming a consistent or characteristic arrangement”!”, “g customary way of operation or behavior”!® or “Consistent and recurring characteristic or trait that helps in the identification of a phenomenon or problem, and serves as.an indicator or model for predicting its future behavior.”!? 37, Florida Statutes define a “pattern” in the context of the Agency’s discretionary authority to deny a home health agency’s renewal license if, during the previous two (2) years, the applicant or any controlling interest has been administratively sanctioned by the agency during the 2 years prior to the submission of the licensure renewal application for one or more of the following acts: (e) Demonstrating a pattern of falsifying documents relating to the training of home health aides or certified nursing assistants or demonstrating a pattern of falsifying health "' See Exhibit “K”, attached hereto and incorporated herein by this reference. ” See Exhibit “L”, attached hereto and incorporated herein by this reference. 8 See Exhibit “M1”, attached hereto and incorporated herein by this reference, ' See Exhibit “N”, attached hereto and incorporated herein by this reference, 5 See . © See . "’ See . See . . See . Page 13 of 17 38. statements for staff who provide direct care’ to patients. A pattern may be demonstrated by a showing of at least three fraudulent entries or documents; (£) Demonstrating a pattern of billing any payor for services not provided. A pattern may be demonstrated by a showing of at least three billings for services not provided within a 12-month period; (g) Demonstrating a pattern of failing to provide a service specified in the home health agency's written agreement with a patient or the patient's legal representative, or the plan of care for that patient, unless a reduction in service is mandated by Medicare, Medicaid, or a state program or as provided in s. 400.492(3). A pattern may be demonstrated by a showing of at least three incidents, regardless of the patient or service, in which the home health agency did not provide a service specified in a written agreement or plan of care during a 3-month period. See § 400,471 (10)(e)-(f), Fla. Stat. (2010). Florida Statutes also define a “pattern” in the context of the Agency’s discretionary authority to impose fines/sanctions for falsification of training documents or staff health statements as follows: “A pattern may be demonstrated by a showing of at least three fraudulent , entries or documents. The fine shall be imposed for each fraudulent document or, if multiple staff members are included on one document, for each fraudulent entry on the document.” See § 400,474 (3), Fla. Stat. (2010). 39. “Webster's New World Dictionary... provides for a definition of ‘pattern’ in the context of a behavior pattern, as ‘a regular, mainly unvarying way of acting ot doing.’ Webster's Third New International Dictionary (1986) provides fora definition of ‘practice’ as being ‘to do or perform often, customarily, or habitually’ or to ‘engage regularly in.” See Galvan v. Ayers, 2006 U.S. Dist. LEXIS 10612, 91-92 (E.D. Cal. Mar. 15,2006). Page 14 of 17 40. A demonstrated pattern of deficient practices supports the Agency’s revocation of licensure. § 408.815(1)(d), Fla. Stat. (2010). 41. That the twenty-nine (29) survey deficiencies and four (4) Final Orders show, inter alia, that Respondent demonstrated a pattern of deficient performance sufficient to subject Respondent’s facility to license revocation pursuant to § 408.81 5(d), Fla. Stat. (2010). 42. Where, as is the case sub judice, the violations were not merely isolated or sporadic, but rather consistent over time throughout the course of multiple surveys, several of which were based upon complaints, most of which were substantiated, so as to effectuate an anticipated course of conduct, the unfortunate reality in this case results in a conclusion that the numerous and distinct violations of the-Facility, when taken together, constitute an unfettered continuum of violations commonly referred to as a pattern. 43. There can be no doubt that the legislature intended fully that applicable statutory sections be used to punish violators severely, especially for such prolonged, pervasive, and knowing violations. 44, The existence of the violations at the time they were assessed and reported in the surveys in support of the Agency’s allegation of a history of deficient performance would not be erased by timely correction, Coming into compliance does not remove a deficiency or change the fact that residents were affected by the deficiency at the time of the survey and citation. 45, That the above facts show, inter alia, that Respondent has consistently violated repeated minimum standards of law for ALFs and thus subjected itself to revocation based upon twenty- nine (29) violations since August 2007. WHEREFORE, the Agency intends to revoke Respondent’s license to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815, 429.14, and 429.49, Fla. Stat. (2010). Page 15 of 17 ~b 7, Respectfully submitted this 30 day of November, 2010. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building §25 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1942 Facsimile: (727),582-1440 sbury@ahca.myflorida.com Fla. ‘Bar No. 567503 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) 412-3630. 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 furnished by U.S. Certified Mail, Return Receipt No. 7010 0780 0001 9835 6625 on November 3%, 2010 to Lake View Nutrition Consulting Services, Inc. d/b/a Henderson Housgy ATTN: Barbara K. Nemec, Registered Agency and President,. 14806 CR 450 W, Unmatill, 32784 and via U.S. Page 16 of 17 Copies furnished to: Lake View Nutrition Consulting Services, Inc. d/b/a Henderson House ATIN: Barbara K, Nemec, Registered Agency and President 14806.CR 450 W Umatilla, FL 32784 (U.S. Certified Mail) Thomas F. Asbury, Esq. Agency for Health Care Admin. 525 Mirror Lake Dr. N., 330 St. Petersburg, Florida 33701 (Interoffice) Kathleen Varga Facility Evaluator Supervisor 525 Mitror Lake Drive, 4" Floor St. Petersburg, Florida 33701 (Interoffice) Lake View Nutrition Consulting Services, Inc. d/b/a Henderson House ATTN: Evelyn Richardson, Admin. 907 E. Orange Ave. Eustis, FL 32726 (U.S. Mail) Page 17 of 17 Composite Exhibit “A” Fax 8504870470 Apr 28 2010 10:03am 002/006 JEB BUSH, GOVERNOR vs a — ALAN LEVINE, SECRETARY August 1, 2005 Henderson House. Sosa onsgpfvenin = Eustis, FL 32726 , a ATIN: Facility Administrator or Human Resource Director ee RECORD RE: Stacey Gray 2100 Dear Administrator/Human Resource Ditectot: The Background Screening Unit has received the results of the criminal history search as requested by your facility for the purpose of employment screening for the above referenced individual. During the review we noted one or more disqualifying offense(s). Section 435,06(02) of Florida Statutes states “The employer soust cither terminate the employment of any of its personnel found to be in noncompliance with the miniaum standards for good moral character contained in this section or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to section 435.07.” To apply for an exemption, Certified Nursing Assistants should call (850) 245-4567; PN/RN's should call (850) 245-4125; and all non-licensed individuals should . call our office, If you have any questions or need further assistalice, please contact me at (850) 410-3400. ) Sincerely, Jamie Bowman, Consultant Background Screening Unit Visit AHCA onlite at www fdke. stetejius 2727 Maban Drive » Mail Stop #40, Tallahassen, PL. 32308 Fax 9504870470 fer 2B 2010 10:03am 003/006 _BHI2005 , STATE OF FLOKICA Page 1 of 1 Printed by: HIGHTOWM AGENCY Fog HEACTHCATE ADMINISTRATION Background Screening Results HENDERSON HOUSE 907 E. ORANGE AVENUE EUSTIS, FL. 32726 Attn: Facity Administrator or Human Resource Manager Phone #: (352) 367-8258 - # : ‘ Fax LEVEL 1 CHR - FDLE RECORD FOUND - NOT OK Count: 1 _” STACEY GRAY 268-65-2109 8701/2005 : Entity: 11 6622 HENDERSONHOUSE = Total Count: 1. Background Screening Unit (850) 410.3400 Fax 8504870470 for 28 2010 10:02am 004/008 FLORIDA DEPARTMENT OF LAW ENFORCEMENT . Pursuant to federal regulation (28 CER 20) this xecord may be used only for stated purpose for which it was requested. Charges and dispositions as coded herein reflect. standardized uniform offense and disposition classifications fox computerized criminal history racords.More detailed and specific informa- tion may be available from contributors. The department doas not. warrant that. these racords are comprehensive or accurate, only that this record contains all information on the subject that the department has received and is pre- gently authorized by law to disseminate, . eh pO GO fo SSSR NZ 8 A PN 9 8D = a a 8S Eco REPORT FOR AGENCY FOR BEAL TH CARE ADMIN. BATCH 20080728058 THR FOLLOWING RECORD IS ASSOCIATED WITH TRANSACTION: 600029 CONTROL NBR: 31218 ‘RAME: GRAY, STACEY R , SID NER: 2335249 PURPOSK CObE:P : ' PAGE NAR: 1 BECAUSE ADDITIONS OR DELRTIONS MAY BE MADK AT ANY TIME, A NEW COPY SHOULD BE REQURSTED WHEN NEEDED FOR YUTURE USE - . PLORTDA CRIMINAL HISiORY - NAME STATE ID NO. BBE NO. + DATR REQUEBTED GRAY, STACEY RESWAMN . PL-02235249 * 08/01/2008 SEX RACH BIRTH DATS HEIGHT WEIGHT EYES AIR BIRTH PLACE sKIN e ) quam S'06') 2394 BRO BLK FL FINGERPRINT CLASS SOCIAL BECURITY NO. MISCELLANROUS NO. SCR/MRK/TAT , meni; : OS TL Tr 12 O¢ TAT UL ARM 04 TP TT 06 10 oceUPATION "ADDRESS CLty/sTaATE LBR 211 KINGSINSTON st : RUSTIS, FL AKA . DOB . soc SCR/MRK/TAT RESHAWN, STACEY Gam TAT L ARM GRAY, BAY . GRAY, STACY RESHAWN ARREST- 1 02/21/1986 oOBTs NO.- ARREST AGENCY-LAKE COUNTY SHERIFF'S OFFICE ; (?1.0350000) AGENCY. CAGE-31592 . OFFENSE DATE- CHARGE 001-CARRYING CONCEALED WEAPON- . STATUTE/ORDINANCE-FL790. 01 LEVEL~ FELONY DISP-HELD SID NBR: 2235249 PURPOSE CONE: P JODTCIAL- AGENCY» LAKE COUNTY SHERIFE' 8 (OFFICE CHARGE 001 -COURT SEQ COURT DATA-CARRYING CONCEALED WRAPON-— FIREARM SBTATUTE/ ORDINANCE -FL790 . 01 DISP DATE~03/18/1986 ARREST 2 08/29/1986. OBTS NO. - ARREST AGENCY-EUSTIS POLICE DBPARIVRNT AGENGY CASE-30862 CHARGE 001-AGGRAV ‘BATTERY - STATUTE/ORDINANCE- #1784 ,045 DIEP-TURNED OVER TO ANOTHER AGENCY FLO3S0000 AND HOLD JUDICTIAL,- AGENCY-~LAKE COUNTY SHERIVP’S OFFICE CHARGE 001 -COURT sq : COURT DATA“AGGRAV ‘ASSLT-WRAPON- Xx - BATTERY C) STATUTE/ORDINANCR-FI704, 045 CS DISP DATR-07/31/1986 : PROBATION~3Y ARREST 3 06/23/1997 OBTS NO.-0006990762 ARREST AGENCY-LAKE COUNTY SHERIFF'S OFFICE AGENCY CASE-31882 CHARGE -001-FAILURE TO APPEAR- REF WRIELS CK STATUTS/ ORDINANCR-FL843.18 DISP-HELD JUDICIAL -~ AGENCY-DAKE COUNTY COURT ADDED CHG -COURT SEQ - SUPPLEMENTAL ARREST DATA- STATUS- : . Fax 8504870470 far 28 2010 10:03am 005/008 PAGE NBR: 2 "(FL0350000) court No. “869Z1CP, LEVEL-PRLONY - DISP-DISMISBED (¥L0350100) OPFBNSE ‘DATE . LEVRL- FELONY (310350000) COURT NO. -~8659S5CP LEVEL-~FELONY DI8P~CONVICTED {PL0350000) OFFENSE DATE- LEVEL-_ (710380339) count NO.-9701269MMA0 102 . LEVEL =MISDRMBANOR, 18T DEG . PROSC NATA-INIT BY PROSC, FRAUD-INSUFF FUNDS CHECK- WORTHLESS (CracRs GonDs svCS LESS THAN 150 LEVEL-MISDEMBANOR, 1ST DEG DIBP-N/A STATUTE/ORDINANCE- PISP DATE~06/23/1997 Fax 6504870470 for 28 2010 10:0dam P006/006 SID NBR: 2235249 . PURPOSE CoDE:P /' PAGE NBR: 3 COURT DATA-SAME AS AROVE,FRAUD-INSUFF FUNDS CHRCK- - : WORTHLESS CHECKS GOODS AVCS LESS TRAN 150 STATUTE /ORDINANCE- ‘LEVEL~MISDEMEANOR, 18T DEG DISP RATR-07/08/1997 DI§P-GUILTY/ CONVICTED COUNSEL-OTHER TRIAL-NONE * PLEA -NOLO-GONTENDRE SENT DATE-07/08/1997 CONFINEMENT - 15D, 0AIL 98g , ‘oo DR LIC SUsP- — . RESTITUTION- $8 FINE- $150 , COURT CosT- CRT PROVISION-, CONFINEMENT oR’ FINE ; : ABIDE BY COURT RESTRICTIONS SPECIAL SENTENCE PROVISIONS-NOT APPLICABLE + Bae nm enna em ee ee Ve bene m emma eee Omen te ae . THIS RECORD CONTAINS FLORIDA XNFORMATION ONLY. WHEN BXPLAMATION OF A CHARGE | OR DISPOSITION IS NERDRD, COMMUNICATE DIRECTLY WITH TRE AGENCY THAT CONTRIBU- TED THE RECORD INFORMATION. IF YOU Dip Nor’ SUBMIT FINGBRPRINTS, THIS RECORD ts PROVIDED AS A RESULT OF A NANR INQUIRY ONLY. POSITIVA IDENTIFICATION CAN ONGY BR VERIFIRD BY SUBMISSION OF A FINGERPRINT CARD AND COMPARTSON BY FDLE., THIS RECORD WAS REQUESTED PURSUANT TO 943.053(3), F.S.. . RND OP RECORD . #€ Exhibit “B” ee UHUTLD Printed by: KELLEYG STATE OF FLORIDA Page 1 of 1 AGENCY FOR HEACTHCARE A MINISTRATION Background Screening Results HENDERSON HOUSE" 907 E.. ORANGE AVENUE: EUSTIS, FL 32726 Attn: Facility Administrator or Human Resource Manager Phone #: (362) 357-8266 - Fax oo Count: LEVEL 2 CHR - NO FBI RECORD FOUND - OK Stacey Gray. 08-30 o-B0- - 6622 Total Cdlat: 1, —, Pome oo oe On aanneiase et ann nee nS Ra rte teens argent aeanerenererttertistamtats 2727 Mahan Oriva Backgrolind Séreaning Unit . 4850} 418-3408. Taliphessee, “FL 32308 Exhibit “C” Sate ue piotiaa Printed by RAMOSA Serene ens reenter ee neta eestor aden Background Screening Resuits . HENDERSON HOUSE 907 E ORANGE AVENUE EUSTIS FL 32726 Alia, Facdity Aumumusiator or Human Resource Mansper Phoné # (362) 357-6258" Fai@ LEVEL 1 CHR - NO FDLE 2ECORD FOUND -OK Count 1 Tina Dick 02-05-1969 156-62-3749 e ae . . . "x ‘ae, Entity: 11 6622“ HENDERSON HOUSE Tota Count 4 me ~ , meer etna titecarenaeentimet a ents e tenga Sackgiourd-Screesiniy Unit: 7 (850) 6t0.3400 2" 2727 Mahan Dave Tatiahosses, FC 9100 Exhibit “D” 3410/2004 Printed by: RAMOSA TEENCY FOR HEALTHOARE ADI nt. _ "Background Screening Results HENDERSON HOUSE 907 G, ORANGE AVENUE EUSTIS, PL 32726 Alln: Faciity Adminictrator or Human Resaurce Manager Phone # (382) 357-8258 Fax a | LEVEL 1 CHR - NO FOLE RECORD FOUND - OK : - Count: o TONYA RAYE ADAMS «°° -BZ 593-80-2978 Entily: 14 6622 . MENOERSON HOUSE : : Totat Count: 0° a, Background Scienning Unt (86D) 419-2400 2727 Mahan Giwe Talshesote, RL 92308 Exhibit “E” US2B-Us STATE OF FLORIDA Page-1 of 1 Printeg. by: KELLEYG A A me . aes a ee AGENCY FOIE HEALTHCARE ADMINISTIATION ~ . Background Screening Results HENDERSON HOUSE 907 E. ORANGE AVENUE EUSTIS, FL 3272 Attn: Facility Administrator of Human Resource Manager “Phone #: (462) 987-8258 Fax #: LEVEL:4 CHR - NO FDLE RECORD FOUND - OK Latoya Reshond 589-32-9584 Bon ae » Entity: 11 6622 HENDERSON HOUSE -Fotal Count 1 Background Streaning Unlt (850) 410-3409 2727 Mahan Drive Tallahassee. Fl. 32308 Exhibit “F” PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X41) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF GORRECTION a (IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING Cc 8B, WING AL11932557 07/08/2010 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES U PROVIDER'S PLAN OF GORRECTION (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL . (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAY CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) INITIAL COMMENTS Surveyor: 21366 An unannounced complaint survey, in response to CCR# 2010006791 was conducted on July 8, 2010. As a result of the survey, the facility was not in compliance with Chapter 429, Part |, Florida Statutes and Chapter 58A-5, Florida Administrative Code. PHYSICAL PLANT STANDARDS The facility's physical structure, including the interior and exterior walls, floors, roof and cellings shall be structurally sound and in good repair. 58A-5.023(1)(b), F.A.C. This STANDARD is not met as evidenced by: ' Surveyor: 21366 Based on observation and interview, the facllity failed to maintain the roof and the downstairs bathroom wall in good repair. Failure to keep the facility in good repair can lead to potential injury to the residents. Findings: During a tour of the second floor, with the Administrator, on 07/08/10 at 10:00 AM, it was noted that there was a large plastic trash bucket half full of dirty water, During an interview with the administrator at approximately 10:15 AM it was revealed that the bucket is in place to catch water that is leaking from the ceiling. it was observed that the ceiling tile above the AFCA Form 3020-0001 . TITLE (X86) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE . re haat 7 OF 4 STATE FORM : . 9899 QLOT11 \foontinuation sheet 1 of 4 - PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES Xt) PROVIDER/SUPPLIER/CLIA TIPLE CONSTRUCTION (X@) DATE SURVEY AND PLAN OF GORRECTION Oe ENTIFICATION NUMBEE pe) MU CONSTR COMPLETED A. BUILDING C B. WING AL11932587 07/08/2010 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, Fl. 32726 (<4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR ‘LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A1002| Continued From page 1 bucket is bulging and has what appears to be a mold like substance on it. There is also a water stain around the same ceiling tile. The ceiling tile also appeared to be painted over with white paint. During the same tour of the second floor it was noted that there was a second small red bucket with dirty water in the hall. The Administrator was unable to explain why the bucket was there or where the water had come from. Further tour of the facility it was observed that the bathroom located at the back of the facility, and shared by several residents, had visible holes in the plaster beneath the tiles presenting an opening for bugs or smail animals to enter the facility. Class Ill Correction Date: 8/8/2010 A1003} PHYSICAL PLANT STANDARDS SS=D Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced. 58A-5.023(1)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 21366 Based on observation and interview, the facility failed to maintain a clean, safe environment as evidericad by missing floor tiles and bulging, . water stained ceiling tile. Failure to replace AHCA Form:3020-0007 STATE FORM 809 QLoT+41 If continuation sheet 2 of 4 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY AND PLAN OF CORRECTION om (IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING Cc B. WING AL11932557 07/08/2010 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES I PROVIDER'S PLAN OF CORRECTION (X8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 2 missing ceiling and/or floor tiles has the potential to be a hazard for the residents. Findings: During a tour of the facility at approximately 10:00AM it was observed that the bathroom located at the back of the facility, and shared by several residents, had missing tiles from the baseboard. The shower room attached to the same bathroom was observed to have a wet face cloth, a bar of soap, a leaf and the shower head was on the floor. Room 2 had a dead bug on the floor. An interview with an employee who was cleaning the room at the time of the tour, revealed that "there are a few bugs here and there, | know they spray twice a month". During the entrance interview with the Administrator on 07/08/10 at 9:00AM there were two dead cockroaches observed under a desk, there was also a hornet between the window and window blinds. The administrator stated that the facility is treated twice a month for bugs, The first treatment encompasses the entire facility while the second treatment is for the kitchen area only. A telephone interview was conducted with the owner at 9:30 AM and a request for a copy of the contract with the exterminating company was made and provided, Class Il Correction Date: 7/8/2010 AHCA Form 3020-0001 STATE FORM anne QLOT1i If continuation sheet 3 of 4 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES - |(X1) PROVIDER/SUPPLIER/CLIA TION (X8) DATE SURVEY AND PLAN OF CORRECTION Me ENTIFICATION NUMBER: Dey irre Gonsvat COMPLETED A. BUILDING Cc AL11932587 8 WING —_____——— 07/08/2010 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 &, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES i PROVIDER'S PLAN OF CORRECTION (X8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE “TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO: THE APPROPRIATE OATE DEFICIENCY) Continued From page 3 PHYSICAL PLANT STANDARDS All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. 88A-5.023(1)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 21366 Based on observation, the facility failed to maintain the facility clean. Failure to maintain a clean facility may result in reducing the residents’ self-esteem and self-worth. Findings: During the tour of the facility on 07/08/10 commencing at 10:00 AM revealed the kitchen has a small sink that had a white residue in it and on the surrounding counter. There were paint supplies on top and under the sink. It was also observed that the stove and the plumbing connected to it had a buildup of grease and dust. The staircase leading to the upper floor of the 1 facility had a buildup up of dust and dirt on every step. Class: Ill Correction Date: 08/08/10 AHCA Form 3020-0001 : STATE FORM 0809 QLoT11 if continuation sheet 4 of 4 Exhibit “G” PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDERISUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION Oe OENTIFICATION NUMBERE (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING 8. WING AL11932557 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) SG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A000) INITIAL COMMENTS Surveyor: 26868 An unannounced Biennial Licensure survey was conducted on 9/2-9/3/2009. The facility was not in compliance with Chapter 429, Part |, Florida Statutes and 58A-5 Florida Administrative Code. A200] FACILITY RECORDS STANDARDS SS=D . ’ - | The facility shall maintain written facility records in a form, place and system ordinarily employed in good business practice and accessible to Department of Elder Affairs and Agency staff. 429,41(1)(e), F.S. §8A-5.024, F.AC. This STANDARD is not met as evidenced by: Surveyor: 26868 Based on observation and interview, it was determined that the facility staff failed to ensure that the Agency had access to facility records when requested. Failure to ensure that the Agency staff has access to facility records has the. potential to result in delays in the survey. Findings: During record review, it was noted that no record of the facility's elopement drills was present in the facility. During an interview with Employee # 1 conducted on 9/3/2009 at 7:55 AM, it was noted that the record of elopement drills was at the Administrator's home and not available for review AHCA Form 3020-0001 TITLE {(X6) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM anee KNOF414 IF continuation sheat.1 of 13 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY AND PLAN OF CORRECTION a IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED A, BUILDING B. WING : AL11932557 ‘09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 G CROSS-REFERENCED TO THE APPROPRIATE DATE j DEFICIENCY) Continued From page 1 at the time of the survey. Class I! Correction date: 10/3/2009 FACILITY RECORDS STANDARDS An up-to-date admission and discharge log must be maintained listing the names of all residents and each resident's: 1. Date of admission; 2. Place from which the resident was admitted; 3. Admission with a stage 2 pressure sore, if applicable; 4. Date of discharge; 5. Reason for discharge; 6. The facility to which the resident is discharged or home address, or if the person is deceased, the date of death. 429.41(1)(e), F.S. 58A-5.024(1)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 26868 Based on record review and interview, it was determined that the facility failed to ensure that an up-to-date admission and discharge log was present. Failure to maintain an up-to-date admission and discharge log has the potential to result In confusion in the event of an emergency. FINDINGS: During review of the admission and discharge log, it was noted that 37 residents were residing in the facility. Further record review revealed that AHCA Form 3020-0001 STATE FORM a 8899 KNOF11 I continuation sheet 2 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION ™) IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED AL11932557 ; 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE _ | EUSTIS, FL 32726 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION (6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE Tac | REGULATORY OR LSC IDENTIFYING INFORMATION) GROS$-REFERENCED TO THE APPROPRIATE DATE { DEFICIENCY) i Continued From page 2 one resident listed on the admission and discharge log was deceased, and no date of discharge was listed. Continued review revealed another resident had a date discharge but no reason for discharge. During an interview with the administrator conducted on 9/2/2009 at 1:45 PM, it was noted that 36 residents were in the facility at the time of the survey Class III Correction date: 10/3/2009 ADMISSIONS CRITERIA STANDARDS Medical examinations completed after the admission of the resident to the facility must be completed within 30 days of the date of admission and must be recorded on the Resident Health Assessment for Assisted Living Facilities, AHCA Form 1823, January 2008. 58A-5.0181(2)(b), F.A.C, This STANDARD is not met as evidenced by: | Surveyor: 21366 Based on record review and interview it was determined that the facility failed to ensure resident's had Medical examinations completed with in 30 days of admissions for three of ten (#1, #2, and #5) residents’ records reviewed. The i facility also failed to ensure they obtained . | ompleted health assessments for two (#3 and AHCA Form 3020-0001 STATE FORM . 6899 KNOF11 If continuation sheet 3 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING AL11932557 B WING 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ip PROVIDER'S PLAN OF CORRECTION PREFIX (BACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE ' DEFICIENCY) A418| Continued From page 3 #4) of ten residents’ records reviewed. Failure to obtain completed health assessments may result in residents’ needs not being met by the facility. Findings: Review of resident #1's record revealed the resident was admitted into the facility on 8/1/08. Review of resident #2's record revealed the resident was admitted into the facility on 10/15/08. Review of resident #5's record revealed the resident was admitted in to the facility on 1/5/08 Further review of resident #1's, #2's and #5's record failed to reveal a health assessment | conducted within 30 days of admissions. During an interview with the Administrator at 9:10 AM on September 2, 2009 it was revealed that he/she was aware that the health assessments were missing. He/she stated she called the doctor's office and asked to have them faxed. Review of resident records revealed resident's #3 And #4 had incomplete Health Assessments. Resident # 4 is missing Known Allergies and admission height and weight. Resident #3 is missing Known Allergies. Class Il Correction date: 10/3/2009 RESIDENT CARE STANDARDS The facility will comply with the Resident's Bill of Rights. AHCA Form 3020-0001 STATE FORM 6299 KNOF11 If continuation sheet 4 of 13 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA on (X3) DATE SURVEY AND PLAN OF CORRECTION aE ldtctich petted (X2) MULTIPLE CONSTRUCT COMPLETED A. BUILDING B. WING Al.11932557 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL. 32726 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES I ; PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 4 429,28(1), F.S. This STANDARD is not met as evidenced by: Surveyor: 21366 Based on record review and interview the facility failed to observe the residents Bill of Rights. Failure to adhere to a resident's rights has the potential for dectine in the resident psychosocial well being. | Findings: { Review of the provider's "House Rules” revealed item #3 stating: " All residents must assist with personal hygiene, when personal tells you its time for your shower your must take it." During an interview with the administrator on 9/3/2009 at 9:35 a.m. revealed he/she knew that the house rule "sounds like a violation of rights" but that the resident's can refuse to take their shower and schedule another time. Class ll Correction date: 10/3/2009 PHYSICAL PLANT STANDARDS Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or replaced, 58A-5.023(1)(b), F.A.C. ; This STANDARD is not met as evidenced by: AHCA Form 3020-0001 STATE FORM aoe KNOF11 It continuation sheet 5 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X14} PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION oy IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING B. WING AL11932557 TT 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 opin | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE Tag! REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE .: DATE ; DEFICIENCY) ! Continued Fram page 5 Surveyor: 26868 Based on observation and interview, it was determined that the facility staff failed to ensure that repairs conducted at the facility were neat, clean, and hazard free. Failure to routinely and skillfully maintain the physical plant has the potential to result in reduced psychosocial wellbeing of the residents. FINDINGS; 1) During the initial tour of the facility, on 9/2/09 at 9:15 AM, it was observed that part of the floorboards were missing near the common sitting room near the kitchen and the area where medications are distributed. The area where the floorboards were missing was approximately 4 inches wide by 12 inches long. During an interview with Employee # 1, conducted on 9/3/2009 at 9:15 AM, Employee # 1 said that they were aware that the floorboard needed to be fixed near the kitchen and where | the medications were being distributed. | 2) Near room # 4, it was noted that the wall had | been covered with drywall plaster and no paint \ covered the areas where paint was missing. | Further observations revealed those areas were | approximately 24 inches long by 12 inches wide. Also noted was that the trim around the door was missing, leaving an area that appeared to be in disrepair. During an interview with Employee # 1, conducted on 9/2/2009 at 9:15 AM, Employee # 1 said that they were aware that the drywail needed repair and said that repairs at the facility were ongoing. AHCA Form 3020-00014 . STATE FORM 6808 KNOF11 continuation sheet 6 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X14) PROVIDERISUPPLIERICLIA (X3) DATE SURVEY AND FLAN OF CORRECTION *) IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED . AL11932557 : OOO 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HENDERSON HOUSE EUeTig Fo sere (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID * PROVIDER'S PLAN OF CORRECTION (x5) PREFIX. (EACH DEFICIENCY MUST. BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ‘AG . CROSS-REFERENCED ane APPROPRIATE DATE i DEFICIENCY) A 003 Continued From page 6 3) The bathroom floor grout near raom # 4 was discolored and soiled. The area around the toilet base was missing several floor tiles. During an interview with Employee # 1, conducted on 9/2/2009 at 9:20 AM, Employee #1 said that they were aware that the bathroom needed repair and said that repairs at the facility were ongoing. 4) The floor near room # 16 was in disrepair near the door hinge. The area of the floor was missing several layers of floor tile, and the door did not open or close easily as a result of the disrepair. During an interview with Employee # 1, conducted on 9/2/2009 at 9:25 AM, Employee # 1 said that they were aware that the floorboards needed repair and said that repairs at the facility } were ongoing. Class III Correction date: 10/3/2009 PHYSICAL PLANT STANDARDS. Windows, doors, plumbing, and appliances shall be functional and in good working order. 58A-5.023(1)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 26868 Based on observation and interview, the facility failed to ensure all doors and windows were _| functional and in good repair. Failure to.ensure doors and windows are functional and in good AHCA Form 3020-0001 . STATE FORM - see KNOF11 If continuation sheet 7 of 12 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Gare Administration STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA IULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION Oe PO RINTIFIGATION NUMBER 02) i" Ne COMPLETED "TA BUILD AL11932887 8 WING _£_ 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION : (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE “TAG REGULATORY OR LSC IDENTIFYING INFORMATION) . CROSS-REFERENCED TO THE APPROPRIATE DATE - DEFICIENCY) A1004| Continued From page 7 repair may result in an accident and injury to the resident. Findings: Tour of the facility on 9/2/09 at 9:15 AM revealed the following concerns: 1. The closet doors in room # 21 were off of the tracks. The doors, which were the full size folding type, were observed to be leaning up against the closet and could not be easily moved by the residents of the room if they wanted to access the clothing in the closets. During an interview with Employee # 1, conducted on 9/2/2009 at 9:35 AM, Employee # 1 said that repairs at the facility were ongoing. 2. The window sill on the second floor across from the stairway was dusty, dirty, and had a layer of accumulated dirt. During an interview with Employee # 1, conducted on 9/2/2009 at 9:40 AM, Employee #.1 said that repairs at the facility were ongoing. 3. On the exterior of the facility on the south side of the home, near the walkway between the front of the home and the driveway in the back of the home was an access way to underneath the home. That access way was approximately two feet wide by two feet tall and appeared to have been covered at one time. At the time of the survey, the access way was not covered, which left the area exposed to resident access, and possibly to pests and rodents. During an interview with Employee #7, conducted on 9/3/2009 at 12:35.PM, it was noted that the AHCA Form 3020-0001 STATE FORM cd KNOF11 if continuation sheet 8 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION i) IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION COMPLETED A. BUILDING _— AL11932557 8 WANG eran 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP. CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32728 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X8) PREFIX | (EACH DEFICIENCY MUST BE PREGEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG > REGULATORY OR LSC IDENTIFYING INFORMATION) : CROSS-REFERENCED TO THE APPROPRIATE DATE j DEFICIENCY) A1004| Continued From page 8 access way door had been recently removed by the plumber in order to fix the pipes. Further interview revealed that the pipe work had been completed but the access way door was never reinstalled. Class III Correction date: 10/3/2009 A1005) PHYSICAL PLANT STANDARDS SS=D! ! All furniture and furnishings shall be clean, ; functional, free-of-odors, and in good repair. ; 58A-5.023(1)(b), FA.C. 4 | This STANDARD is not met as evidenced by: Surveyor: 26868 Based on observation and interview, it was determined that the facility staff failed to ensure that each resident had furniture that was clean and in good repair. Failure to ensure that each | resident has furniture that is clean and In good | repair has the potential to result in reduced psychosocial wellbeing. FINDINGS: 1. During observations conducted at the facility, it was noted that the beige leatherette coach in the sitting room near the kitchen had a conspicuous area on the right arm of the couch where the leatherette was missing. The area of missing leatherette was approximately five inches wide by four inches long. An interview conducted with employee # 7 on 9/3/2009 at 11:35 AM revealed that the staff was aware that the couch had some missing AHGA Form 3020-0001 , STATE FORM eno8 KNOF14 If continuation sheet 9 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X41) PROVIDER/SUPPLIERICLIA 2) MULTI RUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION ‘ IDENTIFICATION NUMBER: ; ) MULTIPLE CONST COMPLETED . BUILDING AL41932587 B.WING —__________— 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (xa) 1D SUMMARY STATEMENT OF DEFICIENCIES 1 ‘ PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL } {EACH CORRECTIVE ACTION SHOULD BE 1 COMPLETE “TAG I REGULATORY OR LSC IDENTIFYING INFORMATION) iy i CROSS-REFERENCED TO THE APPROPRIATE jj DATE - i DEFICIENCY) Continued From page 9 leatherette and that the facility staff was planning to replace the furniture soon. 2. During the initial tour of the facility conducted 1 on 9/2/2009 at 9:15 AM, it was noted that room # | 1 had a strong odor of urine. It was noted that the | room had two residents who lived in the room at the time of the survey. Further observations conducted revealed no clear source of the odor. During follow-up observations conducted on 9/2/2009 at 2:45 PM, the same strong urine odor was present in room # 1. It was noted again that no source of the odor was able to be clearly discerned. During an interview with Employee # 6, observations of the both residents belongings revealed no source for the odor. During continued interview with Employee # 6, it was noted that a ! previous resident of room # 1 was routinely incontinent and that urine was soaked into the floor, especially into the tiles in the restroom. 3. Two of three of the light bulbs in the bathroom | near room # 20 were inoperative. When the light was turned on, one bulb lit the room, but not with | enough light to adequately provide illumination ; throughout the room. : During an interview with Employee # 1, | conducted on 9/2/2009 at 9:30 AM, Ernployee # 1 said that they were aware that the facility was in need of repairs and that they were ongoing. 4. There was a missing vent cover in room # 17 in the ceiling. Further observations revealed that area where the vent was missing was approximately 10 inches in diameter. During an interview with Employee # 1, AHCA Form 3020-000 STATE FORM eae0 KNOF14 If continuation sheet 10 of 43 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration (X3) DATE SURVEY STATEMENT OF DEFICIENCIES X1) PROVIDERS CLA (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION COMPLE TSO AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AL11932657 ao OOO 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (xayID- | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5) PREFIX (EAGH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE tac |. REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENGED TO THE APPROPRIATE |. DATE DEFICIENCY) Continued From page 10 conducted on 9/3/2009 at 8:35 AM, Employee # 1 did not provide a clear explanation for why the ‘ vent was missing a cover in the ceiling of room # 17. During an interview with Employee # 7 that was conducted on 9/3/2009 at 12:40 PM, it was noted that the vent was to an ald air conditioning duct and that covers of that size were no longer available for purchase. Employee # 7 indicated that they would find a way to cover the opening ! sometime soon, i | Class III Correction date: 10/3/2009 PHYSICAL PLANT STANDARDS Facilities shall make available linens and personal laundry services for residents who require such services, Linens provided by a facility shall be free of tears, stains, and not | threadbare. i $8A-5,023(6), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 26868 | Based on observation and interview, the facility ‘ failed to ensure the linens were clean and in good condition. Failure to provide residents with linens that are clean and in-good condition may result in the spread of infections or diseases. AHCA Form 3020-0001 STATE FORM a9e8 KNOF11— if continuation sheet 11 of 13 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA ULTIPLE 0 ~ | (%8) DATE SURVEY AND PLAN OF CORRECTION “ IDENTIFICATION NUMBER: ae none CONSTRUCTION COMPLETED AL11932587 8. WING —_____~___—— 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HENDERSON HOUSE fusris he sare (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID i PROVIDER'S PLAN OF CORRECTION PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE ‘TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i TAG CROSS-REFERENCED TO THE APPROPRIATE i : DEFICIENCY) Continued From page 12 the administrator obtained at least 2 hours of continuing education in topics pertaining to ‘ nutrition and food service in the facility. FINDINGS: During a record review conducted at the facility, it was noted that the administrator's record did not have evidence of the completion of a minimum of 2 hours of continuing education in topics pertaining to nutrition and food service in the facility. During an interview with Employee # 1, conducted on 9/3/2009 at 8:15 AM, it was noted that the last dietary In-service attended by any facility staff member was 9/9/2007. Class III Correction date: 10/3/2009 AHCA Form 3020-0001 STATE FORM e800 KNOF11 If continuation sheet 13 of 13 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA {X3) DATE SURVEY AND PLAN OF CORRECTION on IDENTIFICATION NUMBER: taULDNG CONSTRUCTION COMPLETED AL11932587 8. WING 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HENDERSON HOUSE euSTig, FL arse (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF GORRECTION x8) PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL (GACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) INITIAL COMMENTS Surveyor: 26868 A Limited Mental Health Services survey was conducted concurrently with the unannounced Biennial Licensure survey on 9/2-9/3/2009. The facility was not in compliance with Chapter 429, Part |, Florida Statutes and 58A-5, Florida Administrative Code. COMMUNITY LIVING SUPPORT PLAN Each limited mental health resident is covered by a community living support plan and the plan is on file in the facility. $. 429.075(3)(a), F.S. a. The community !iving support plan is completed within 30 days of admission or within 30 days of receiving the mental health appropriate placement assessment whichever is later, 68A:8,029(2)(¢)3.a., F.A.C. b. The community living support plan is developed in consultation with the ALF { administrator or designee, mental health resident, and the resident's mental health case manager. s. 429,02(8), F.S. This STANDARD is not met as evidenced by: Surveyor: 26868 Based on record review and interview, it was determined that the facility staff failed to ensure that 3 of 3 residents (Residents # 4, #6, & # 10) who received limited mental health (LMH) services at the facility had a community living AHCA Form 3020-0001 TITLE (X6) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE : STATE FORM - ~ 8808 KNOF11 Ifcontinuation sheet 1 of 3 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X14) PROVIDER/SUPPLIER/CLI. (X3} DATE SURVEY AND PLAN OF CORRECTION mm IDENTIFICATION NUMoER (X2) MULTIPLE CONSTRUCTION COMPLETED A, BUILDING AL11932557 BL WING 09/03/2009 NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE ‘ 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 : (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) G CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 1 support plan that was completed within 30 days of admission. Failure to ensure that a community living support plan Is in piace for residents has the potential to result in residents not receiving necessary care and services. Findings: During record review, it was noted that Residents #4, #6, & #10 did not have a community living support plan in their resident record. During an interview with employee # 1 conducted on 9/2/2009 at 10:45 AM, it was confirmed that no community support plans were present for Residents # 4, #6, and # 10. During another interview conducted on 9/2/2009 at 1:55 PM, Employee # 1 said that the lack of community support plans in Resident # 4, #6, & # 10's chart was “an oversight." Class Ill Correction date: 10/3/2009 COOPERATIVE AGREEMENT Each mental health resident has a cooperative agreement prepared by the mental health provider and ALF administrator or designee. s, 429.075(3)(a), F.S. 58A-5,029(2)(c)4., F.A.C. This STANDARD is not met as evidenced by: Surveyor: 26868 Based on record review and interview, it was determined that the facility staff failed to ensure that a cooperative agreement between a mental ; health provider and the assisted living facility's AHICA Form 3020-0001 STATE FORM 2690 KNOF11 If continuation sheet 2 of 3 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES <4) PROVIDERISUPPLIER/CLIA } . (X3) DATE SURVEY AND PLAN OF CORRECTION oo) IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED . : A. BUILDING AL11932557 > {8 WING __________. 09/03/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HENDERSON HOUSE uene rz (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE Tas: | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE OEFICIENCY) L300] Continued From page 2 | (ALF) administrator was present. Failure to | ensure that a cooperative agreement is present | has the potential to result in needed services not \ being provided in the event of an emergency. Findings: | During record review, it was noted that no { cooperative agreement prepared by the mental | health provided and the ALF administrator or designee was present. During an interview with employee # 1 conducted , on 9/2/2009 at 10:15 AM, it was noted that no i such agreement was present. Employee # 1 stated that they "were not aware of such a requirement." Class tll ' Correction date: 10/3/2009 AHCA Form 3020-0004 STATE FORM ene KNOF14 If continuation sheet 3 of 3 PRINTED: 10/12/2010 . FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES —_| «x1) PROVIDER/SUPPLIER/CLIA (x3) DATE SURVEY AND PLAN OF CORRECTION Ce RENIN TION NUMaaie {X2) MULTIPLE CONSTRUCTION COMPLETED AL11932557 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION H (X85) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION. SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ° CROSS-REFERENCED TO THE APPROPRIATE OATE DEFICIENCY) N00) INITIAL COMMENTS Surveyor: 21366 An unannounced Limited Nursing Service Survey was conducted in conjunction with the Biennial Licensure survey on September 2-3, 2009. Deficiencies were identified during the course of the survey. The facility is not in compliance with Chapter 429, Part 1, Florida Statutes and 58A-5 Florida Administrative Code. STAFFING STANDARDS Facilities licensed to provide limited nursing services must employ or contract with a nurse(s) who shall be available to provide such services as needed by residents. 58A-5.031(2)(d), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 21366 Based on interview and review of the facilities current Limited Nursing Services (L.NS) contract revealed that the facility failed to employ or contract with a registered nurse or health care professional that provides supervision to staff providing limited nursing services. Findings: During the review of the agreement entered into 1 on August 1, 2009 with Lake View Nutrition ; Consulting Services, inc d/b/a Henderson House i ALF it was discovered that the facility has | contracted with an Licensed Practical Nurse. Interview with the Administrator at 8:20 AM on 9/3/09 revealed that she was not aware that a Registered Nurse was required to supervise the implementation of Limited Nursing Services. AHCA Form 3020-0001 TITLE (X6) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM | 6000 ~ KNOF11 - 7 if continuation sheet 4 of 2 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA {X3) DATE SURVEY AND PLAN OF CORRECTION Oe ORNTIBICATION NUMBER (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING B. WING AL41932557 ’ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32728 09/03/2009 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF GORRECTION ' (X8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | Continued From page 1 Administrator stated that the facility has never used its LNS license. Class III Correction Date: 10/3/2009 AHCA Form 3020-0001 STATE FORM 8809 KNOF11 If continuation sheet 2 of 2 Exhibit “H” STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE (X4) ID PREFIX TAG AHCA Form 3020-0001 AL11932557 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PREGEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) INITIAL COMMENTS Surveyor: 17843 Unannounced complaint investigations, CCR# 2008003586 and CCR# 2008003633 were conducted on 03/27/08. Deficiencies were identified at the time of the survey. Facility was not in compliance with Ch. 429, Part |, F.S. and Ch. 58A-5, F.A.C. MEDICATION STANDARDS Any change in directions for use of a medication for which the facility is providing assistance with self-administration or administering medication must be accompanied by a written medication order issued and signed by the resident's health care provider, or a faxed copy of such order. New directions for use of a medication must promptly be recorded in the resident's medication observation record. 58A-5.0185(7)(d), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 17843 Based on medical record review and interview the facility failed to ensure that there was a written medication order issued and signed by the resident's health care provider in the medical record for 1 (#1) of 4 sampled residents, who had a medication change. Failure to accurately document the change of medication has the PRINTED: 10/42/2010 FORM APPROVED (X3) DATE SURVEY {X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING C 8 WING 03/27/2008 STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE EUSTIS, FL 32726 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM sen0 M30V11— (Fcontinuation sheet 1 of 7 STATEMENT OF DEFICIENCIES AND PLAN OF GORRECTION NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE (X4) ID PREFIX TAG (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: AL11932557 | (82) MULTIPLE CONSTRUCTION 907 E. ORANGE AVENUE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 potential of a resident not receiving medication as ordered by the physician. Findings: Resident #1's Medical record revealed a Resident Health Assessment for Assisted Living Facilities (ALF) [Form 1823] that was undated, but was faxed to the facility on 07/19/04. On this 1823 there were two medications listed for resident #1. On the current 1823 dated 02/06/07 there are no medications listed. Across the area where medications are to be listed is a note to “see MARS" (medication administration records). The Medication Observation Record (MOR) dated 03/01/08 - 03/31/08 documents 3 medications, two are noted as being discontinued on 12/31/08, The 2 discontinued medications (Eldephryl and Abilify) are the medications from the initial 1823. The third medication is Levoxyl, which the resident was receiving daily until hospitalization. There was no order in the medical record for this change in medication. Interview with the Administrator revealed that the prescriptions for medications are taken or sent to the pharmacy. The facility does not always keep a copy of the prescriptions. Class III . Correction Date: 04/27/08 RESIDENT CARE STANDARDS Contacts the resident's health care provider and other appropriate party such as the resident's family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case manager EUSTIS, FL 32726 CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 10/12/2010 FORM APPROVED (X38) DATE SURVEY COMPLETED Cc . 03/27/2008 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE {X5) COMPLETE DATE OEFICIENCY) AHA Form 3020-0007 STATE FORM ean M39Vvi1 Mf continuation sheet 2 of 7 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE (x4) (D PREFIX TAG (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: AL11932557 PRINTED: 10/12/2010 FORM APPROVED {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 03/27/2008 STREET ADDRESS, CITY, STATE, ZIP CODE 907 FE. ORANGE AVENUE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 if the resident is discharged or moves out. 58A5.0182(1){d), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 17843 Based on record review and interview the facility failed to document that the health care provider and resident's family were notified after 3 residents (#1, #2, and #3) had a change in condition. Failure to notify the health care provider and resident's family of change in condition has the potential of a severe adverse outcome for the resident. Findings: 1. Resident #1 was currently at a rehabilitation facility and his/her bed was on hold pending the resident's return. Interview with the Administrator at 12:50 PM on 03/27/08 revealed that she had been to the rehabilitation facility and assessed the resident for return. Review of the 24 Hour Communication Log for Resident #1 revealed no documentation of a health status change event or documentation of notification of the resident's physician or responsible party of a health status changing. The 24 hour Communication Log documentation stated: “3/8/08: 3 - 11 [shift]: 90% meds [medications] Js" "3/14/08: 3 - 11 [shift]: Hospital JS” "3/14/08: 11 - 7 [shift]: Hospital LG" On 3/17/08 the documentation changes to AHCA Form 3020-0001 STATE FORM EUSTIS, FL 32726 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) oen9 M39Vi1 Ye) COMPLETE DATE IF continuation sheat 3 of 7 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION Oe TR ATIPLEATION NUMBGEe (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING Cc 8. WING AL11932557 03/27/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL. 32726 (X4) ID; SUMMARY STATEMENT OF DEFICIENCIES te) PROVIDER'S PLAN OF GORRECTION i (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE : DEFICIENCY) Continued From page 3 | "Nursing Home" and is repeated for 3/18/08, 03/20/08, 03/24/08, and 03/25/08. 2. According to a letter dated 02/01/08, in resident #2's record, from his/her Medicaid Waiver case management company had not been in the facility since 01/31/08. The 24 hour Communication Log documentation stated: "4/27/08: 3 - 11 [shift]: 100% meds LW" "2/1/08: 3 - 3 [shift]: Hospital HP" The documentation oh " hospital ” continues on 3/2, 3/3, 3/4, 3/6, 3/7, and 3/8, Below the documentation of 03/8/08 is the word "discharge" with no date or time. The 24 Hour Communication Log for Resident #2 revealed no documentation of a health status change event or documentation of notification of the resident's physician or responsible party of a health status changing event. 3. According to an Adverse Incident report dated 01/14/08, resident #3 had a fall and injured his/her left hip. The 24 hour Communication Log documentation stated: "4/14/08: 7 - 3 [shift]; 100% meds JA" "41/16/08: 3 - 11 [shift]: care home [at] 7:30 pm had meds L' "4/22/08; 3 - 11 [shift]; 100% meds LW". There was an additional document from the Medical Examiner's Office dated 01/25/08 asking for additional documentation from the resident's falt and death. The 24 Hour The 24 Hour Communication Log for Resident #3 revealed no documentation of health status change events or documentation of notification of the resident's physician or responsible party of health status changing events. AHCA Form 3020-0001 STATE FORM nog M39V14 {f continuation sheet 4 of 7 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE {(X4) 10 PREFIX TAG (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: AL11932557 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Interview with the Administrator on 03/27/08 at 2:00 PM revealed that the staff chart if they are out of the facility and when they come back usually, but the staff usually do not chart. They should chart more. Class tll Correction Date: 04/27/08 RESIDENT CARE STANDARDS Facilities maintain a written record, updated as needed, of any significant changes, any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. 58A-5.0182(1)(@),F.A.C. This STANDARD is not met as evidenced by: Surveyor: 17843 Based on record review and interview the facility failed to document the occurrence of a change in condition of 3 (#1, #2, and #3) of 4 sampled residents. Failure to document the changes in the resident's condition has the potential for the resident not reaching or maintaining the highest level of physical and emotional well-being. Findings: 41. Resident #1 was currently at a rehabilitation facility and his/her bed was on hold pending the resident ‘ s return. AHCA Form 3020-0001 STATE FORM (X2) MULTIPLE CONSTRUCTION M39V14 PRINTED: 10/12/2010 FORM APPROVED (X83) DATE SURVEY COMPLETED Cc 03/27/2008 STREET AODRESS, CITY,. STATE, ZIP CODE 907 E. ORANGE AVENUE EUSTIS, FL 32726 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENGED TO THE APPROPRIATE DEFICIENCY) if continuation sheet 5 of 7 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES x1) PROVIDERISUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION x IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED Cc AL11932557 : nA 03/27/2008 NAME OF PROVIDER OR SUPPLIER : STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE GOMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | Continued From page 5 | Interview with the Administrator at 12:50 PM on | 03/27/08 revealed that she had been to the ! rehabilitation facility and assessed the resident for return. | Review of the 24 Hour Communication Log for | Resident #1 revealed no documentation of a health status change event or documentation of notification of the resident's physician or responsible party of a health status changing: The 24 hour Communication Log documentation stated: t "3/8/08: 3 - 11 [shift]: 90% meds [medications] i Js” | "3/14/08: 3 - 14 [shift]: Hospital JS" "3/14/08: 11 - 7 [shift]: Hospital LG" On 3/17/08 the documentation changes to “Nursing Home" and is repeated for 3/18/08, 03/20/08, 03/24/08, and 03/25/08. | 2. According to a letter dated 02/01/08, in resident #2's record, from his/her Medicaid Waiver case management company had not been in the facility since 01/31/08. The 24 hour Communication Log documentation stated: "4/27/08: 3 - 11 [shift]: 100% meds LW" "2/1108: 3 - 3 [shift]: Hospital HP" The documentation oh " hospital" continues on 3/2, 3/3, 3/4, 3/6, 3/7, and 3/8. Below the documentation of 03/8/08 is the word "discharge" with no date or time. The 24 Hour Communication Log for Resident #2 revealed no documentation of a health status change event or documentation of notification of the resident's _ physician or responsible party of a health status changing event. 3. According to an Adverse Incident report dated 01/14/08, resident #3 had a fall and injured his/her left hip. . AHCA Form 3020-0001 : STATE FORM bd M39V11 if continuation sheet 6 of 7 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA {X3) DATE SURVEY AND PLAN OF GORREGTION TIFICATION NURpere (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING C B. WING AL11932557 03/27/2008 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 807 E, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL. 32726 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING (INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 6 The 24 hour Communication Log documentation stated: "4/14/08: 7 - 3 [shift]: 100% meds JA" "4/16/08: 3 ~ 11 [shift]: came home [at] 7:30 pm had meds LW" "4/22/08: 3 - 11 [shift]: 100% meds LW” There was an additional document from the Medical Examiner's Office dated 01/25/08 asking for additional documentation from the resident's fall and death. The 24 Hour The 24 Hour Communication Log for Resident #3 revealed no documentation of health status change events or documentation of notification of the resident's physician or responsible party of health status changing events. | Interview with the Administrator on 03/27/08 at 2:00 PM revealed that the staff chart if they are out of the facility and when they come back usually, but the staff usually do not chart. They should chart more. Class Ill Correction Date: 04/27/08 AHCA Form 3020-0001 - : STATE FORM 6600 M39V114 Ifconlinuation sheet 7 of 7 Exhibit “I” PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X14) PROVIDERISUPPLIERICLIA TION (X3) DATE SURVEY AND PLAN OF CORRECTION ail IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUC COMPLETED . A. BUILDING _| 8. wing AL11932557 NAME OF PROVIDER OR SUPPLIER : STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32736 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1 PROVIDER'S PLAN OF GORRECTION 1 (xey PREFIX (EAGH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) INITIAL COMMENTS Surveyor: 09560 The Biennial Licensure survey was conducted on 8/6-7/07 to determine the facility compliance with Chapter 429, Part I, Florida Statutes and Chapter 58A-5, Florida Administrative Cade. The facility was not in substantial compliance. FISCAL STANDARDS A facility whose owner, administrator, or staff, or representative thereof, servas as the representative payee or attorney-in-fact for facility residents, must maintain a surety bond, a copy of which shall be filed with the agency. Upon the annual issuance of a new bond or continuation bond the facility shall file a copy of the bond with the AHCA central office. | 429.27(2), F.S. | This STANDARD is not met as evidenced by: Surveyor: 09560 Based on record review and interview the facility failed to purchase a surety bond for 1 (#5) of 3 residents who they are representative payee for. This has a potential to place the residents at risk of a financial dectine. Finding: Review of Resident #5 financial record revealed the facillty applied for representative payee for “| the resident on June 11, 2007. AHCA Form 3020-0001 TITLE . (X6) DATE. ~ LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER. REPRESENTATIVE'S SIGNATURE te pte ett STATE FORM Le ° step 34BX11 . we Kf continuation sheet 1 of 14 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES %1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION mH) {DENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED AL11932557 : _ 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (44) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE | DEFICIENCY) Continued From page 1 During the interview with the business consultant on 8/7/07 at 9:30 am, he stated that the facility did not have a surety bond, because he was not aware of the facility's status of representative payee. Class Ill Correction Date: 9/7/07 Facility Records Standards The facility conducts a minimum of two resident elopement prevention and response drills per year. 429.41(1)(a)3., F.S. 429.44(1)(I), FS. 5BA-5.0182(8)(c), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Based on facility record review and interview, the facility failed to ensure that staff received a minimum of 2 resident elopement prevention and response drills per year. This has a potential to delay the response time in locating residents who elope from the facility. Finding: Review of the facility's elopement drills for 2006, revealed the facility has conducted only 4 drill (10/19/06) for the year. The administrator did not respond on 8/6/07 at 9:00 am to the question when asked for the second elopement drill documentation. AHCA Form 3020-0001 : : STATE FORM 4899 34BX11 tf continuation sheet 2 of 14 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION a IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING AL11932557 8 WING 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ‘ 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION ! (X5) PREFIX (EAGH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TA CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 2 Class Ill Correction Date: 8/7/07 RESIDENT RECORDS STANDARDS if a resident is an OSS recipient the resident record must contain a copy of Alternate Care Certification for Optional State Supplementation (OSS) Form, CF-ES 1006, March 1998. 5B8A-5,024(3)(I), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Based on resident record review and interview, the facility failed to ensure that 3 (#3,4,5) of 3 residents receiving Optional State Supplementation (OSS) Form , CF-ES 1006 was in their files. In the event of facility closure failure to have the required form may place the residents at risk financial harm. Finding: Review of Resident #3,4 &5 clinical record, revealed the required OSS Form, CF-ES 10006 was not in their records. During the interview with the assistant administrator on 8/7/07 at 2:30 pm, she stated that she was not aware that the forms were required. Class II! Correction Date: 9/7/09 AHCA Form 3020-0001 . : STATE FORM ae 34BX11 {ftcontinuation sheet 3 of 14 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration “ STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA TION (063) DATE SURVEY AND PLAN OF CORRECTION all IDENTIFICATION NUMBER: (x2) MULTIPLE CONSTRUC COMPLETED A, BUILDING B. WING. AL11932557 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION ' (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE ; COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE OATE DEFICIENCY) Continued From page 3 STAFFING STANDARDS The administrator shall participate in 12 hours of continuing education in topics related to assisted living every 2 years, $.429,52(4),F.S. 58A-5.0191(1)(c), F.A.C. | This STANDARD is not met as evidenced by: Surveyor: 09560 Based on personnel record review and interview the administrator failed to received the required 12 hours of continuing education in topics relating to assisted living every 2 years. Finding: Review of the administrators training file revealed she was hired in July 2001. Continued review of the file revealed that the administrator could not produce documentation of continuing education for the past 2 years. During the interview with the financial consultant on 8/7/07 at 11:00 am, he stated that the administrator attends a meeting every month and training is given at that time. He continued to state that the administrator does not document the meetings as training, nor could he produce a calendar or schedule of the meetings (the administrator was not present on the last day of the survey). Class II! Correction Date: 9/7/07 AHCA Form 3020-0001 - STATE FORM 6899 34BX11 {f continuation sheet 4 of 14 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION a IDENTIFICATION NUMBER: AL11932557 NAME OF PROVIDER OR SUPPLIER PRINTED: 10/12/2010 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A, BUILDING B. WING (X3) DATE SURVEY COMPLETED 08/07/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE HENDERSON HOUSE SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) 1D PREFIX TAG MEDICATION STANDARDS If providing assistance with self-administration of medication, staff must observe the resident take ; the medication. §8A-5.0185(3)(c), F.A.C. A trained designated staff person assists the resident to self-administer medications in the following manner: Medication, in its dispensed, properly labeled container, shall be taken from where it is stored and brought to the resident. 429,256(3)(a), F.S. Verbally prompt a resident to take medications as prescribed. 58A-5.0185(3)(b), F.A.C. In the presence of the resident, read the label, open the container, remove a prescribed amount of medication from the container, and close the container. H 429,256(3)(b), F.S. Place an oral dosage in the resident's hand or place the dosage in another container and help the resident by lifting the container to his or her mouth. 429.256(3)(c), F.S. Apply topical medications. 429.256(3)(d), F.S. AHCA Form 3020-0001 STATE FORM EUSTIS, FL 32726 PROVIDER'S PLAN OF CORRECTION (BACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE iD i PREFIX ! TAG: DEFICIENCY) 34BX11 tS) COMPLETE DATE ifcontinuation sheet Sof 14 _ PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X3) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETED (X2) MULTIPLE CONSTRUCTION iDENTIFICATION NUMBER: A. BUILDING B. WING AL11932557 08/07/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE EUSTIS, FL 32726 NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE (x4) 1D PREFIX TAG SUMMARY STATEMENT OF OEFFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE PROVIDER'S PLAN OF CORRECTION (x8) (EACH GORRECTIVE ACTION SHOULD BE COMPLETE DATI DEFICIENCY) Continued From page 5 Returning the medication container to proper storage. 429.256(3)(e), F.S. Keeping a record of when a resident receives assistance with self-administration. 429,256(3)(f), F.S. Medication which appears to have been contaminated, must not be returned to the container. 58A-5.0185(3)(b), F.A.C. | This STANDARD is not met as evidenced by: Surveyor: 09560 Based on observation, review of the medication observation record (MOR),-and interview the facility failed to ensure that staff observed 6 (1,3,6,7,8,9) of 6 residents take their medication during the assistance with self-administration of medication. This has a potential for medication errors. Finding: Observations of the self-administration of medication on 8/6/07 starting at 1:05 pm, revealed the following: 1. Resident #1 was given the Glucosamine medication in a souffle cup, staff did not offer the resident water or observe the resident take the AHCA Farm 3020-0001 STATE FORM 6899 34BX11 If continuation sheet 6 of 14 STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ° oon iG B, WIN AL11932557 ° NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HENDERSON HOUSE evetis caw PRINTED; 10/42/2010 FORM APPROVED {X3) DATE SURVEY. COMPLETED 08/07/2007 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG GROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 6 medication. 2. Resident #3 was given the Furosemide 20 mg medication in a souffle cup, staff did not offer the resident water or observe the resident take the | medication. Continued observations revealed the resident had a prescription for Saliva Solution with the directions. "squirt 1/2 teaspoon in mouth before meals”. The resident was sitting at the dining room table eating, when the staff person called the resident and told him/her to bring the teaspoon with him/her. Staff poured the medication in the teaspoon gave it to the resident, turned her back to the resident without observing the medication. The resident then went back to the table and starting eating dessert with the spoon. 3. Resident #6 was given the Tegretol 200 mg medication in a souffle cup, staff did not offer the resident water or observe the resident take the medication. 4, Resident #7 was given the Seroquel 25 mg medication in a souffle cup, staff did not offer the resident water or observe the resident take the medication. 5. Resident #8 was given the Methocarbamol 500 mg medication in a souffle cup, staff did not offer the resident water or observe the resident take the medication. 6. Resident #9 was given the Risperdal 1 mg medication in a souffle cup, staff did not offer the resident water or observe the resident take the medication. AHCA Form 3020-0001 . STATE FORM sooo 34BX11 DEFICIENCY) Ifcontinuation sheet 7 of 14 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIERICLIA (X8) DATE SURVEY AND PLAN OF CORRECTION ox) IDENTIFICATION peirirtrd (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILOING B. WING. AL11932557 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL. 32726 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES \ PROVIDER'S PLAN OF CORRECTION 1 x6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 7 Class Il Correction Date: 9/7/07 MEDICATION STANDARDS The facility must maintain a daily medication observation record (MOR) for each resident who receive assistance with self-administration of medications or medication administration. 5BA-5.0185(5)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Based on review of the medication observation record (MOR) and interview the facility failed to ensure that staff documented in the MOR when they assisted 11 (#1-#11) of 11 residents in the sample, with their medications. This has a potential for medication error. Finding: Review of the August 2007 MOR revealed that the resident caregiver assigned to assist residents with their evening medications for August 3, 2007, did not document whether or not Residents #1-#11 was assisted with their medications. During the interview with the administrator on 8/6/07 at 2:07, she stated that she was not aware of the missing documentation. Class Ill . Correction Date: 9/7/07 AHCA Forn 3020-0001 . STATE FORM 2699 34BX11 if continuation sheat 8 of 14 PRINTED: 10/42/2010 FORM APPROVED STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA (X) DATE SURVEY AND PLAN OF CORRECTION an IDENTIFICATION NUMBER: (42) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING AL11932557 BRING ener 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E, ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE : COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAL CROSS-REFERENCED TO THE APPROPRIATE —; DATE DEFICIENCY) A6z8| Continued From page 8 A 628) MEDICATION STANDARDS SS=D! | If the medication directions for use are "as | needed" or "as directed," the health care provider { must be contacted and requested to provide 1 revised instructions. | 58A-5.0185(7)(c), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Based on record review, observations, and interviews, it was determined the facility did not clarify medication directions for "as needed” (PRN) medications for 2 residents (#3 & #4) out of a sample of 11 residents. Failure to contact \ the health care provider for instructions on PRN medications usage may result in residents receiving improper dosages of medications, Findings: Review of the Medication Observation Record (MOR) for August 2007 and facility medication storage, with the assigned staff who assisted with self-administered medication at approximately 1:00 pm, revealed the following: 1. Review of Resident #3 medication revealed the resident has a prescription for Darvocet 10 mg, 1-2 tablets every 4 hours as needed for pain and a pain reliever 325 mg tab use as directed. Review of the resident's clinical record revealed the resident has a diagnosis of schizophrenia. AACA Form 3020-0007 . STATE FORM 6908 348X141 {f continuation sheet 9 of 14 PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X41) PROVIDER/SUPPLIER/CLIA Mi UCTION (43) DATE SURVEY AND PLAN OF CORRECTION ARV OATION NUMBER (X2) MULTIPLE GONSTRUGTIO COMPLETED AL11932557 : TOO 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES t PROVIDER'S PLAN OF CORRECTION 1 4x8) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL t (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) Acze| Continued From page 9 ‘ Observations of the resident throughout the { survey of 8/6-7/07 revealed the resident was : directed by staff for meals and medication, the resident is extremely hard of hearing and is ! unable to comprehend what staff is saying. 2. Review of Resident #4 medication revealed the resident has a prescription for Benadryl 25 mg kapseais, take 1-2 caps at night as needed. | Review of the resident's clinical record revealed the resident has a medical diagnosis which includes, bipolar and anxiety. 3. During the interview with staff assigned to assist residents with their medication on 8/6/07 at 1:00 pm, she stated that Resident #3 Is not always able to ask for medications. Class Ill Date of Correction: 9/7/07 MEDICATION STANDARDS Pursuant to Section 465.0276(5), F.S., and Rule 64F-12.006, F.A.C., sample or complimentary prescription drugs that are dispensed by a health care provider, must be kept in their original manufacturer ' s packaging, which must also include the practitioner ‘ s name, the resident's name for whom they were dispensed, and the date they were dispensed. If the sample or complimentary prescription drugs are not dispensed in the manufacturer ‘ s labeled package, they shall be kept in a container that bears a label containing the following: 1. Practitioner's name; 2. Resident's name; 3. Date dispensed; 4, Name and strength of the drug; AHCA Form 3020-0001 : STATE FORM 8890 34BX11 if continuation sheet 10 of 14 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES X14) PROVIDER/SUPPLIERICLIA {X3) DATE SURVEY AND PLAN OF CORRECTION ™ IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION COMPLETED AL11932557 ; TT 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE * | 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (x4) ID; SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) PREFIX | (BACH DEFICIENCY MUST BE PRECEDED BY FULL. (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG {| .REGULATORY OR LSC IDENTIFYING INFORMATION) TA GROSS-REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) Continued From page 10 5. Directions for use; and 6. Expiration date. §8A-5,0185(7)(g), F.A.C. Pursuant to Section 465.0276(2){c), F.S., before dispensing any sample or complimentary prescription drug, the resident’ s health care provider must provide the resident with a written prescription, or a fax copy of such order. 58A-5.0186(7)(h), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Based on review of medications and interview, the facility failed to ensure that 1 (#11) of 14 residents in the sample, complimentary medication included the physician's name, the date it was dispensed and a written prescription. This has a potential for medication errors. | Finding: Review of the medication cart on 8/6/07 revealed Resident #11 had a complimentary packet of Mirapex 0.125 mg. The package did not contain the physician's name or the date it was dispensed. Review of the resident record did not reveal a prescription for the medication. During the | interview with the staff person assigned to assist ‘ with self-administration of medication on 8/6/07 at 1:05 pm, she stated that she was not aware of the missing prescription. AHCA Form 3020-0001 STATE FORM Cd 34BX11 If continuation sheet 11 of 14 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETEO (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING tn B. WING AL11932557 08/07/2007 NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE EUSTIS, FL 32726 (4) ID SUMMARY STATEMENT OF DEFICIENCIES (x5) PREFIX {EAGH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) FAG CROSS-REFERENCED TO THE APPROPRIATE DATE PROVIDER'S PLAN OF CORRECTION DEFICIENCY) | Continued From page 11 Class Ill Correction Date: 9/7/07 RESIDENT CARE STANDARDS An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 58A-5.0182, F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09560 Review of resident records and interview, the : | facility failed to ensure that 1 (#3) of 11 residents in the sample received wound care as ordered by the physician. This has a potential to put the resident at risk of infections are an increase in the size of the wound, t Finding: Review of Resident #3 clinical record revealed the resident had a physician order dated 4/17/07 for wound care. Continued review of the resident's record did not reveal the required Limited Nursing Services documentation on the care of the wound. During the interview with the administrator on 8/6/07 at 3:200 pm, she stated that the facility did not provide nursing care to the resident, but instead a family cared for the wound. Continued interview with the administrator revealed the family member is not a nurse or has power of attorney for the resident. Class I! Correction Date: 9/7/07 AHCA Form 3020-0001 z STATE FORM 8890 34BX11 if continuation sheet 12 of 14 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILOING AL11932587 B. WING NAME OF PROVIDER OR SUPPLIER STREET AODRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL. 32726 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL STAFF RECORDS STANDARDS New facility staff must obtain an initial training on HIV/AIDS within 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. 429,275(2), F.S. 58A-5.0191(3), F.A.C. 58A-5.024(2)(a)1., F.A.C. 58A-8.0191(11), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 08560 Based on personnel record review and staff interview, the facility failed to ensure that 5 of 5 employees received their initial HIV/AIDS training within 30 days of employment. This has a potential to place residents at risk of contracting an infection. . Finding: Review of the training records for employees #1-#5 (including the administrator), did not reveal the required initial or the biennial continuing education in HIV/AIDS. Continued review of the files revealed that all employees have been employed with the facility for over 1 year. The administrator was not present on the second day of the survey (8/7/07) and the assistant administrator could not locate the documentation nor could she comment on the reason the AHCA Form 3020-0004 STATE FORM $890 34BX11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PRINTED: 10/12/2010 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/07/2007 if continuation sheet 13 of 14 PRINTED: 10/12/2010 FORM APPROVED Agency for Health Care Administration : STATEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA <2) MI c UCTION {X3) DATE SURVEY AND PLAN OF CORRECTION a IDENTIFICATION NUMBER: (42) MULTIPLE CONSTR COMPLETED A. BUILDING B. WING AL11932557 08/07/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ‘ PROVIDER'S PLAN OF-CORRECTION xg PREFIX, (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE i GOMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i GROSS-REFERENCED TO THE APPROPRIATE [| DATE ' DEFICIENCY) i Continued From page 13 documentation was not in the file. Class III Correction Date: 9/7/07 AHCA Form 3020-0004 J STATE FORM 6899 348X141 iF continuation sheet 14 of 14 Exhibit “J” PRINTED: 10/12/2010 FORM APPROVED STATEMENT OF DEFICIENCIES X4) PROVIDERISUPPLIER/CLIA (x3) DATE SURVEY AND PLAN OF CORRECTION ms) IDENTIFICATION NUMBER: (2) MULTIPLE GONSTRUCTION COMPLETED A. BUILDING R 8. WING AL11932557 09/12/2007 NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE 907 E. ORANGE AVENUE HENDERSON HOUSE EUSTIS, FL 32726 (xa) 1D SUMMARY STATEMENT OF DEFIGIENGIES { PROVIDER'S PLAN OF CORRECTION (X68) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (GACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE | DEFICIENGY) {A.000}| INITIAL COMMENTS {A 000} | Surveyor: 09094 | During the 09/12/07 follow-up to the 08/07/07 | Biennial Licensure Survey, the following | deficiencies were corrected: A 1119, A223, A | 327, A 505, A610, A 628, A 632, A700, and A 1104. The facility continued to be deficient at A 615, resulting in a recite for non-compliance. The facility is not compliant with Chapter 429, Part |, F.S. and Chapter 58A-5, F.A.C. Surveyor: 09560 {A 615}} MEDICATION STANDARDS SS=D The facility must maintain a daily medication observation record (MOR) for each resident who receive assistance with self-administration of medications or medication administration. ' 5BA-5.0185(5)(b), F.A.C. This STANDARD is not met as evidenced by: Surveyor: 09094 Based on facility record review , and interview, it was determined that for 2 (#1, #2) of 6 sampled residents, the facility failed to maintain an up to date daily medication observation record (MOR) | for each resident that, reflected that the residents : Who receive assistance with self-administration of ! medications had received their medications as | ordered. Failure to maintain up-to-date MORs | may result in a resident being overdose as no one would know the resident had already taken the medications. AHGA Form 3020-0001 TITLE (X8) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE et STATE FORM 6909 34BX12 . . If continuation sheet 1 of 2 Agenc' STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER HENDERSON HOUSE (4) ID PREFIX | TAG {A 615} for Health Care Administration (X1) PROVIDER/SUPPLIER/CLIA (IDENTIFICATION NUMBER: AL11932557 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST 8E PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Findings: Review of the facility's 09/2007 MOR revealed that the facility failed to record that resident #1 had taken his/her medication, and that resident #2 had refused to take his/her medication. Resident #1 was scheduled to receive the following medications at 8:00 AM: Aspirin 325 milligram (mg); Benztropine MES 0.5 mg; Stelazine 2 mg; and colace 100 mg. The facility had not recorded that the resident had received his/her medications. Per the 2:45 PM, at 09/12/2007 interview the medication tech assigned to assist with medications reported that she had assisted with the medications, but failed to record them as taken, because she turned the page to fast. | Resident #2 was scheduled to take 16, 8:00 AM medications, including Zoloft 50 mg; Lexapro 10 i mg; Aspirin 352 mg; and Lasix 20 mg. i Pre interview, conducted on 09/12/07 at 2:45 PM, | the med tech reported that resident #2 had refused to take his/her medication; and that she { had not recorded, R, to indicate that the resident ! had refused. j Class Ui ‘ Correction Date: 10/12/07 | i | Surveyor: 09560 | AHCA Form 3020-0001 STATE FORM 6899 (X2} MULTIPLE CONSTRUCTION PRINTED: 10/42/2010 FORM APPROVED (X3) DATE SURVEY COMPLETED R 09/12/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 907 EF: ORANGE AVENUE EUSTIS, FL 32726 ~ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 34BX12 {f continuation sheet 2 of 2 Exhibit “K” FILED AHCA AGENCY CLERK STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 201 APA. 20 FI Bt STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO. 2007000215 Vv. LAKEVIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. / FINAL ORDER OF DISMISSAL WITH PREJUDICE THIS CAUSE concerns a request for hearing that the Agency for Health Care Administration received pertaining to agency action of January 25, 2007 (Exhibit A). FINDINGS OF FACT On the above-noted date, the Agency for Health Care Administration sent the Respondent notice of agency action. At the same time, the Agency for Health Care Administration advised the Respondent of the right to ask for a hearing under Chapter 120, Florida Statutes. On February 21, 2007, the Agency received a request for hearing (Exhibit B). The request for hearing appeared to be untimely and legally insufficient. On March 15, 2007, the Agency issued an Order of Dismissal Without Prejudice (Exhibit C). The Order of Dismissal without Prejudice gave the Respondent an opportunity to show why the Petition should not be dismissed. There has been no response to the Order of Dismissal Without Prejudice. Therefore, the relevant factual allegations of the Administrative Complaint and the Order of Dismissal Without Prejudice are hereby adopted. . CONCLUSIONS OF LAW Section 120.569(2)(c), Florida Statutes, requires the Agency to dismiss the request for hearing if it is untimely filed. Cann v. Department of Children and Family Services, 813 So.2d 237 (Fla. 2"! DCA 2002). . Section 120,.569(2)(c), Florida Statutes, requires the Agency to dismiss the request for formal hearing if the request does not meet the requirements of Rule 28- 106.201, Fla, Admin. Code, See Section 120.569(2)(c), Florida Statutes, and Brookwood Exten e Center of Homestead, LLP ency for Health Care Administration, 870 So.2d 834 (Fla. 3 DCA 2003). IT IS THEREFORE ORDERED AND ADJUDGED THAT: The request for hearing is dismissed with prejudice, and the pertinent agency action, namely the imposition of a $500 fine, became final twenty-one (21) days after the date on which notice was received. Respondent shall be governed accordingly. Unless payment has already been made, payment in the amount of $500 is now due from the Respondent as a result of the agency action. Such payment shall be made in full within 30 days of the filing of this Final Order of Dismissal with Prejudice. The payment shall be made by check payable to Agency for Health Care Administration, and shall be mailed to the Agency for Health Care Administration, Attn. Jean Lombardi, Office of Finance and Accounting, 2727 Mahan Drive, Fort Knox Building 2, Mail Stop 14, Tallahassee, FL 32308. Office of Finance and Accounting, 2727 Mahan Drive, Fort Knox Building 2, Mail Stop 14, Tallahassee, FL 32308. DONE and ORDERED thisdfay of pa 2007, in Tallahassee, ANDREW C. XAGWUNOBI, M.D; SECRETAR AGENCY FOR/ HEALTH CARE ADMINIST: Florida. NOTICE OF RIGHT TO JUDICIAL REVIEW A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER OF DISMISSAL WITH PREJUDICE IS ENTITLED TO JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY, ALONG WITH THE FILING FEE PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF THE RENDITION OF THE ORDER TO BE REVIEWED. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been furnished by U.S. or interoffice mail to the persons named below on this a day of Aber os , 2007. RICHARD J. SHOOP, Agency aot _Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 922-5873 COPIES FURNISHED TO: Barbara K. Nemec, President Lake View Nutrition Consulting, Inc. d/b/a Henderson House 907 East Orange Avenue Eustis, Florida 32726 Jan Mills Facilities Intake Unit Elizabeth Dudek Health Quality Assurance Jean Lombardi Finance and Accounting FILED STATE OF FLORIDA agers, eek AGENCY FOR HEALTH CARE ADMINISTRATION" WO MAY 22 A 05 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO. 2007000215 vy. LAKEVIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. ORDER THIS CAUSE came before the Agency on Respondent’s Motion to Vacate Final Order of Dismissal (“Motion”). In the Motion, the Respondent argues that the Final Order rendered in this matter on April 20, 2007 should be vacated because, contrary to the Final Order, the Respondent did file a response to the Order of Dismissal Without Prejudice that cured the defects noted in the Order of Dismissal Without Prejudice. Upon review of the Motion, the Agency concedes that it appears that the Respondent did send in a response to the Order of Dismissal Without Prejudice that was received by the Agency but not given to the Agency Clerk prior to the entry of the Final Order. However, the response to the Order of Dismissal Without Prejudice, which was in the form of an Amended Answer to Administrative Complaint and Request for a Hearing, did not address the untimeliness of the. initial hearing request or offer an explanation for the untimeliness of the initial hearing request that would have excused the untimeliness under the doctrine of equitable tolling. Further, accepting the facts stated in the Motion as true also does not present-a legitimate defense to the the untimeliness of the initial hearing request under the doctrine of equitable tolling. Respondent claims to have received the Administrative Complaint on February 1, 2007, yet offers no proof to substantiate this claim or explains why the certified receipt for the Administrative Complaint reflects that the Respondent received it on January 29, 2007. Additionally, there is no requirement that the Agency serve the Administrative Complaint on Respondent’s officers and directors. The Agency served the Administrative Complaint on the Respondent at its address of record and obtained proof of such service. "Generally, the tolling doctrine has been applied when the plaintiff has been misled or lulled into inaction, has in some extraordinary way been prevented from asserting his rights, or has timely asserted. his rights mistakenly in the wrong forum," Cann v. Department of. Children and Families, 813 So.2d 237, 239 (Fla. 2d DCA 2002) (quoting Manchules v. Department of Administration, 523 So.2d 1132 (Fla. 1988)). The facts contained in Petitioner’s Motion do not meet this criteria, The essence of due process is notice and an opportunity to be heard. The Agency afforded both to the Respondent, who failed to timely take advantage of them. The “[flailure of a party to take the required steps necessary to protect its own interest, cannot, standing alone, be grounds to vacate judicially authorized acts to the detriment of other innocent parties; the law requires certain diligence of those subject to it, and this diligence cannot be lightly excused.” Sabates v. Padron, 777 So.2d 1148, 1149-50 (Fla. 3d DCA 2001) (quoting John Crescent, Inc. v. Schwartz, 382 So.2d 383, 385-86 (Fla. 4th DCA 1980)). However, notwithstanding Respondent’s failure to timely respond, the Final Order should be amended to reflect that the Respondent did respond to the Order of Dismissal Without Prejudice. IT IS THEREFORE ORDERED AND ADJUDGED THAT: Respondent’s Motion is granted to the extent that an amended final order will be entered reflecting the changes noted above. DONE and ORDERED on thiso¥/ day of py lay , 2007, in Tallahassee, Florida. ANDREW C. SGWUNOBI, SECRETARY AGENCY FOR HEALTH CARE ADMINISTRATION CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing Order has been furnished by U.S. or interoffice mail to the persons named below on this ZZ day of Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 922-5873 COPIES FURNISHED TO: Barbara K. Nemec, President Lakeview Nutrition Consulting Services, Inc. 907 East Orange Avenue Eustis, Florida 32726 Jan Mills Facilities Intake Unit Elizabeth Dudek . Health Quality Assurance * Jean Lombardi Finance & Accounting PILED . STATE OF FLORIDA AHCA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY CLERK 1 HAY 22, A 805 - STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO. 2007000215 v. LAKEVIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. / nt AMENDED FINAL ORDER OF DISMISSAL WITH PREJUDICE THIS CAUSE concems a request for hearing that the Agency for Health Care Administration received pertaining to agency action of January 25, 2007 (Exhibit A). FINDINGS OF FACT | On the above-noted date, the Agency for Health Care Administration sent the Respondent notice of agency action. At the same time, the Agency for Health Care Administration advised the Respondent of the right to ask for a hearing under Chapter 120, Florida Statutes. On February 21, 2007, the Agency received a request for hearing (Exhibit B). The request for heating appeared to be untimely and legally insufficient. -On March 15, 2007, the Agency issued an Order of Dismissal Without Prejudice (Exhibit C). The. Order of Dismissal without Prejudice gave the Respondent an opportunity to show why the Petition should not be dismissed. On March 27, 2007, the Respondent sent in a response to the Order of Dismissal Without Prejudice (Exhibit D). However, the response, while legally sufficient, did not offer any explanation for the untimeliness of the original hearing request that would have excused its untimely filing under the doctrine of equitable tolling. Specifically, the Respondent did not offer any evidence to indicate that it was misled or lulled into inaction by the Agency, that it timely filed the hearing request, but filed it in the wrong forum, or that it was prevented from timely filing the hearing request by extraordinary circumstances. Therefore, the relevant factual allegations of the Administrative Complaint and the Order of Dismissal Without Prejudice are hereby adopted. CONCLUSIONS OF LAW Section 120,569(2)(c), Florida Statutes, requires the Agency to dismiss the request for hearing if it is untimely filed. Cann v. Department of Children and Family Services, 813 So.2d 237 (Fla. 2d DCA 2002). IT IS THEREFORE ORDERED AND ADJUDGED THAT: The request for hearing is dismissed with prejudice, and the pertinent agency action, namely the imposition of a $500 fine, became final twenty-one (21) days after the date on which notice was received. Respondent shall be governed accordingly. Unless payment has already been made, payment in the amount of $500 is now due from the Respondent as a result of the agency action. Such payment shall be made in full within 30 days of the filing of this Final Order of Dismissal with Prejudice. The payment shall be made by check payable to Agency for Health Care Administration, and shall be mailed to the Agency for Health Care Administration, Atta. Jean Lombardi, Office of Finance and Accounting, 2727 Mahan Drive, Fort Knox Building 2, Mail Stop 14, Tallahassee, FL 32308. DONE and ORDERED this J day of ‘nay , 2007, in Tallahassee, Florida. ANDREW C. AGWUNOBI, M.D., SECRETARY AGENCY FOR MEALTH CARE ADMINISTRATIQN NOTICE OF RIGHT TO JUDICIAL REVIEW A PARTY WHO JS ADVERSELY AFFECTED BY THIS FINAL ORDER OF DISMISSAL WITH PREJUDICE IS ENTITLED TO JUDICIAL REVIEW, WHICH SHALL BE INSTITUTED BY FILING THE ORIGINAL NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A COPY, ALONG WITH THE FILING FEE PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE . DISTRICT WHERE THE AGENCY MAINTAINS _ ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF THE RENDITION OF THE ORDER TO BE REVIEWED. ERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has been furnished by U.S. or interoffice mail to the persons named below on this, day of cS , 2007. ee ee RICHARD J, SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 922-5873 COPIES FURNISHED TO: Barbara K. Nemec, President Lake View Nutrition Consulting, Inc. d/b/a Henderson House 907 East Orange Avenue - Bustis, Florida 32726 Jan Mills Facilities Intake Unit _ Elizabeth Dudek Health Quality Assurance Jean Lombardi Finance and Accounting . @ @ @ @ ; (Certified Mail Recei 7003 1010 0003 9715 3030) STATE OF FLORIDA _ AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR . HEALTH CARE ADMINISTRATION, | Petitioner, AHCA NO: 2007000215 . We . LAKEVIEW NUTRITION CONSULTING "SERVICES, INC. d/b/a HENDERSON HOUSE, ; -COMES NOW the. AGENCY ‘FOR HEALTH CARE ADMINISTRATION CAHCA?, by through the undersigned counsel, and files this Administrative Complaint against. ‘LAKEVIEW NUTRITION CONSULTING SERVICES, ING. a/b/; a HENDERSON HOUSE, (“Henderson House”) pursuant ‘ro Section 120.569, and 120.57, Fla. Stat., (2006), and alleges: al This is an action to impose one (1) administrative fine in the amount of Five Hundred Dollars ($500.0), against Henderson House for one (1) uncorrected class 111 deficiency, pursuant to Sections 429.19(2\(c), 429.23(3), Fla. Stat. (2006) and Sections 58A- 5,0241(1), Fla. Admin. Code (2006). ; . oO ! Exhibit _4 Ce JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. tS LO) $n 3. Venue lies in Lake County, Eustis, Florida, pursuant to Section 12057, Fla. Stit, (2006), and Chapter 585, Fla. Admin. Code (2006). 4, AHCA is .the regulatory authority responsible for licensure and enforcement of all applicable statutes and tules governing assisted living facility puisuant to Chapter 429, Part I, Fla. Stat’ (2006), and Chapter 58A-5 Fla. Admin. Code. 5. Henderson House is a forptofit corporation, whose 44bed assisted living facility is located at 907 E. Orange Avenue, Bustis, Florida. Henderson House is licensed as an assisted living facility license #AL6622; certificate number 19636, effective November. 22, 2006 through November 07, 2007. Henderson House was at all time material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all : applicable rules, and statutes, . COUNT] OF 5 SAMPLED RESIDENTS, RESIDENT #1. TAG A218: FACILITY RECORDS STANDARDS Section 429.19(2)(c), Fla. Stat. (2006) — Section 429.23(3), Fla, Stat. Code (2006) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. @ @ ee 7. On or about November 27, 2006, AHCA conducted a follow-up survey at the Respondent facility. AHCA cited the facility based on the findings below, to wit: a.) On or about October 19, ; adverse incident teport to the Agency for Health Care Administration (AHCA) within one business day after the occurrence of an elopement. | b.) On or about November 21, 2006, Henderson House failed to submit an ” adverse incident report to the Agency for Health Care Administration (AHCA) within one “business day after the occurrence of an elopement for 1 of 5 sampled residents, Resident at, : The findings are: “Review of medical record for resident #1 revealed the resident had eloped and had co cencttenmeee eens veecallen outside the facility on 09/12/06, time unknown. The injury sustained from the fall required a visit to the hospital emiergericy department. Interview with the administrator on 11/27/06 at 11:25 AM, revealed: that the adverse incident reporthad not been filed. , Class: - Correction Date: 12/27/06 8. The regulatory provisions of “the Fig "StE-(7006), tha are pertinent-t0-this. Ce "alleged violation read:as follows: 400.419 Violations; imposition of administrative finess grounds. ~ (2c). Class "T]I" violations are those conditions or occurrences related to the operation and maintenance. of a facility or to the personal care of residents which. the agency determines indirectly or potentially threaten the physical or emotional _ health, safety, or security of facility residents, other than class I or class Il violations. The agency shall impose an administrative fine for a cited class 11] violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class II] violation roust specify the time within which the violation is required ws ro be corrected. If a class Ww violation is corrected within the 4 peated offense- . ina’ be imposed, uniess it is a TE . - 419.23 Internal risk management and quality assurance prograrns incidents and yeporting requirements.~ (3) Licensed facilities shall provide within 1 busines adverse incident, bY electronic mail, facsimile, OF United States mail, a preliminary report must include information regarding He type of adverse incident, and the status of the facility's investigation of the gncident- a ee 9, The violation alleged herein constitutes an uncorrected class Sl deficiency: and warrants a fine of $500. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings 38 set forth in the allegations of this adrninistcative complaint. d this Py day of January 2007, Leon County, Tallahassee: Florida. Respectfully submitte a en . Michael O- Mathis, Fsquire 7 - Fila. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration e Tallahassee Florida 32308 (850) 9275813 (office) (850) 9210158 (fax) Respondent is notified that it has & right to request an administrative hearing pursuant to Section 120.569, Fia- Stat. (2006). Specific options for administrative action até get out in the attached Election of Rights (one page) and explained in the attached Explanation of - Rights {one page): EEE All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2127 an Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior. Attorney, RESPONDENT 18 FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF ‘THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. c C ER . . | HEREBY CERTIFY. syst a sue and gofrect copy “by certified mail on Qo day of auern} . Administrator, Henderson House, 907 E. Orange Avenue, of the foregoing has been served 2007 «to Evelyn Richardson, “Bustis, Florida 32726.: Michael ©. Mathis, Esquire , p03 L010 0000 4725 3030 ° ago Feb 20 07 09:16p 000 352-0000000000 p.3 STATE OF FLORIDA. AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 Mahan Drive Building #3, MSC #3 Tallahassee, Florida 32308 Petitioner, AHCA NO: 2007000213 * VS. a ; ie) LAKE VIBW NUTRITION ~ CONSULTING SERVICES, INC., > d/b/a HENDERSON HOUSE, ALF, or Respondent e Cames now respondest Lake View Nutrition Consulting Services, Inc. (“Lake View”) ‘and for its ‘answer aud request for a hearing states: . . 2: Adeiitted ay Ct Gan lceceent sooth ub oee + suscomssin eto tet nani sane ont fsnth Fann Ee saachamnnne stnie ge westee e 4. Admitted 5. Admitted 6. Respondent re-alleges paragraphs 1-5, above. 7. Denied 8 Admitted Exhibit BEB Feb 20 07 09:16p 000 352-0000000000 p.4 9. Denied 10. In response to an Administrative Complaint dated 1 (2.5 [200 Tag mailed to. "Respondent on //, 26/2027 ”_qnd received by denton, CeERUARy | -AeLRespondent states: ‘ ; (a) The name and. address that the agency affected is: Agency for Healthcare Administration 2727 Mahan Drive Building # 3, MSC #3 Tallahassee, FL 32308 ‘The identification number is ‘2007000215 (b) The name, address and telephone number of the Respondent and its ' representative is: ; Lake View Nutrition Consulting Services, Inc. Barbera K. Nemec, President -.. : 907 East Orange Avenue Bustis, Florida 32726 (352) 669-9278 Respondent's substantial interests will be affected by the Agency’s decision as, if upheld, Respondent’s will be forced to pay a fine in the amount of $500. . (c) Respondent received notification of the Agency’s action by certified moail, reezived f-" 42, Paspondent disputes that it did not correct the cited deficierney within che time allowed for correction. | “4 (©) ‘Respondent states that it corrected the cited defriency within the time allowed for correction. () Kesvondent coptends the r-ovisions of Section . 400.41 9( ZY FS require | the reversal ofthe Agenoy’s proposed actic-.. . (g) Respondent seeks the following relief: Feb 20 07 09:17p 000 352-0000000000 po . ‘That the Agency’s determination to assess against Respondent a fine in the cnnount of $500.00 be reversed; . . ‘That Respondeat be reimbursed for its costs and expenses in responding ta the Agency’s Complaint; aod, That Respondent be granted such other relief as may be appropriate. Submitted thisQZ. day of edesenmy shit 2 : “5 Borbara K. Nemec, cold lent Lake View Nutrition Consulting Services, inc. 907 East Orange Avenue Bustis, Florida 32726 (352) 669-9278 Respondent CERTIFICATE OF SERVICE LHEREBEY CERTIFY that a copy of the foregoing was mailed on... ‘by U.S. Mail, postage prepaid to: _ Michael Mathis : Agenvy for Healthcare Administration wo 2727 Mahan Drive Building No. 3, MSC #3 Tallahassee, Florida 32308 Barbara K. Ni resident: - + Lake View Nutrition Consulting Services, Inc. Feb 20 07 09:18p 000 362-0000000000 : p. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Case Name HENDERSON HOUSE CASE NO: 2007000215 EL 10 GHTS This Election of Rights form is attached to a proposed administrative action by the Agency for Health Care Administration (AHGA). The title may be Notice of Intent to Deny, Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, Administrative Complaint, or some other notice of intended action by AHCA. Au Election of Bizhts must be returned by mail or by fax within 2} days of the day vou it tice of acti SA receive the at tent to tics of rs Im eal If an election of rights with your selected option is not received by AHCA within twenty-one (21) days from the date you received a notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. PLEASE RETURN YOUR ELECTION OF RIGHTS TO: 4S VIZ 933 im contained in. the tice of Tntent to my Y right toa ‘poaring, a . final order will be issued that adopts the: :proposed agency action and imposes. the penalty. fine or action. OPTION Two (2) I admit to the allegations of facts contained in the Notice of Intent to: Deny, the: Notice. of Intent to Levy a Late Fee, the: Notice of Intent to Levy a Late Fine, the Administrative Complaint, or other.proposed action by AHCA, but I wish to be heard at.on. informal proceeding (pursuant to. Section 120. 57(2), Florida Statutes) where I may. submit-testimony and written evidence. to the” Agency-to show that the proposed administrative action 'is too severe: or that the fi ne. should be reduced. OPTION THREE (3) ) 1 do dispute the allegations of fact contained in the Notice of Intent to Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent ta Levy 2 Late Fine, the Administrative Complaint, or other proposed action by AHICA, and J request a formal hearing (pursuant to Section 120.57(1), Florida Statutes (2006) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE G), by itself,.is NOT sufficient to obtain a formal hearing. You must file a written petition in order to obtain a formal hearing before the Feb 20 07 09:16p 000 362-0000000000 pz Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action, The request for formal hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, which requires that it contain: 1. The name and address of each agency affected and each agency’s file or identification number, if known; 2. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any; ; ; 3. An explanation of how your substantial interests will be affected by the Agency’s proposed action; . ‘4. A statement of when and how you received notice of the Agency’s proposed action; : 5. A statement of all disputed issues of material fact. If there are none, you must state that there are none: . . 6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; 7. A statement of the specific rules or statutes you claim require reversal or modification of the Agency’s proposed action; and 8. A statement of the relief you are seeking, stating exactly what action you wish the ' Agency to take with respect to its proposed action. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, Facility type: A L - (ALF? nursing home? medical equipment? Other type?) Facility Name: lt+e NOERION \4 Ouse License number: AL, GL22, Contact person(or attorney or representative): Panmana Nemec Pres ‘ Name ; tle Address: orc. | R209 Street and number City Zip Code .. Telepin one No‘Bs “G5 ie No. Same Bat Signed: . Date: NOTE; If your facility is owned or operated by a business entity (corporation, LLC, etc.) please include a written statement from one of the officers or managers that you are the authorized representative. If you are aye of the managers or officérs, please state which office you hold. Laat Vied Nivettion Consyctwe Entity name:__9 etuiess ; lw & Name of office you hold: Pr te Qvbl wT : You, your attorney or representative may reply according Subsection 120.54 Florida Statutes (2006) and Rule 28, Florida Administrative Code or you may use this recommended form. STATE OF FLORIDA poo AGENCY FOR HEALTH CARE ADMINISTRATION... In Re: The Request for Hearing concerning: LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, FRAES No, 2007000215 This Order of Dismissal Without Prejudice is directed to: ' BARBARA K. NEMEC, Respondent. / ‘ORDER OF DISMISSAL WITHOUT. PREY JUDICE PURSUANT TO SECTION 120.569(2)(c), FLORIDA STATUTES, TO ALLOW FOR AMENDMENT AND RESUBMISSION OF PETITION - BY THIS ORDER, the ‘Agency Clerk advises that the Agency is dismissing the request for hearing without prejudice and providing the person who requested the hearing with an opportunity to amend the hearing request to correct or address the problem(s) noted below. Please be advised that the Agency Clerk must receive the written response to this Order of Dismissal Without Prejudice within fifteen (15) days of the date on which it was signed. Please consider using U.S. Certified Mail, return receipt requested, to ensure that you receive proof of the date on which the Office of the Agency Clerk received your response. If the Agency Clerk does not receive a response to this Order of Dismissal Without Prejudice within 15 days of the date on which it was signed, a final order will be entered dismissing the hearing request with prejudice. The Agency is dismissing the request for hearing without prejudice because: (1) _X. It was untimely filed,’ Please note: “According to Section 120.569(2)(c), Florida Statutes, the Agency is required to dismiss a request for hearing if it is not timely filed. If this item is checked, it means that, contrary to Rule 28-106.111(2), Florida Administrative Code, a’ written request for a hearing was not received by the Agency on or before twenty-one (21) days from the date on which the charging document was delivered. Accordingly, a Final 1 The Agency sent the Administrative Complaint or the Notice of Intent on January 25, 2007, but did not ‘receive the request for hearing until February 21, 2007, suggesting that more than 2} days had elapsed since the receipt of the Administrative Complaint or Notice of Intent. “Exhibit _C-~ (2) _X _ Order will be entered consistent with the charging document unless the person requesting a hearing can show that the Agency received the written request for hearing on. or before. twenty-one (21) days from the date on which the charging document was delivered (See Cann v. Department of Children and Family Services, 813 So.2d 237 (Fla. 24 DCA 2002)). The request for hearing was legally insufficient. Please note: If this item is checked, the Agency recognizes that you requested a formal hearing pursuant to the provisions of Section 120.569 and 120.57(1), Florida Statutes. Your request, however, did not meet the requirements of Rule 28-106.2015(5), Florida Administrative Code? as required by law and as noted on ‘the Election of Rights form. Since your request for hearing did not conform to the Rule, the Agericy is required by law to dismiss it. See Section 120.569(2)(c), Florida Statutes, and Brookwood Extended Care Center of Homestead, LLP_v. Agency for Health Care Administration, 870 So.2d 834 (Fla. 3d DCA 2003). You have time, however, to amend your request for hearing if it was received on time. Please ensure that the amended request includes the information required by Rule 28-106.2015(5), Florida Administrative Code and indicated on the attached copy thereof, and that the Agency Clerk receives the amended request on or before fifteen (1 5) days from the date on which the Agency Clerk signed this Order of Dismissal Without Prejudice. a 2A copy of Rule 28-106.2015, Florida Administrative Code, is attached to this‘order. This rule sets out the ~ Gnformation required to be in a request for a formal hearing. You must review your request for hearing and amend it to conform to and contain all the information required by the rule. . CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the foregoing has been sent to the persons listed below either by U.S. or interoffice mail. : - DONE and ENTERED on this (9 day of red, 2007. RICHARD J. SHOOP, Agency State of Florida, Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 COPIES FURNISHED TO: Barbara K, Nemec, President Lake View Nutrition Consulting Services, Inc. d/b/a Henderson House ALF 907 East Orange Avenue Eustis, Florida 32726 Jan Mills Facilities Intake Unit 28-106.2015 Agency Enforcement and Disciplinary Actions. (1) Prior to entry of a final order to suspend, revoke, or withdraw a license, to impose administrative fines, or to take other enforcement or disciplinary action against a licensee or person or entity subject to the agency’s jurisdiction, the agency shall serve upon the licensee an administrative complaint. For purposes of this rule, an agency pleading or communication that secks to exercise an agency’s enforcement authority and to take any kind of disciplinary action against a licensee or other person shall be deemed an - administrative complaint, (2) An agency issuing an administrative complaint shall be the petitioner, and the licensee’ against whom the agency seeks to take disciplinary action shall be the respondent. : , (3) The agency's administrative complaint shal} be considered the petition, and service of the administrative complaint ori the respondent shall be deemed the initiation of proceedings. - (4) The agency’s administrative complaint shall contain: (a) The name of the agency, the respondent or respondents against whom disciplinary action is sought and a file number. (b) The statutory section(s), rule(s) of the Florida Administrative Code; or the agency order alleged to have been violated. (c) The facts or conduct relied on to establish the violation, ‘ (d) A statement that the respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, F.S., and to be represented by counsel or other qualified representative. ; . (5) Requests for hearing filed by the respondent in accordance with this rule shall include: (a) The name, address, and telephone number, and facsimile number (if any) of the xespondent, (b) The name, address, telephone number, facsimile number of the attomey or qualified representative of the respondent (if any) upon whom service of pleadings and other papers shall be made, ” . : (c) A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate, . . : (d) A statement of when the respondent received notice of the administrative complaint. (c) A statement including the file number to the administrative complaint, Specific Authority 120.54(5) FS. Law Implemented 120,569, 120.57, 120.60 FS. History-New 1-15-07. Exhibit “L” STATE OF FLORIDA FILED AGENCY FOR HEALTH CARE ADMINISTRATION AHCA AGENCY CLERK STATE OF FLORIDA, AGENCY FOR 20 APR A 840 HEALTH CARE ADMINISTRATION, DOAH Case No. 05-4578 Petitioner, AHCA No. 2005009267 vs. : RENDITION NO.: AHCA-06- O104 = -S-OLC LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE, Respondent. FINAL ORDER The Agency for Health Care Administration, having entered into a Joint Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised In the premises, decides as follows: The attached Joint Stipulation and Settlement Agreement is approved and adopted as a part of this Final Order, and the parties are directed to comply with the terms of the Joint Stipulation and Settlement Agreement. THEREFORE, it is ORDERED that: | 1. | The parties hereto are directed to comply with the terms of the Joint Stipulation and Settlement Agreement. 2. A sum of $250.00 is hereby ‘imposed upon the Respondent. This amount Is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this Case number, should be sent directly to: Jean Lornbardi Agency for Health Care Administration Office of Finance & Accounting 2727 Mahan Drive, Mall Stop #14 Tallahassee, FL 32308 4. Unpaid fines will be subject to statutory interest and may be collected by all methods legally available. 5. Other than the executory features of this final order, the request for hearing is deemed withdrawn and this case and file deemed closed. DONE and ORDERED this Bday of CAaeecA_ _, 2006, in Tallahassee, Leon County, Florida. A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF - ANOTICE OF APPEAL WITH AGENCY CLERK AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, IN THE DISTRICT COURT OF APPEAL WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION. OF THE ORDER TO BE REVIEWED. Copies furnished to: Michael O. Mathis, Esq. Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., Suite 3808-D Tallahassee, Florida (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bidg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mall) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail). Barbara K.-Nemec, President Henderson House, Inc. 907 East Orange Avenue Eustis, Florida 32726 (U.S. Mail) Ella Jane P. Davis Administrative Law Judge - Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Jan Mills (Inter-office Mall) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy of the foregoing was mailed to the above-named addressees on this day of Apr. , 2006, - —— Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32303 - (850) 922-5873 arab 33 06 02:45p 000 352-0000000000 ~ p.2 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . DOAH Case No. 05-4578 AHCA NO.: 2005009267 v5. LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/n HENDERSON HOUSE, PETITIONER, State of Flotida, Agency for Health Care Administration (hercinafter the “Agency”), through its undersigned representatives, and Lake View Nutrition Consulting d/b/a Henderson House (hereinafter “Respondent”) and pursuant to Sec. 120.57(4), Fla. Stat, 2005, cach individually, a “party,” collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: ‘WHEREAS, Respondent is a for-profit corporation whose 39-bed assisted living facility is locaved at 907 E. Orange Avenue, Eustis, FL 32726. Respondent is licensed as an assisted living facility, license # AL6622, certificate number 15394, effective November 08, 2003 through November 07, 2005., and ‘WHEREAS, Respondent was at all times maverial hereto, a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. Chapter 400, Part INI, Florids. Stacutes, and Chapter 584-5, Florida Adminiserative Code (2005): and- WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Respondent pursuant to Seotions 120.569 and 120.57, Florida Statues. (2004); and WHEREAS, the Agency served Respondent with an administrative complaint, charging Respondent with untimely submission of its emergency plan to the county emergency «Feb, 43,06 02:46p 900 352-0000000000 p.3 management agency. Subsequently, Respondent complied with the requirement to submit the plan, which was approved; and ; WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the beat interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are trac and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein sre binding findings of the parties. 3. Upon full execution of this Agreement, Respondent agrees to withdraw its Petition for an informa) administrative proceeding; agrees to waive any and al] appeals and proceedings; agrocs to waive compliance with the form of the Final Order (findings of fact and. conclusions of law) to which it may be entitled including, but not limited to, an informal procesding under Subsection 120.57(2) Florida Statutes (2005), a foxmal proceeding under Subsection 220.57(1), appeals under Section 120.68, Florida Stavutes (2005); any declaratory and all writs of relief in any court or quasi-court (DOA) of competent jurisdiction, 4. Respondent agrecs to pay to the Agency the sum of $250.00 (two hundred and fifty dollars) to the Agency with 30 days of the entry of the Final Onder in full setiloment of this casc. 5, Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 6, Neither party admits to any violation of law ox rule. However, no agreement made hbercin shall preclude the Agency from imposing a penalty against Respondent for any other violation of law or rule which may arise, or for any late-filed document or application that may arrive at the Agency in the future. ; 7. Upon fail execution of this Agresment, the Agency shall enter a Final Order adopting and incorporating the tenns of this Agreement and dismissing the sbove-styled case. B Bach party shall bear its own conte and attorney's fees. 9. This Agreement shall become effective on the date upon which it is fully executed byallths parties, , Feb m6 11:21a coo $bzZ-~ULUUUUUUUU pz 10. Respondent for itself and for its Telated or resulting organizations, its successors or transferees, attemeys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attomoys of and from all claims, demands, actions, causes of action, suits, damages, lossos, and expenses, of any and every nature whatsosver, arising out of or in any way related to this matter-‘and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this matter, by or on behalf of the Respondent or related facilities. 11. This Agreement is binding upon all parties herein and those identified in paragraph (10) of this Agrecment. 12. ‘The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. . 13. This Agreement contains the entire understandings and agreements of the partics. 14. This Agreement supersedes any prior oral or written agrecments between the parties. 15. This Agreement may not be amended. except in writing. Any attempted assignment of this Agreemeut shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. , DATED: 3/23/66 od Barbara K. ec, President Henderson House, Division Health Quality Assurance -907 East Orange Avenue. . Agency for Health Care Administration Eustis, Fl. 32726 DATED: _ 7/27/06 DATED: SATL2 6 Christa Calamas Michael O. Mathie General Counsel Attomey for the Agency for Agency for Health Care Health Core Administration Administration 2727 Mahan Drive - Tallahassee, Florida 32308 Exhibit “M” F ILE D STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATHOINY chery 16 JA 23 4.99 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, CASE NO. 2005003581 _— _ DOAH NO. 05-2320 Petitioner, vs RENDITION NO.: AHCA 06. 0018 -S-OLC LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE, Respondent. EINAL ORDER Having reviewed the administrative complaint dated May 10, 2005, attached hereto and Incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered _Into a Stipulation and Settlement Agreement (Ex. 2) with the Respondent in these proceedings, and being otherwise well advised In the premises, finds and concludes as follows: | ORDERED: 1. The attached Stipulation and Settlement Agreement Is approved and adopted as part of this Final Order, and the parties are directed to ‘comply with the terms of the Stipulation and Settlement Agreement. 2, _ The Respondent agrees to pay FIVE HUNDRED DOLLARS ($500.00) as an administrative fine to the Agency. This amount is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this case number, should be sent directly to: Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, MS# 14 Tallahassee, Florida 32308. 4. The Respondent's petition for formal hearing Is hereby dismissed. 5. Unpaid fines will be subject to statutory interest and may be collected by all methods legally available. 6. Each party shall bear Its own costs and attorney’s fees. 7. The above-styled case is hereby dismissed. DONE and ORDERED this_/“Zday of _CLehudiated 20.0@__ In Tallahassee, Leon County, Florida. Alan Lene, Secretary Agency Jor Health Care Administri A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Barbara K. Nemee President Lake View Nutrition and Consulting Services, Inc., d/b/a Henderson House ALF 907 E. Orange Avenue Eustis, Florida 32726-6249 U.S. Mail Jean Lombardi Finance & Accounting Agency for Health Care Admin. 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 Interoffice Mail) Jan Mills Agency for Health Care Admin. 2727 Mahan Drive, Bldg #3, MS #3 Tallahassee, Florida 32308 Joan Fowler, Esquire Assistant General Counsel Agency for Health Care Admin. 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Admin, 2727 Mahan Drive, Bldg #1, MS #9 Tallahassee, Florida 32308 (Interoffice Mail P. M. Ruff, AU Division of Admin. Hearings The DeSoto Bidg. 1230 Apalachee Parkway Tallahassee, FL_ 32399-3060 ERTIFICA FS Ic I HEREBY CERTIFY that a true and correct copy of this Amended Final Order was served on the above-named person(s) and entitles by U.S. Mail, or the method designated, on this the Z3™" day of ~cJaacary 20906 _. Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Bullding #3 Tallahassee, Florida 32308-5403 (850) 922-5873 | caraenaiyentmattonsidermutslin we Seunanryees “AMRIT See ON “STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No. 2005003581 LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE, Respondent. f ADMINISTRATIVE COMPLAINT ‘The AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), through undersigned counsel, files this Adtninistrative Complaint against LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE (“Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000 and a complaint’ investigation survey fee of $500, for a total fine amount of $1,500 against Respondent, an assisted living facility (“ALF”), for a Class I violation pursuant to the various citations, statutes, and rules cited in the two counts below. 2. In summary, Respondent was cited as follows: h 29, 2005 Complaint Investigation. Respondent was cited for one Class 1 Marc . violation. EXHIBIT 4. ——=T Page lof 7 JURISDICTION AND VENUE 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), 4, Venue shall be determined pursuant to Chapter 28-106.207, Florida Administrative Code (2004), __ PARTIES ee. 5. Pursuant to Chapter.400, Part Ill, Florida Statutes (2004), and Chapter 584-5, Florida Administrative Code (2004), AHCA is the licensing and enforcing’ authority with regard to assisted living facility laws and rules. 6. Respondent is an assisted living facility located at 907 E. Orange Avenue, , Eustis, Florida 32726. Respondent is and was at all times material hereto a licensed facility under Chapter 400, Part III, Florida Statutes (2004), and Chapter 58A-5, Florida Administrative Code (2004), having been issued license number 6622. COUNT I Respondent faited to protect one resident from an atmosphere of verbal abuse. § 400.419(2)(b), Fla. Stat, (2004) § 400.428(1)(a) and (b), Fla. Stat. (2004) 7. AHCA re-alleges paragraphs 1-6 above. 8. On March 29, 2005, AHCA conducted a Complaint Investigation at Respondent’s facility. AHCA cited Respondent for a deficiency, based on the findings below, to wit: a) Per resident interview conducted on 3/29/05 at 3:00 PM a resident reported that after calling the Department of Children and Family Services he/she was approached by the administrator regarding what was reported and reported being cursed at and called a name by the administrator. The administrator was advised of this report at 4:40 PM during the exit conference and denied the allegation that she cursed at any of the residents. Page 2 of 7 3. Respondent failed to protect one resident from an atmosphere of verbal abuse, as tequired by Section 400.428(1)(a) and (b), Florida Statutes (2004), which provides, in pertinent part, as follows: “400.428 Resident bill of rights.— (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and emmepapaintnnannnbtitla respect and with due recognition of personal dignity, individuality, and the need for privacy.” 10. The foregoing violation constitutes a Class II violation due to the nature of the violation and the gravity of its effect on the residents of the facility, to wit: “400.419 Violations; imposition of administrative fines; grounds,— ...(2) Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (b) Class "II" violations are those conditions or occurrences related to the operation atid maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation.” § 400.419(2)(b), Fla. Stat. (2004) 11. The foregoing violation constitutes a Class II violation pursuant to Section 400.419(2)(b), Florida Statutes (2004) (quoted above), due to the nature of the violation and the gravity of its effect on the residents of the facility, and warrants a fine of $1,000. 12, AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fine in the amount of $1,000 for the referenced violation; and Page 3 of 7 3. Impose such other relief as this tribunal may find appropmate. COUNT IE A survey fee in the amount of $500 is imposed upon Respondent. § 400.419(10), Fla, Stat, (2004) 13. AHCA re-alleges paragraphs 1-12 above. 14. A survey fee is imposed pursuant to Section 400.419(10), Florida Statutes, which states as follows: “(10) In addition to any administrative fines imposed, the agency may 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 initial complaint investigations that result in the firiding of a violation that was the subject of the complaint or monitoring visits conducted under s. 400.428(3)(c) to verify the correction of the violations.” WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Impose a fee in the amount of $500 for the referenced survey; and 3. Impose such other relief as this tribunal may find appropriate. NOTICE Respondent, LAKE VIEW NUTRITION CONSULTING SERVICES, INC., d/b/a HENDERSON HOUSE is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). Ali requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr, Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. Page 4 of 7 THE RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING 1S NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. re Submitted on this_/0” day of Claw _ 2005. < , Timothy B. Elliott, Senior Attorney Fla. Bar No, 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FI. 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or (850) 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested (receipt # 7004.1160 0003 3739 7661) to Henderson House, Attention: Administrator, 907 E, Orange Avenue, Eustis, Florida 32726. Submitted on this (7 day of _ Vad k A= 2005. 7 => Timothy B. Elliott, Senior Attomey Agency for Health Care Administration Page 5 of 7 EXPLANATION OF RIGHTS _ UNDER SEC. 120.569, FLORIDA STATUTES (To be used with the attached Election of Rights form) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order. OPTION2, If Respondent does not dispute any material fact alleged in the ‘Administrative Complaint (Respondent admits alt the material facts alleged in the Administrative Complaint), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3, If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a forma) hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent’s request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. IF YOU SELECT OPTION 3, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH; : In order to preserve the right to a hearing, Respondent’s Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondents selected option is not received by AHCA within twenty-one (21) days from the date of Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. rn SAU pe conpeens teh oc cete RAE a. etry eRe ne edger gous rn Page 6 of 7 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Henderson House Case No. 2005003581 ELECTION OF RIGHTS FOR ADMINISTRATIVE BEARING PLEASE SELECT ONLY 1 OF THE 3 OPTIONS (An Explanation of Rights form is attached) OPTION ONE (1) © Respondent does not dispute the allegations of fact contained in the Administrative Complaint and waives Respondent’s right to object or to be heard. Respondent understands that by waiving Respondent’s rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 0 Respondent does not dispute and Respondent admits the allegations of fact in the Administrative Complaint, but Respondent does wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time Respondent will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. . . OPTION THREE, (3) 0 Respondent does dispute the allegations of fact contained in the ‘Administrative Complaint and Respondent requests a formal hearing, ‘pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If Respondent chooses OPTION THREE (3), in order to obtain a formal proceeding before the | Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Respondent’s request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if the Agency agrees to it. In order to preserve Respondent’s right to a hearing, Respondent’s Election of Rights in this matter must be recelved by ABCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent's selected option is not received by ANCA within twenty-one (21) days from the date of the Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. If Respondent has elected either OPTION TWO (2) or T: E (3) above and if Respondent is interested in discussing a settlement of this matter with the Agency, please also mark and check this block. a Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO. PAYMENT NOW — REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL RESPONDENT RECEIVES A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (lease sign and fill in your current address.) Respondent (Licensee) Address: License. No. and facility type: Phone No. ; PLEASE RETURN YOUR COMPLETED FORM TO: . Agency for Health Care Administration, Office of the General Counsel, 2727 Mahan Drive, _ Building 3 il Stop #3, Tallahassee, Florida 32308, Attention: Agency Clerk. Telephone ~ Number: 850-921-8177; 850-921-0158; ~800-955-8771. Page 7 of 7 } prEAAH): ADMINISTRATOR COMPLETE THIS SECTION ON DELIVERY A. Signatyrg x da ENDER: COMPLETE THIS SECTION m Complete items 1, 2, and 3, Also complete item 4 if Restricted Delivery is desirad. . § Print your name and address on the raversé so that we can return the card to you, q WrAttach this card to the back of the mallpiece, ora fo if space permits, D. ty delivery adevess efferent fom item 1? C3 Yes tl EYES, enter delivery address below: = C) No : G07 B, ORANGE AVENUE " €USNS, FLoeiba 32726 3. Service Type EYCentitied Mall «CO Express Mal T Registered turn Recetpt or Merchandiea 4 ft Clinsurad Mail = 6.09. [ 4, Restdoted Dellvery? (Extra Fee) joer a 7004 210 0003 3734 7bbI i y 102595-08-M-1840 + PS Form 3811, February 2004 Domestia Retum Receipt . STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005003581 DOAH No.: 05-2320 vs, LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON : HOUSE, Respondent. ° / STIPULATION AND SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”) through their undersigned representatives, and LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE (hereinafter “Respondent”) pursuant to Sec. 120.57(4), Florida Statutes (2005) each individually, a “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE is an assisted living facility licensed pursuant to Chapter 400 Part TH, Florida Statutes (2005), and Rule 58A-5, Florida Administrative Code, (2005), and; WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority. over LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE pursuant to Chapter 400, Florida Statutes, and; EXHIBIT PA WHEREAS, the Agency served LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE with an Administrative Complaint on May 10, 2005, notifying the party of its intent to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00), and a survey fee of FIVE HUNDRED DOLLARS ($500.00) for a total administrative fine of ONE THOUSAND FIVE HUNDRED DOLLARS ($1,500.00). WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute, and; WHEREAS, the parties have negotiated and agreed that the best interest of all the parties _ will be served by a settlement of this proceeding, and; NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties, 3. Upon full execution of this Agreement, LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. 4, Upon full execution of this Agreement LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE agrees to pay FIVE HUNDRED DOLLARS ($500.00) as an administrative assessment to the Agency within 30 days of the entry of the Final Order. In addition, the Agency agrees to waive the survey fee of FIVE HUNDRED DOLLARS ($500.00). 5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 6. | LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE neither admits nor denies the allegations raised in the administrative complaint referenced herein, The Agency agrees that it will not impose any further penalty against Respondent as a result of the March 29, 2005 survey. However, no agreement made herein shall preclude the Agency from imposing a penalty against Respondent for any deficiency/violation of statute or rule identified in a future survey of Respondent, which constitutes a “repeat” deficiency from the March 29, 2005 survey. This agreement does not limit Respondent from defending or challenging such findings in any such “repeat” deficiency/violation proceeding, if made. Furthermore, the Agency agrees that it will not use these deficiencies as the sole basis for denial of licensure at the next renewal. 7. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 8. Bach party shall bear its own costs and attorney fees. 9. This Agreement shall become effective on the date upon which it is fully executed ‘by all the parties. 10. LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, atising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent or related facilities. 11. This Agreement: is binding upon all parties herein and those identified in the aforementioned paragraph nine of this Agreement. 12. The undersigned have read and understand this Agreement and have authority to — bind their respective principals to it. Respondent has the capacity to execute this stipulation and have done so... Respondent affirm that the Respondent understand that counsel for the Agency represents solely the Agency, and Agency counsel has not provided legal advice to or influenced the Respondent in its decision to enter into this stipulation. 13. This Agreement contains the entire understanding and agreement of the parties. 14. This Agreement supersedes any prior oral or written agreements between the parties. 15. This Agreement may not ‘be amended except in writing. Any attempted assignment of this Agreement shall be void. 16. Facsimiles of signatures shall be deemed to be the same as original signatures. Dac 02 05 09:55a DEL-WI-eued «14133 HHH ps go97 200 core rede 17. The following representatives hereby acknowledge that they are duly authorized to cnter inte this Agreement. 18 ‘This Agrecment is not effective and binding until executed by all parties hereto. This Agreement may be executed simultaneously in two or more counterparts, each of which shall be deemed to be an original, but all of which together shall constitute one amd the same Barbara K, Nemec instrament. HQA, Depyty Secretary President Agency fof Health Care Admin. Lake View Nutrition Consulting Services 2727 Drive, Bldg #2 907 B. Orange Avenue Tallahassee, Florida 32308 Eustis, Florida 32726-6249 DATED: Wiz 200lo DATED: /2/2/0 = Christa Calamas, General Counsel Florida Bar No, 0142123 Agency for Health Care Admin. 2727 Mahan Drive, Bldg #3 Tallahassee, Florida 32308 patgp: _*{ lt] ®6 TOTAL P,a2 Exhibit “N” PILED KOA STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA ZING HAR 31 2: OS AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. AHCA NO. 2007012301 LAKE VIEW NUTRITION CONSULTING SERVICES, INC. d/b/a HENDERSON HOUSE, Respondent. FINAL ORDER Having reviewed the Administrative Complaint dated November 9, 2007, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) finds and concludes as follows: FINDINGS OF FACT 1. The Agency Issued an Administrative Complaint stating the Intent to impose a fine against the Respondent, Lake View Nutrition Consulting Services, Inc. d/b/a Henderson House (hereinafter “Respondent”), an assisted living facility. 2. The complaint charged that Respondent failed to maintain an up- to-date daily medication observation record for each resident that reflected that the residents who receive assistance with self administration of medications had received-thelr medications as ordered. Failure to maintain up-to-date MOR’s may result in a resident overdosing as no one would know the resident had already taken the medications. This is a violation of Section 429.19(2)(c), Florida Statutes (2007), and Rule 58A-5.0185(5)(b), Florida Administrative Code (2007), a class II deficiency. The fine sought is $500.00. 3. Respondent was served the Administrative Complaint on November 16, 2007, by U.S. Certified Mail, return recelpt requested (7003 1010 0000 9715 4136). See Exhibit 2. 4, Enclosed with the Administrative Complaint was an Election of Rights form (Ex. 3), which advised Respondent of its right to a hearing pursuant to Section 120.57(1) or Section 120.57(2), Fla. Stat, (2007). 5. Respondent selected Option (3) within the Election of Rights (Ex.4), disputing the allegations of fact contained in the administrative complaint and requests a formal hearing. 6. The Respondent informed the Agency for Health Care Administration, Headquarters General Counsel Office, 2727 Mahan Drive, MS#3, Tallahassee, FL 32308, in a motion to dismiss of March 4, 2008, of her decision to voluntarily withdraw its request for a formal hearing. See Exhibit 5. 7. The facts, as alleged and found, establish that Respondent failed to maintain an up-to-date daily medication observation record for each resident that reflected that the residents -who receive assistance with self administration of medications had received their medications as ordered. Failure to. maintain up-to-date MOR’s may result in a resident overdosing as no one would know the resident had already taken the medications. This is a violation of Section 429.19(2)(c), Florida Statutes (2007), and Rule 58A- 5.0185(5)(b), Florida Administrative Code (2007), a class III deficiency. The fine sought Is $500.00. CONCLUSIONS OF LAW i. The Respondent is an assisted f{Iving facility over which the Agency has jurisdiction pursuant to the provisions of § 20.42, Fla. Stat, and Chapter 429, Part I, Fla. Stat. (2007). 2. An administrative fine shall be Imposed by the Agency for a cited deficiency as provided for by law. §§ 429.19(2)(c), Florida Statutes. (2006), and Rule 58A-5.185(5)(b), Florida Administrative Code (2007). 3. - The Respondent expressly waived Its right to a hearing and consented to the entry of a Final Order, adopting the allegations and conclusions set forth in the administrative complaint and imposing the sanction sought. . 4. The administrative law judge filed an order closing file on or about March 5, 2008, based on Respondent’s Motion of withdrawal of Petition requesting administrative hearing. Based on the foregoing findings of fact and conclusions of law, It Is ORDERED: 1. An administrative fine in the amount of $500.00 is hereby Imposed upon Respondent. The administrative fine is due and payable within thirty (30) days of the date of rendition of this Order. 2, Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this case number, should be sent directly to: Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive, Mail Stop Code # 14 Tallahassee, Fl. 32308 3, Unpaid fines will be subject to statutory interest and may be collected by all methods legally available. DONE and ORDERED this ~Gfiay of fnack—, 2008 in Tallahassee, Leon County, Florida. Holly Benson, Secretary Agency for-Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS: PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS.HEADQUARTERS OR WHERE A PARTY. RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Michael O. Mathis, Esq. Assistant General Counsel Agency for Health Care Administration 2727 Mahan Drive Bldg #3 Mail Stop Code #3 Tallahassee, Florida 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Heaith Care Administration 2727 Mahan Drive Bldg #1 Mall Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 - (Interoffice Mall) Barbara K. Nemec, President Lake View Nutrition Consulting Services, Inc. 14806 CR 450 Umatilla, FL 32784 (U.S, Mail) Jan Mills (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named persons and entities by U.S. Mail, or the method designated, on this Ay of “Gre4 Richard Shoop, Agency Clere—~ Agency for Health Care Administration 2727 Mahan Drive, Building #3 , Tallahassee, Florida 32308-5403 (850) 922-5873 a . Certified Mail Receipt (7003 1010 0000 9715 4136) | ‘STATE OF FLORIDA _ AGENCY FOR HEALTH CARE ADMINISTRATION. STATE OF FLORIDA’ AGENCY FOR HEALTH CARE " ADMINISTRATION, Petitioner; / AHA Nos: 2007012301 vb "LAKE VIEW NUTRITION CONSULTING: SERVICES, INC. d/b/a HENDERSON HOUSE, ; Respondent. so . - | ". ADMINI STRATIVE COMPLAINT “COMES NOW the Agency for Health Cate. Administration (hereinafter “AHCA”), ) by and through the undersigned counsel, and files ‘this Administrative Complaint against Lake View Nutrition’ Consulting Services, Inc. d/b/a Henderson House (hereinafter “Ann's House Inc IP, pursuant to Section 120,569, and 120,57, Fla. Stat, (2007), alleges: NATURE OF ‘THE ACTI oN | ) 1. “This is an-action to impose one (1) administrative fine against Henderson House in the amount of One Thousand Dollars ($500.00), based upon one a) uncorrected class III deficiency, pursuant to Sections 429. 19(2Ke), Fla. Seat. (2007), and Rule 58A- 5. 185(5)(b), Fla. Admin. “Code (2007). a JURISDICTION AND VENUE 2.. This Agency has jurisdiction pursuant t0 429, Part I arid Section 120.569 and 120.57, Fla, Stat. (2007). 1 . EXHIBITI ¢h 3. Venue lies in Lake County, Eustis, Florida, pursuant to Section 120.57 Fla. Stat. (2007); Rule 58A5, Fla. Admin. Code (2007) and Section 28,106,207, Fla. Stat. (2007). | . PARTIES . ; 4. AHCA, is the regulatory authority . responsible for . licensure and enforcement of all applicable statutes and n tules governing assisted living fact pursuant ) to Chapier 429, Part 1 Fla. Stat. (2007) and Rule 58A-5, Fila. Admin. Code (2007), 5. Henderson House is a for-profit: corporation, whose. dhe sesired living. facility is located at 907 E. Orange Avenue, Eustis, Florida 32726. ‘Henderson House is . licensed as assisted living fale licensé ‘# A622; certificate auimber ams, effective | November 8, 2007 through February 7, 2008. Henderson House was at all - ‘times intel hereto, licensed facility under the Neensing suthort ot ABCA, and. reauired to comply with all applicable rules, and statutes. . | “ COUNTI HENDERSON HOUSE FAILED TO MAINTAIN STATE TAG A619: MEDICATIONS CARE STANDARDS. . Section 429. 19(2)(c), Fla. Stat. (2007) VIOLATIONS; IMPOSITION OF ; : ADMINISTRATION FINES; GROUNDS . Rule. 58A-5. 185(5)(b), Fla; “Admin. Code (2007) MEDICATION PRACTICES 6. . AHCA realleges and incorporates paragraphs (1) through (5).a8 if fully set forth herein, 7 oe ra On or about September 12, 2007, AHCA conducted a follow-up survey at the Respondent's facility. AHCA cited the Respondent based on the.findings below, to wit: a.) On or about August 8, 2007, Henderson House failed to ensure that staff documented in the (MOR) Medication Observation Record when they assisted 11 (#1-#1 1) _ of 11 residents iri the potential for medication errot. : b.) Dacin a follow- “Up survey On oF about September 12, 2007, Henderson : House filed to maintain an up to date ally medication ‘observation record for each resident that, reflected that the residents who receive asitance with self administration of medications had received their medications as érdered. Failure to maintain up-to-date MORs may regult in a resident being overdose as no cne would know the resident had already taken the medications. - _ The Findings are: Review of the ‘facility's 09/ 2007 MOR revealed that the facility failed to s record that -resident’#1 had taken his/her medication, and that fesident #2 had refused to > take his/her medication. Resident #1 was scheduled to. receive. the following medications at 8:00 AM: Aspirin 325 milligram (mg); Benztropine MES 0.5 mg; Stelazine 2: mg; and colace 100 mg. The facility had not recorded that the. ‘resident had received his/her medications. Per the 2:45 PM, at 09/12/ 2007 interview the medication tech assigned to assist . with medications reported, that she had assisted with the medications, but failed to record them as taken, because she turned the page to fast. . Resident #2 was scheduled to take 16, 8: 00 AM medication, including Zoloft 50 - mg; Lexapro 10 mg; Aspirin 352 mg; and Lasix 20 tng. Pre interview, conducted on 09/12/07 at 2:45 PM, “the med tech reported thar - resident #2 had refused to take his/her medication, and that she had not ‘tecorded, R, to indicate that the resident had refused. Class II ; Correction Date: 10/12/07 - 8. The regulatory provisions of the Fla. Stat. (2007), that is pertinent to this “alleged violation réad.as follows: 429.19 Violations; imposition. of administrative fines; grounds: ~ - (2(c) Glass "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal -cate of residents which the agency determines indirectly or ‘potentially threaten the physical or emotional health, safety, or security of facility residents, other than classI 6r.class Il violations. The agency shall impose an administrative finé for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class III violation must specify the time within which the violation ‘is required to. be corrected. If a class III violation is corrected within the time ‘specified, no fine may be imposed, unless itisa repeated offense. . * 58A-5.0185 Mediation Practices, (5)(b) The facility shall m maintain a daily medication observation: secord (mor) for each resident who receives assistance with éelf-administration of medications or medication administration. A MOR must include the name of the.resident and any known alletgies the resident may have; the name of the tesident’s health care " provider, the health care provider’s telephone number; the name, strength, and directions for use of cach 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 MOR. must be immediately’ ‘updated each time ‘the medication | is offered or administered. . . co - * The violation alleged ‘herein constitutes an uncorrected cls: WW deficiency, and warrants a fie of $500. 00.. . WHEREFORE, AHCA demands ‘the following relief: 1. Enter factual and findings as set forth in the allegations ofthis ‘administrative complaint. . . . 2. Impose a fine in the amount of $500.00. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief ) 1. Make factual and legal findings in favor of the Agency on Count L a Henderson House an administrative fine in the amaunt of $500.00 for the violation cited above. : 3. : Grant such other relief as the court deems is just and proper. Respondent is notified that it has ‘a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2007). Specific options for administrative action.are set out in the attached Election of Rights (one page) and explained in the attached Bsplanation, of Rights (one page). o All requests for hearing shall be madé to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 “Mahan Drive, ‘Tallahassee, Florida 32308; Michael oO. Mathis, Senior Attorney. . RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE, TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL - REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL he THE AGENCY, Respectfully S Submitted this le day of, pyeimn 007, Leon County, Tallahassee, Florida. : Michael O. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration ‘Bldg. 3, MSC #3 .2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921.0158 (fax) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY ghac a true an mBectycopy of the foregoing has been served’ by certified mail on _1? day ‘of i» 2007 to “Evelyn Richardson, . Administrator, Henderson. House, 907 E, Orange Avenue, Eustis, Florida 32726. 7 Michael O. Mathis, Esq. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Case Name: HENDERSON HOUSE CASE NO: 2007012301 ELECTION OF RIGHTS -. This Election of Rights form is attached to a proposed admitiisteative action by the Agency for “Health Care Administration (AHCA). The title may be Notice of: Intent’ to Deny, Notice of “Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, Administrative Complaint, or some other notice of intended action by AHCA. | : : An Election of. Rights must be returned by mail or by fax within 21 nays ‘of the day you Late Fee,Notice of _receive the attached Notice of Intent to Deny, Noticé of Intent to Impos Intent to Inipose a Late Fine, Administrative Complaint or any other proposed: action by AHCA. Ifan election of rights with your selected option i is not received by AHCA Within twenty-one . (21) days from the date you received a notice. of proposed action by AHCA, you will have given up your right to contest the Agency’s: ‘proposed. action and § a fi nal order will be issued. PLEASE RETURN YOUR ELECTION OF RIGHTS TO: Agency for Health Care Administration - ‘Attention: Agency Clerk 2727 Mahan Drive,.Mail Stop #3 Tallahassee, Florida 32308... - Phone: 850-922- 5873 Fax:'850-921-0158, PLEASE SELECT ONLY LOF THESE 3 OPTIONS | OPTION ONE (1) I admit to ‘the allegations. of facts and: law contained in the Notice of Intent to 0 Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent to Levy a Late Fine, the Administrative Complaint, or other notice of intended action by AHCA and I waive my right to object ar to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the. proposed ‘agency action and oi imposes ; the penalty, fine or action. ; . ‘OPTION TWO (2). 1 admit to the allegations of facts contained in the Notice of Intent to Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent to Lévy a Late Fine, the Administrative Complaint, or other proposed action by AHCA, but I wish to be heard at an informal proceeding (pursuant to Section 120. 57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that ‘the ¢ proposed administrative action is too severe or that the fine should be reduced. . OPTION THREE G3). 1 do dispute the allegations of fact contained in the Notice of ’ Intent to Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent to Levy:a Late _ Fine; the Administrative Complaitit, or other proposed action by AHCA, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes (2006) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by ‘itself, is NOT * sufficient to obtain a formal hearing. You rmust.file a written petition i in order to obtain a formal hearing before the Division of Administrat, Hearings under Section 120.57(1), . -rida Statutes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, which requires that it contain: 1. The name and address of each agency affected and each agency’s file or ; identification number, if known; 2. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any; : 3, An explanation of how your substantial interests will be affected by the Agency’ s proposed action; . 4, A statement of when and how you received notice of the Agency’s proposed action; 5. A. statement. of all disputed issues s of material fact. if there are none, you must state that there are none; 6. A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification.of the Agency’s proposed action; 7. A statement of the specific rules or’ statutes you claim require reversal or ' modification of the Agency’s proposed action; and ° 8. A statement of the relief you are seeking, stating exactly what action you wish the Agency to take with respect to its proposed action. . Mediation under Section 120. 573, Florida Statutes, may be available i in this matter if the Agency agrees. : Fadility type: : (ALF? nursing home? medical equipment? Other type?) Facility Name: . : License number:. Contact person(or attorney or representative): : Name Title Address: ; : : ' §treet and number City Zip Code Telephone No. . Fax No. . Email Signed: : . Date: NOTE: If your facility i is owned or operated by.a business entity (corporation, LLC, ete. ) please include a written statement from one of the officers or managers that you are the authorized representative. If you are one of the managers or officers, please state which office you hold. Entity name: Name of office you hold: You, your attorney or representative may reply according Subsection 120.54 Florida Statutes (2006) and Rule 28, Florida Administrative Code or you may use this recommended form. — USPS - Track & Confirm Page | of” Ea UNITED STATES. POSTAL SERVICE Home | Help | Sign. Track & Contirm Search Results Label/Receipt Number: 7003 1010 0000 9715 4136 TET near ee Status: Delivered Track & Confirm Enter Label/Receipt Number, Your {tem was delivered at 1:20 pm on November 16, 2007 in EUSTIS, FL 32726. A proof of delivery record may be available through your local an Post Office for a fee. “Gas | Additional Information for this item is stored in files offline. Site Map Contact Us Forms Gov't Sarvicos dobs Privacy Policy Terms of Use al & Promii nts Copyright® 1999-2007 USPS, All Rights Reserved, NoFEAR Act EEO Datla FOIA Qoviore, 4 “ Exuipir # & ltt s/ tule me awn VT neat len 22 io, weer sae. 6 & Complete Items 1, 2, and 3. Also complate item 4 if Restricted Delivery is desired, © @ Print yourname and address on thé reverse 80 that We-oan return the card to you. ‘mm Atjach:{his-eard to the back of the malipiece;- ‘+ ° fa PALA aA enaliiaianall C, Date of Delivery ‘or on the front H space permits. - TL arictp Aaa te 0, Is delivery address different from item 17. Yes Geel mn ete Tegedsers, Heb rind. ILYES, enter delivery address below: 1 No Ferolowccon Uae 907 &. Dronge. Ale. auchs, PL 3a 1a LE Hapalirven fferrr— 3. Service Type D Certified Mall (C1 Express Malt 1 Registered © Return Receipt for Merchandise C1 Insured Mat! £1. .0.0. 4. Restricted Delivery? (Extra Fee) 2, Article Number i . (Tenster rom service abe) 7003 1010 0000 4735 423b PS Form 3811, August 2001 Domestic Return Raceipt 102505-02.M-1035 SUOHIRNSH] JO) 9819A04 BOS 2002 ounr ouge mod sg (papiaosg oBvionog aoueinsuy ON ‘AluQ [ley onsawog) 1d13944 “VIN G3ISLLYSO “DIAIIS [EISO ‘SN FETh STtb Gooo OTOT Enoe STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Case Name: HENDERSON HOUSE CASE NO: 2007012301 ELECTION OF RIGHTS This Election of Rights.form is attached to a proposed ‘administrative action by the Agency for Health Care Administration (AHCA), The title may be Notice ‘of’ ‘Intent’ to Deny, Notice of ‘Intent to Impose a Late Fee, Notice of Intent’ to: Impose ‘a Laté Fite, Administrative Complaint, or some other notice of intended action by AHCA. | _ . . An Election of Rights must be returned by mail or by fax within 21 2 dae of ihe day yo you t hed Ni " Fee, ) Intent to Inipose a Late. Eine, Administrative Complaint or. any other proposed. action by AHCA. Ifa an election of rights with. your selected option is not received by AHCA Within twerity- one " . (21) days from the date you received a notice. of proposed action by AHCA, you will have given up your right to contest the Agency’s: proposed action and a a final order will be issued. . PLEASE RETURN YOUR ELECTION OF RIGHTS TO: Agency for Health Care Administration | Attention: Agency Clerk 2727 Malian Drive, Mail Stop #3 Tallahassee, Florida 32308. — - EXHIBIT #3 ‘Phone: §50-922- 5873. Fax: 850-921-0158. So PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS ’. OPTIONONE (1) I admit to ‘the allegations. of facts. and: Jaw cointained in a the Notice of Intent to Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent to Levy a Late Fine, the Administrative Complaint, or other notice of intended action by AHCA and I waive my right to object or to have a hearing. | understand that by giving up my. right to a hearing, a final order will be issued that adopts the. Proposed | agency action and i imposes the penalty, fine or action. . . Doe . opt ION TWO 2). . I admit to the allegations of facts contained i in the Notice of Intent to Deny,.the Notice of Intent to Levy a Late Fee, the ‘Notice of Intent to Levy a Late Fine, ‘the Administrative Complaint, or other proposed action by AHCA, bit I wish to be heard at an informal proceeding (pursuant to Section 120.57(2),, Florida Statutes) where I may submit testimony and written evidence to the Agency to show that ‘the © propased administrative action is too. severe or that the fine should be reduced. . OPTION THREE 8). - I do dispate the allegations of fact contained in the Notice: of Intent to Deny, the Notice of Intent to Levy a Late Fee, the Notice of Intent to Levy-a Late Fine, the Administrative-Complaint, or other proposed. action by-AHCA, and-I Tequesta formal hearing (pursuant to Section 120.57(1), Florida Statutes (2006) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT ‘sufficient to obtain a formal hearing. You must. file a written petition i in order to obtain a formal hearing before the Division of Administrat, Hearings under Section 120,57(1), . vrida Statutes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.201, Florida Administrative Code, which requires that it contain: 1, The name and address of each agency’ affected and each agency’s file or ___ identification number, if known; : 2. Your name, address, and telephone number, and the name,.address, and telephone number of your representative or lawyer, if any; oo 3. An explanation of how your substantial interests will be affected by the Agency’s proposed action; a ; . , 4: -A. statement of when and how you received notice of the Agency’s proposed action; . a . ' 5. A.statement. of all disputed issues of material fact. If there are none, you must State that there are none; - . _ ut, 6. A concise statement of the ultimate facts alleged, including the specific facts you _ ‘contend warrant reversal or modification of the Agency's proposed action; 7. A statement of the specific rules or’ statutes you claim require reversal or _ modification of the Agency’s proposed action; and © : . . 8. A statement of the relief you are seeking, stating exactly what action you wish the . Agency to take with respect to its proposed action. . , Mediation under. Section 120,573, Florida Statutes, may be available in this matter if the Agency agrees; | ue , . “ . ; Facility type: (ALF? nursing home? medical equipment? Other type?) Facility Name: _ : License number: - Contact person(or attorney or representative): ‘ Name ‘Title Address: . : . Street and number , City . Zip Code Telephone No. __Fax No. . Email Signed: . _ _ Date: _ : NOTE: If your facility'is owned or operated by a business entity (corporation, LLC, etc.) please include a written statement from one of the officers or managers that you are the authorized representative. If you are one of the managers or officers, please state which office you hold. Name.of office you hold: Entity name: You, your attomey or representative may reply according Subsection 120.54 Florida Statutes (2006) and Rule 28, Florida Administrative Code or you may use this recommended form. -: Dec 31 07 05:49p 000 352-0000000000 p.10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Case Name: HENDERSON HOUSE CASE NO: 2007012301 re ELECTION OF RIGHTS "WME 1 D> 1.95 This Election of Rights form is attached to a proposed administrative action by the Agency for Health Care Administration (AHCA). The title may be Notire ef Intent to Deny, Notice of Intent to Lupese a Late Fee, Notice of Intent to Impose a Late Fine, Administrative Complaint, or some other notice of intended action by ABCA. Ea ‘ "Af an clection of rights with your selected option is not received by AHCA within twenty-one (21) days from the date you received @ notice of proposed action by AHCA, you will have piven up your right to contest the Agency’s proposed action and » final order will be issued. PLEASE RETURN YOUR ELECTION OF RIGHTS TO: Agency for Health Care Administration . Altention: Agency Clerk 2727 Mahan Drive, Mait Stop #3 . Tallahassee, Florida 32308. _ Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY |. OF THESE 3 OPTIONS OPTION ONE (1) X admit to the allegations ef facts avd law contained in the Notice of Inteat to Deny, the Notice of Intent to Lavy a Late Fee, the Notice of Intent to Levy a Late Fine, the Administrative Cowplaiat, or other notice of intended action by ABCA and | waive my right to ebject or to have a hearing. I understand that by giving up my vight to a besring, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. , OPTION TWO (2) _ + I admit to the allegations of facts contained in the Notice of ' Intent to Demy, the Notice of Intent to Levy a Late Fee, the Notice of Intemt to Levy a Late Fine, the Administrative Complaint, or other proposed action by AHCA, bat I wish to be heard at am informal proceeding (pursuant to Section 120.57(2), Floxida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine shouk? Be 'veduced. OPTION THREE (3) XK 1 de dispute the allegations of fact contained in the Notice of Intent to Demy, the Netice of Intent to Levy a Late Fee, the Notice of Intent to Levy 2 Late Fine, the Administrative Consplaiut, or other proposed action hy AHICA, and I request 2 formal hearing (pursuant to Section 120.57(1), Florida Statutes (2006) before an Administrative Law Judge appointed by the Division of Administrative Hearings. : Cheosing OPTION THREE (3), by itectf, is NO'T sufficient to obtain a formal hearimg. You must file a written petition in order to obtain a forinal hearing before the EXHIBIT #4 enna Dec 31 07 05:49p 000 352-0000000000 p.i1 ‘Division of Administrative Hearings under Section 120.57(1), Florida ‘Stanmtes. It must be received by the Agency Clerk at the address above within 21 days of receipt of this proposed administrative action. The request for formal heexing must Conform to the requirements of Rule 28..106.201, Florida Administrative Code, which requixes that it’contain: 1. 2. 3. 4. 5. 6. 7 8 The name and address of each agency affected and ‘each agency's file or identification number, if own; ‘Your name, address, and telephone number, and. the name, address, and telephone number of your representative or lawyer, if any; An explanation of how your substantial interests will be affected by the Agency’s proposed action, =~ A statement of when and how you. received notice of the Agency’s proposed action; sr event of all disputed tarues of material fact. If there are none, you must state that there ate none; A concist statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; A statement of the specific rules or statutes you claim require reversa} or modification of the Agency’s proposed action; and . A staiement of the relief you are secking, stating exactly what action you wish the Agency to take with respect to its proposed action. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Facility type: ALF aur nursing bone? medical equipment? Other type?) "Facility Names H BNO £A8 an y ouse License number, Aka 422, Contact person(or attorney or representative): Bagg ane 14. Nemec Caesingny Street Name . Title Address: 14906 CRuge Umaruin “ait . find mumber City Z ap Telephone No.AS2> 649-429 ax No.BS2- 644-9948 Email a } p NOTE: Hf your facility is owned or operated by a. ote: th ‘business entity (corporation, LLC, etc.) please . a include a written statement from one of the offices or mamagers that you are the authorized representative. If you iltremon Consens please state which office you bold. Lem News Batity name; brated Consurt & Name of office you hold: _-Pawsioessr . You, your attomey or representative may reply according Subsection 120.54 Florida Statutes (2006) and Rule 28, Florida Administrative Code or you may use this recommended form. * Mar 5 2008 9:30 Mar 05 08 09:29a 000 352-0000000000 pl STATE OF FLORIDA’ DIVISION OF ADMINISTRATIVE HEARINGS. STATE.OF FLORIDA. AGENCY FOR HEALTH CARE ADMINISTRATION. 2727 Mahan Drive Building #3. MSC #3 DOAH Case No. 08-0101 Tallahassee, Florida 32308 AHCA. CASE Nos, 2007012301. Petitioner. VS. LAKE VIEW NUTRITION CONSULTING SERVICES. INC., dfbfa HENDERSON HOUSE. Respondent SPOND) iQ’ ISMISS IT; REQUEST FOR A HRARING Comes now respondent Lake View Nutrition Consulting Services, Inc. (“Lake View”) and respectfully moves to withdraw its request for a hearing, Submitted this 4" day of March. 2008 Barbara K. Nemec. Frésident Lake View Nutrition Consulting Services, Inc. 14806 CR 450 Umatilla, Florida 32784 (352) 669-9278 Respondent Cc. SER’ THERBBEY CERTIFY that a copy of the foregoing was faxed on March 4, 2008. to EXHIBIT AS STATE OF FLORIDA RECEIVED DIVISION OF ADMINISTRATIVE HEARINGS@EMBRAL COUNSEL MAR © ¢ 2008 AGENCY FOR HEALTH gone: - CARE ADMINISTRATION, eee or nee Petitioner, vs. Case No. 08-0101 LAKE VIEW NUTRITION _ CONSULTING SERVICES, INC., @/b/a HENDERSON HOUSE, Respondent, wee wee ES LS LS EE ORDER CLOSING FILE This cause having come before the undersigned on Respondent's withdrawal of its request for an administrative hearing, and the undersigned being fully advised, it is, therefore, - ORDERED that: 1. The final hearing scheduled for March 13, 2008, is canceled. . . 2. The file of the Division of Administrative Hearings in the above-captioned matter is hereby closed. Jurisdiction is hereby relinquished to the Agency for Health Care Administration for final disposition. DONE AND ORDERED this 5th day of March, 2008, in Tallahassee, Leon County, Florida, BARBARA J. STAROS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675. SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us . Filed with the Clerk of the Division of Administrative Hearings this 5th day of March, 2008. COPIES FURNISHED: Michael 0. Mathis, Esquire ; Agency for Health Care Administration Fort Knox Building TII, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Barbara K, Nemec . - Lake, View Nutrition Consulting Services, Inc. 14806 County Road 450 Umatilla, Florida 32784

Docket for Case No: 11-000023

Issue Date	Proceedings
Oct. 04, 2011	Order Closing File. CASE CLOSED.
Oct. 03, 2011	Motion to Remand filed.
Sep. 02, 2011	Order Continuing Case in Abeyance (parties to advise status by October 3, 2011).
Sep. 01, 2011	Status Report filed.
Jul. 01, 2011	Order Continuing Case in Abeyance (parties to advise status by September 1, 2011).
Jul. 01, 2011	Status Report filed.
May 02, 2011	Order Canceling Hearing and Placing Case in Abeyance (parties to advise status by July 1, 2011).
Apr. 27, 2011	Joint Motion for Continuance filed.
Apr. 13, 2011	Respondent's First Request for Admissions filed.
Apr. 06, 2011	Notice of Service of Respondent's First Request for Production of Documents filed.
Apr. 01, 2011	Notice of Service of Respondent's First Set of Interrogatories filed.
Mar. 18, 2011	Answers to Agency's First Request for Admissions filed.
Feb. 16, 2011	Order Granting Continuance and Re-scheduling Final Hearing (hearing set for May 11 and 12, 2011; 10:00 a.m.; Eustis, FL).
Feb. 16, 2011	Joint Motion for Continuance filed.
Feb. 15, 2011	Order Granting Request for Official Recognition.
Feb. 11, 2011	Respondent's Response to Petitioner's Request for Judicial Notice filed.
Feb. 07, 2011	Petitioner's Request for Judicial Notice filed.
Feb. 07, 2011	Notice of Service of Agency's First Set of Interrogatories, Request for Admissions and Request for Production of Documents to Respondent filed.
Feb. 03, 2011	Notice of Hearing (hearing set for March 9 and 10, 2011; 10:00 a.m.; Eustis, FL).
Feb. 03, 2011	Order of Pre-hearing Instructions.
Feb. 02, 2011	Notice of Unavailability filed.
Jan. 21, 2011	Amended Notice of Transfer.
Jan. 20, 2011	Notice of Transfer.
Jan. 14, 2011	Joint Response to Initial Order filed.
Jan. 07, 2011	Initial Order.
Jan. 05, 2011	Notice (of Agency referral) filed.
Jan. 05, 2011	Petition for Formal Administrative Hearing filed.
Jan. 05, 2011	Administrative Complaint filed.