STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, "VS. Case No. 2011011292 SWEETGRASS & CEDARS HOME, LLC, d/b/a GULF WINDS, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency’), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, SWEETGRASS & CEDARS HOME, LLC d/b/a GULF WINDS (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and states: NATURE OF THE ACTION This is an action to impose an administrative fine against an assisted living facility in the sum of TWELVE THOUSAND DOLLARS ($12,000.00) based upon two (2) Class I violations pursuant to Section 429,19(2)(a), Florida Statutes (2011), and two (2) Class IT violations pursuant to Section 429.19(2)(b), Florida Statutes (2011); to assess a survey fee in the amount of FIVE “HUNDRED DOLLARS ($500.00) pursuant to Section 429,19(7), Florida Statutes (2011), and to revoke the license pursuant to Sections 408.815(1)(b) and (c) and 429.14(1)(e)1 and (j), Florida Statutes (2011). JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 Filed February 6, 2012 2:21 PM Division of Administrative Hearings and 120.57, Florida Statutes (2011). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2011). 3, Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state regulations, statutes and rules governing such facilities. Chapters 408, Part II, and 429, Part I, Florida Statutes (2011); Chapter 58A-5, Florida Administrative Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility, or impose an administrative fine in the manner provided in Chapter 120, Florida Statutes (2011). Sections 408.815 and 429,14, Florida Statutes (2011), 5. The Respondent was issued a license by the Agency (License Number 7804) to operate a 50-bed assisted living facility located at 2745 Venice Avenue East, Venice, Florida 34292, and was at all times material required to comply with the applicable state regulations, statutes and rules governing assisted living facilities. COUNT I The Respondent Failed To Ensure Each Resident’s Right To Live In A Safe And Decent Living Environment, Free From Abuse And Neglect In Violation Of Section 429.28(1)(a), Florida Statutes (2011) . 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, no resident of @ 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. Section 429,28(1)(a), Florida Statutes (2011). 8. On or about September 21, 2011 through September 23, 2011, the Agency conducted a Complaint Survey (CCR# 2011010124) of the Respondent's facility. 9. Based on observations and interviews, the Respondent failed to ensure each resident’s right to live in a safe and decent living environment, free from abuse and neglect for two (2) of two (2) residents observed, Resident number one (1) and Resident number two (2) and two (2) of two (2) residents, Resident number three (3) and Resident number four (4), who were confirmed by staff to be locked in a gated area to "Keep them safe." 10. The Respondent failed to ensure one (a) resident did not develop pressure sores, Resident number five (5), and failed to provide a safe living environment free of hazards as verified by the Fire Inspector. The Respondent secured all doors to the facility in an unsafe manner; failed to staff to meet the needs, including evacuation of the residents, and restrained and segregated wandering residents within the facility. These conditions posed an imminent danger to the residents of the Respondent or a substantial probability that death or serious physical or . emotional harm would result therefrom. 11. Observations on September 23, 2011 of all exit doors with red exit signs revealed the handles were locked and there was also a sliding pin lock at the top of each door. 12, The doors could not be opened without releasing the top pin lock at the top of the door. One (1) red marked exit door in the back living room did not have a handle and had a sliding pin lock keeping the door lockeds-~~-------- 13. Staff member number two (2) stated that the door could not be opened even if the pin lock was released because the handle on the door knob was missing. 14. The alarm to the exit door by rooms nine (9) and ten (10) did not work when the door was opened. basket from in front of the door. 15. An interview with the Fire Inspector on September 23, 2011 revealed locking the doors in this manner was very bad and had to be corrected before he would leave the building. 16. The Fire Inspector was observed collecting all the pin locks in a plastic bag and removing them from the facility when he left. 17, On September 23, 2011, when the locks were being removed by staff with the Fire Inspector, Resident number one (1) was discovered to have slipped past the one-on-one staff member who was assigned to him/her and had exited the building. The staff found Resident number one (1) outside and returned him/her to the facility. 18. Observations on September 23, 2011 revealed a sliding gate that could close off the area between the back living room and resident's rooms and the front area and main dining room. 19, Staff member number two (2) stated the gate was closed and locked so the residents could be kept out of the front area. 20. Staff member number two (2) stated some residents would wander around at night and with only one (1) staff member staying with them, the gate would be shut and locked to keep residents safe. 21. An observation on September 21, 201 \ during a tour of the dining room revealed a sliding glass door leading to an outside patio area. 22. Staff member number three (3) tried to open the door to observe the outside area. The lock on the door was broken. The staff touring tried to open the door after removing a waste 23. Staff member number three (3) said the lock hadn't worked for a long time and didn't know when it would be fixed. The door was not fixed when the Fire Inspector left on September 23, 2011. 24. An observation of the staffing pattern revealed only one (1) staff in the building from 9:30 p.m. to 6:00 a.m. every day. 25. The facility census was twenty six (26) with an additional respite person on the weekends, 26. The assistant administrator verified of the twenty six (26) residents present three (3) residents required a two (2) person assist to move from bed to wheelchair and an additional six ) (6) people who cannot assist in evacuation; ten (10) required the assistance of one (1) person to cue and lead the residents to safety and seven (7) could independently evacuate when an alarm sounded. 27. Resident number five (5) was observed on September 23, 2011 at 2:30 p.m. with the hospice nurse for wound care. 28. Anaide was present to help position Resident number five (5). The nurse removed some patches from her bag, put on a pair of gloves, and removed the dressing from the left trochanter which had a stage IT pressure ulcer. The nurse threw the old dressing jin the waste can, The nurse washed the area with sterile solution, and applied a clean dressing. The nurse removed the dressing from the right trochanter, washed it and put on a clean dressing, This area was a stage IU] pressure ulcer. The nurse removed the dressing from the right inner thigh, cleansed it, and applied a clean dressing. The nurse applied Sensi-Care ointment to the resident’s lower back and buttocks. The nurse then removed her gloves and washed her hands. Resident number five (5) was __ observed to have three (3) pressure sores. nee 29. A record review revealed these were in-house acquired. "30. Observations during the tour on September 21, 2011 revealed one (1) resident, Resident number two (2), in an area of the side living room pacing back and forth in front of a partial fence made of wood with a gate that was all covered in Plexi-glass on the inside. 31. The gate was locked. The room was bare except for five (s) chairs, a sofa, a small table, and two (2) empty book cases. Behind one (1) empty bookcase were front windows with the glass broken in one and the screen broken in the other. 32. Staff member number three (3) stated the bookcase was put in front of the window so the residents wouldn't get hurt. 33. Staff member number three (3) stated a resident had punched the windows out a while ago and didn't know when they would be fixed. 34. Staff member number three (3) stated usually there were three (3) other residents in this gated area, Resident number one (1), Resident number three (3) and Resident number four (4); however, at no time during the survey were Resident number three (3) and Resident number four (4) observed locked in the small living area, 35. The staff had stated the residents would be put there for safety. Staff member number three (3) stated these residents wander, go into other residents’ rooms and go outside and it causes problems, so the facility built this fence for this little area to be able to keep these residents secure while staff works. 36. Staff member number three (3) stated the staff takes these residents out of the locked area for meals and for walks during the day. 37, Observations at 10:45 a.m. on September 21, 2011 revealed another resident, Resident number one (1), being put in the locked area with Resident number two (2). .38.___ Resident number one (1) was put on the sofa by Stalf member number four (4) and told to stay there. Resident number one (1) got up from the sofa and walked to the fence and paced up and down the fence with Resident number two (2). 39. Staff member number three (3) stated Resident number one (1) stayed up late at night and usually slept late and that's why he/she wasn't in the locked area with Resident number two (2) earlier. 40. Staff member number three (3) stated that Resident number three (3) and Resident number four (4) would be put in the locked area if they started to wander around and didn't stay in their room or stay with the other residents in the back living room. 41. Observations of Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) eating lunch revealed them in a separate room. The room had one (1) table and four (4) chairs. There were no decorations in the room and nothing on the table. 42. Observations on September 23, 2011 revealed a gate across the small dining room doorway. This’ gate could swing to close the doorway to the small dining room. 43. Staff member number two (2) stated the gate would be closed and locked to keep Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) in the room while they helped serve the other residents in the main dining room. 44. Observations of the tables in the main dining room where the other residents were eating revealed tablecloths, flowers, utensils, napkins, glasses and condiments. 45. During an interview, Staff member number three (3) stated Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) didn't eat with the other residents because they would take food and drinks from the other residents and it caused problems. 46. During an interview on September 21, 2011 after the administrator arrived at the __facility, the administrator confirmed Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) were put in the locked area "for their own safety." 47. The administrator also stated Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) ate in the separate dining room away from the other residents. The administrator said she thought it was all right for the residents to be put in the locked area to keep them safe. a ee ee 48. The administrator stated family members were aware of the safety precaution and it was okay with them. 49. The Respondents deficient practice constituted a Class I violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. Section 429.19(2)(a), Florida Statutes (2011). 50. The Agency shall impose an administrative fine for a Class I violation in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for cach violation as set forth in Section 429.19(2)(a), Florida Statutes (2011). A fine shall be levied notwithstanding the correction of the violation, WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(a), Florida Statutes (2011). COUNT IL The Respondent Failed To Provide A Safe Living Environment Free Of Hazards And Failed To Ensure All Existing Mechanical And Structural Systems Were Maintained In Good Working Order In Violation Of Rule S8A-5.023(3)(a), Florida Administrative Code 51. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 52. Pursuant to Florida law, all facilities must provide a safe living environment pursuant to Section 429 28(1)(a), Florida Statutes (201 1), must be maintained free of hazards, and must ensure that all existing architectural, mechanical, electrical and structural systems and appurtenances are maintained in good working order. Rule 58A-5.023(3)(a); Florida Administrative Code. 53. Onor about September 21, 2011 through September 23, 2011, the Agency conducted a Complaint Survey (CCR# 2011010124) of the Respondent’s facility. 54, Based on observations and interview, the Respondent failed to provide a safe living environment free of hazards as verified by the Fire Inspector. 55. The facility secured all doors to the facility in an unsafe manner and restrained and segregated wandering residents within the facility. These conditions pose an imminent danger to the residents of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. 56. Observations on September 23, 2011 of all exit doors with red exit signs revealed the handles were locked and there was also a sliding pin lock at the top of each door. The doors could not be opened without releasing the pin lock at the top of the door. 57. One (1) red marked exit door in the back living room did not have a handle and had a sliding pin lock keeping the door locked. 58. Staff member number two (2) stated the door could not be opened even if the pin lock was released because the handle on the door knob was missing. The alarm to the exit door by rooms nine (9) and ten (10) did not work when the door was opened. 59. An interview with the Fire Inspector on September 23, 2011 revealed locking the doors in this manner was very bad and had to be corrected before he would leave the building. 60. The Fire Inspector was observed collecting all the pin locks in a plastic bag and removing them from the facility when he left. 61,-. -The-facility--was-instructed -to-dismantle.the. gates.and fenced. area.before .the. fire inspectors returned on September 26, 2011. 62. On September 23, 2011 when locks were being removed by the staff with the Fire Inspector, Resident number one (1) was discovered to have slipped past the one-on-one staff member who was assigned to him/her and exited the building without an alarm sounding. 63. The staff found Resident number one (1) outside and returned him/her to the 9 facility. 64. Observations on September 23, 2011 revealed a sliding gate that could close off the area between the back living room and residents’ rooms and the front area and main dining room. 65. Staff member number two (2) stated. the gate was closed and locked so the residents could be kept out of the front area. . 66. Staff member number two (2) stated some residents would wander around at night and with only one (1) staff member staying with them, the gate would be shut and locked to keep residents safe. 67. Anobservation on September 21, 2011 during a tour of the dining room revealed a sliding glass door leading to an outside patio area. 68. Staff member number three (3) tried to open the door to observe the outside area. The lock on the door was broken. Staff member number three (3) tried to open the door after removing a waste basket from in front of the door. 69, Staff member number three (3) said the lock hadn't worked for a long time and didn't know when it would be fixed. The door was not fixed when the Fire Inspector left on September 23, 2011. 70. During an interview on September 21, 201], the administrator stated that she would get the doors fixed. 11... .An.observation.of the staffing pattern revealed only one (1) staff member in the building from 9:30 p.m. to 6:00 a.m. every day. The facility census was twenty six (26) with an additional respite person on the weekends. 72, The assistant administrator verified of the twenty six (26) residents present three (3) residents required a two (2) person assist to move from bed to wheelchair and an additional (six) 6 people who cannot assist in evacuation; ten (10) required the assistance of one (1) person 10 to cue and lead the residents to safety and seven (7) could independently evacuate when an alarm sounded. ) 73. Observations during the tour on September 21, 2011 revealed Resident number (2) in an area of the side living room pacing back and forth in front of a partial fence made of wood with a gate that was all covered in Plexiglas on the inside. The gate was locked. 74. The room was bare except for five (5) chairs, a sofa, a small table, and two (2) empty bookcases. "78. — Behind one empty bookcase were front windows with the glass broken in one and the screen broken in the other, 76. Staff member number three (3) stated the bookcase was put in front of the window - so the residents wouldn't get hurt. 77. Staff member number three (3) stated a resident had punched the windows out a while ago and didn't know when they would be fixed. 28. . Staff member number three (3) stated these residents wander, go into other resident's rooms and go outside and it causes problems, so the facility built this fence for this little area to be able to keep these residents secure while staff works. Staff member number three (3) stated the staff takes these residents out of the locked area for meals and for walks during the day. 79, Observations at 10:45 a.m, on September 21, 2011 revealed another resident, Resident number one (1) being put in the locked area with Resident number two (2). --80,-- Resident number-one.(1)-was.put.on-the-sofa-by.Staff:member number four.(4) and told to stay there. Resident number one (1) got up from the sofa and walked to the fence and paced up and down the fence with Resident number two (2). 81. Staff member number three (3) stated Resident number one (1) stays up late at night and usually sleeps late and that's why he/she wasn't in the locked area with Resident number two (2) earlier. 82. Staff member number three (3) stated that Resident number three (3) and Resident number four (4) would be put in the locked area if they started to wander around and didn't stay in their room or stay with the other residents in the back living room. 83. Observations on September 23, 2011 revealed a gate across the small dining room doorway. This gate could swing to close the doorway to the small dining room. 84. Staff member number two (2) stated the gate would be closed and locked to keep Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) in the room while they helped serve the other residents in the main dining room. 85. During an interview on September 21, 2011 the administrator confirmed Resident number one (1), Resident number two (2), Resident number three (3) and Resident number four (4) were put in the locked area for their own safety, The administrator also stated they ate in the separate dining room away from the other residents that could be locked. 86. The administrator said she thought it was all right for the residents to be put in the locked area to keep them safe. The administrator stated that family members were aware of the safety precaution and it was okay with them, 87. The Respondent’s deficient practice constituted a Class | violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determines present an imminent danger to the clients of the provider or a substantial probability that death or setious physical or emotional harm would result therefrom. Section 429.19(2)(a), ~-Plorida-Statutes: (2011) 9-2 eect cen cnn seen 88. The Agency shall impose an administrative fine for a Class I violation in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation as set forth in Section 429.19(2)(a), Florida Statutes (2011). A fine shall be levied notwithstanding the correction of the violation. [a three (3) administering medications to Resident number five (5). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of FIVE THOUSAND DOLLARS ($5,000.00) pursuant to Section 429.19(2)(a), Florida Statutes (2011). COUNT UI The Respondent Failed To Ensure Qualified Staff Administered Medications In Violation Of Rule 58A-5.0185(4)(a), Florida Administrative Code 89. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5), 90. Pursuant to Florida law, for facilities which provide medication administration a staff member, who is licensed to administer medications, must be available to administer medications in accordance with a health care provider’s order or prescription label. Rule 58A-5.0185(4)(a),Florida Administrative Code. 91. Onor about September 21, 2011 through September 23, 2011, the Agency conducted a Complaint Survey (CCR# 2011010124) of the Respondent’s facility. 92. Based on observation and interview, the Respondent failed to have qualified staff administer medications to Resident number five (5), a hospice resident. Unlicensed staff administering medications to residents, particularly those who are frail and confused or severely debilitated posed a direct threat to the residents as they are not trained to assess the residents’ conditions and reactions. 93. An observation on September 23, 2011 at 1:30 p.m, revealed Staff member number 94. Staff member number three (3) took two (2) prescribed “Tylenol from the medication cart then put the two (2) pills in applesauce. Staff member number three (3) took the medication to Resident number five’s (5) room. Staff member number three (3) raised the head of the bed to have Resident number five (5) in a sitting position. 95. Staff member number three (3) put one (1) pill on a spoon with some of the 13 applesauce and put the spoon to Resident number five’s (5) mouth and pushed the pill into his/her mouth. Resident number five (5) crunched on the pill. Staff member number three (3) offered Resident number five (5) something to drink from a straw and he/she sipped a little of the fluid. Staff member number three (3) repeated this procedure with the second pill. 96. Staff member number three (3) stated he had been giving Resident number five (5) all of his/her medication this way for months because Resident number five (5) was unable to assist in any way in taking medication, 97. Staff member number three (3) stated he was not a nurse, but he was a medication technician, 98, The Respondent’s deficient practice constituted a Class I violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 429.19(2)(b), Florida Statutes (2011). 99, The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429.19(2)(b), Florida Statutes (2011), A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE _. THOUSAND DOLLARS ($1,000.00) pursuant to Section 429,19(2)(b), Florida Statutes (2011). COUNT IY The Respondent Failed To Ensure An Activities Program For Residents In Violation Of Rule 58A-5.0182(2), Florida Administrative Code 100. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 101. Pursuant to Florida law, residents shall be encouraged to participate in social, 14 recreational, educational and other activities within the facility and the community. (a) The facility shall provide an ongoing activities program. The program shall provide diversified individual and group activities in keeping with each resident’s needs, abilities, and interests, (b) The facility shal] consult with the residents in selecting, planning, and scheduling activities. The facility shall demonstrate residents’ participation through one or more - of the following methods: resident meetings, committees, a resident council, suggestion box, group discussions, questionnaires, or any other form of communication appropriate to the size of the facility. (c) Scheduled activities shall be available at least six (6) days a week for a total of not less than twelve (12) hours per week, Watching television shall not be considered an activity for the purpose of meeting the twelve (12) hours per week of scheduled activities unless the television program is a special one-time event of special interest to residents of the facility. A facility whose residents choose to attend day programs conducted at adult day care centers, senior centers, mental health centers, or other day programs may count those attendance hours towards the required twelve (12) hours per week of scheduled activities, An activities calendar shall be posted in common areas where residents normally congregate. (d) If residents assist in planning a special activity such as an outing, seasonal festivity, or an excursion, up to three (3) hours may be counted toward the required activity time. Rule 58A-5.0182(2), Florida Administrative Code. 102, On or about September 21, 2011 through September 23, 2011, the Agency conducted a Complaint Survey (CCR# 2011010124) of the Respondent’s facility. 103. Based on observations and interviews, the Respondent failed to provide an ongoing activities program for residents living in the facility. The residents instead were segregated in locked areas to pace rather that have activities to keep them occupied. 15 104. An observation during a tour with a staff member of the facility on September 21, 2011 revealed no activities calendar. 105. The staff member stated the facility didn't have an activities calendar. 106. Staff stated they used to have an activities calendar but because of lack of participation they didn't do anything. The staff member stated the residents have some exercise time, they take some of them for a walk every day, and some will watch television. 107. The Staff member stated the residents didn't participate so the facility didn’t plan anything for them. 108. During the day of the survey, there were no activities observed with the residents, Residents were seen in the back living room sitting in front of the television, but were generally asleep. 109. Some residents were noted wandering around the facility doing nothing. Two (2) residents, Resident number one (1) and Resident number two (2) were observed in the front living area that was a fenced and gated locked area. There was nothing for them to do in this area. The room was bare except for five (5) chairs, a sofa, a small table, and two (2) empty bookcases. 110. Staff stated usually there were two (2) other residents also in this room. 111. During an interview on September 21, 2011, the administrator confirmed there was no activities calendar at the facility. The administrator stated she had one but that it was from August and had not been posted, The administrator stated the residents don't want to participate in _. activities. The administrator stated the residents like to take walks and they like to go on outings and some residents will watch television, so the staff just takes them for walks and takes some on outings at least twice a month. 112. When asked about resident council meeting discussions with the residents regarding the things they would like to do, the administrator stated, "We do not have resident meetings. The assistant administrator talks to everyone individually. We just can't get residents to do anything." 113. The Respondent's deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class J violation. Section 429.19(2)(b), Florida Statutes (2011). 114. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation as set forth in Section 429,19(2)(b), Florida Statutes (2011). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2011). COUNT V Revocation Of Licensure Pursuant to Sections 408,815(1)(b) and (c), and 429,14(1)(a) And(e)1, Florida Statutes (2011) 115. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 116. The Agency re-alleges and incorporates by reference the allegations in Count I through Count IV. 117. Pursuant to Florida law, in 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: An intentional or negligent act materially affecting the health or safety of a client of the provider. A violation of Section 408, Part I, Florida Statutes (2011), authorizing statutes, or 17 applicable rules, Section 408,815(1)(b) and (c), Florida Statutes (2011). Pursuant to Florida law, in addition to the requirements of Part II of Chapter 408, Florida Statutes (2011), the Agency may deny, revoke, and suspend any license issued under Part I of Chapter 429, Florida Statutes (2011), and impose an administrative fine in the manner provided in Chapter 120, Florida Statutes (2011), against a licensee for a violation of any provision of Part I of Chapter 429 or Part II of Chapter 408, Florida Statutes (201 1), or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level IT background screening under Section 408.809, Florida Statutes (2011), or for the actions of any facility employee: An intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. A citation of any of the following deficiencies as specified in Section 429.19, Florida Statutes (2011): 1. One or more cited Class I deficiencies. Section 429.14(1)(a) and (e)1, Florida Statutes (2011). 118. The Respondent’s facility violated provisions of Chapter 429, Part 1, Florida Statutes (2011) and Chapter 408, Part II, Florida Statutes (2011) and applicable rules as outlined in Count I through Count IV above. 119... The Respondent’s facility was cited for two (2) Class I deficiencies and two (2), Class II deficiencies arising from circumstances from the Complaint Survey (CCR# 201101 0124) of Respondent’s facility on or about September 21, 2011 through September 23, 2011. 120. The Respondent's facility engaged in an intentional or negligent act materially affecting the health or safety of residents of the facility as outlined in Count I through Count IV above. WHEREFORE, the Agency respectfully requests the Court enter an order REVOKING the license of Respondent, an assisted living facility in the State of Florida, pursuant to Sections 408.815(1)(b) and (c) and 429,14(1)(a) and(e)1, Florida Statutes (2011). COUNT Vi (Assessment of Survey Fee) 121, The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and the allegations in Count I through Count IV. 122. ‘The Agency conducted a Complaint Survey (CCR# 2011010124) of the Respondent's facility on September 21, 2011 through September 23, 2011. 123, As a result of, the Agency’s Complaint Survey (CCR# 2011010124), the Respondent was cited for two (2) Class I deficiencies and two (2) Class II deficiencies, 124, Pursuant to Section 429.19(7), Florida Statutes (2011), the Agency is authorized to, in addition to any administrative fines imposed, assess a survey fee equal to the lesser of one- half of the facility’s biennial license and bed fee or five hundred dollars ($500.00), to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statutes (2011), to verify the correction of the violations, 125. In this case, the Agency is authorized to seek a survey fee of FIVE HUNDRED DOLLARS ($500.00). _WHEREFORE, the Petitioner, State of Forde, Agency for Health Care Administration intends to assess a survey fee against the Respondent in the amount of FIVE HUNDRED _ DOLLARS ($500.00) pursuant to Section 429.19(7), Florida Statutes (2011). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief: 1. Enter findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of TWELVE THOUSAND DOLLARS ($12,000.00). 3. Revoke the license of the Respondent to operate as an assisted living facility. - 4. ‘Assess a survey fee against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). 5. Order any other relief that the Court deems just and appropriate. Respectfully submitted on this , A day of Pacacsahittye 2012. ay feley Luge Agsistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 335-1253 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS ARIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120,569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE 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 AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 412-3630. . THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. 20 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No: 2011011292 SWEETGRASS & CEDARS HOME, LLC, d/b/a GULF WINDS, - Respondent. ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA), The title may be an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (21) days of the date you receive the attached Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. If your Election of Rights with your elected Option is not received by AHCA within twenty-one (21) days from the date you received this 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 use this form unless you, your attorney or your representative prefer to reply in accordance with Chapter 120, Florida Statutes (2011) and Rule 28, Florida Administrative Code. PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 “Phone: 850-412-3630° ~~ ~~ Bax: 850-921-0158 — ne PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) _____ I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and 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 imposes the penalty, fine or action. OPTION TWO (2) I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint, 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 (3) ___ I dispute the allegations of fact and law contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, aud I request a formal bearing (pursuant to Subsection 120.57(1), Florida Statutes) 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 also must file a written petition in order to obtain a formal hearing before the 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 your receipt of this proposed © administrative action, The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. Astatement of all disputed issues of material fact. If there are none, you must state that there are none, Mediation under Section 120.573, Florida Statutes may be available in this matter if the Agency agrees. License Type: (Assisted Living Facility, Nursing Home, Medical Equipment, Other) ; Licensee Name: License Number:___ Contact Person: Name Title Address: Street and Number City State Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the above licensee. Date: Signature: Title: Print Name: COMPLOTE THIS SECTION ON DELIVERY B. Racelvad by (Pointed Namd : ml Complete items 1, 2, and @, Also complete item 4 if Restricted Delivery is desired. 8 Print your name and address on the reverse g0 that we can return the card to you. . M Attach thls card to the bak of the mallpiece, or on the front If space permits. 1. Anllcle Addressedto: 2 + Mana C Wwlham ‘, Adininistre ‘ aud Registered Agent for Shacet yeast “antl Coders Heme, LLC d/b/a Gul & Winds D, Is delivery address different fro (ters WYES, enter delivery address below? __! 8, Service Type C1 Certitled Mail (C1 Express Mall : 2745 Ven te Meenve Gast CO) Registered ° ©] Return Recelpt for Merchandise . ' D1 Insured Malt 0.0.0, : Vou oe Fi loride. 34292 4, Restricted Delivery? (Extra Fee) + 2 Article Numbe } ee ecorromvenicetey __ 007 dbBO OO 5448 Shel FSA a aa OO PS Form 3811, February 2004 Domestlo Retum Recelp! 102596-02-M-1540

Docket for Case No: 12-000508

Orders for Case No: 12-000508