STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003000867 vs, WESLEY MANOR, INC., d/b/a D2»? DSC WESTMINSTER WOODS ON JULINGTON CREEK, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against WESLEY MANOR. INC., d/b/a WESTMINSTER WOODS ON JULINGTON CREEK (‘Westminster NATURE OF THE ACTION 1. This is an action to impose a statutory fine upon WESTMINSTER WOODS, pursuant to Section 400.23(8)(b), Florida Statutes (2002), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2002). 4, Venue shall be determined pursuant to Rule 28-1 06.207, Florida Administrative Code (2002). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Wesley Manor, Inc., d/b/a Westminster Woods on Julington Creek, is a Florida corporation with a principal address of 80 West Lucerne Circle, Orlando, Florida 32801. 7. Westminster Woods is a 60-bed skilled nursing facility located at 25 State Road 13, Jacksonville, Florida 32259. Westminster Woods is licensed by AHCA as a skilled nursing facility having been issued license number SNF15900961 certificate number 9886, with an effective date of January 27, 2003 and an expiration date of December 31, 2003. 8. Westminster Woods is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part Il, Florida Statutes and Chapter 59A-4, Florida Administrative Code, respectively. COUNTI AT THE MOST RECENT ANNUAL SURVEY OF JANUARY 27-29, 2003 AHCA DETERMINED THAT WESTMINSTER WOODS ON JULINGTON CREEK WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF TWO (2) CLASS | DEFICIENCIES § 400.23(7)(b) and (8)(a}, Florida Statutes Rule 59A-4.130(1) and (2), F.A.C., Rule 594-104.6(4)(n) 42 CFR 483.70(a) 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. The regulatory provisions of the Florida Statutes, Code of Federal Regulations and Florida Administrative Code that are pertinent to these alleged violations read as follows: 400.23 Rules, evaiuation and deficiencies; licensure status. — (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of the deficiencies as follows: (b) A class ll deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class || deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class Il deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 483.70 Physical environment The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. (a) Life safety from fire. Except as provided in paragraph (a)(1) or (a)(3) of this section, the facility must meet the applicable provisions of the 1985 edition of the Life Safety Code of the National Fire Protection Association (which is incorporated by reference)... ~~ 59A-4.130 Fire Prevention, Fire Protection, and Life Safety (1) A licensee shall comply with the life safety code requirements and building code standards applicable at the time of departmental approval of the facility's Third Stage — Construction Documents. (2) Fire prevention, fire protection, and life safety practices shall be the responsibility of the facility Administrator. FIRST CLASS | DEFICIENCY 11. On or about January 27-29, 2003, AHCA conducted an annual survey at Westminster Woods. On or about January 27-29, 2003, the AHCA surveyor found that the facility failed to ensure that all residents were free from fire hazards and maintained safely from fire in that the fire alarm system for the second floor was non-functioning and the emergency exit stairwell was obstructed, preventing safe egress from the nursing unit. This posed an immediate and serious threat to the residents. On that basis, the AHCA survey team cited Westminster Woods with a Class | deficiency, supported by the following findings: la 11.1. The NFPA 101 Life Safety Code Standard requires a fire alarm system, not a pre-signal type, with approved component devices or equipment installed to provide effective warning of fire in any part of the building. The Code Standard provides that pull stations in patient sleeping areas may be omitted at exits if they are located at all nurses’ stations, are visible and continuously accessible and travel distances of 7- 6.2.4 are not exceeded. Required sprinklers, detectors, etc. must be arranged to activate the fire alarm system and operate devices such as dampers, door hoiders, etc. Fixed extinguishment protective systems protecting commercial cooking equipment in kitchens protected by a complete automatic sprinkler system need not initiate the building fire alarm system. The fire alarm system is required to be connected to automatically transmit an alarm to summon the local fire department. Every fire alarm and detection system required by Code is required to be continuously in operating condition. 11.2 -.On or about January 27-29, 2003 the AHCA survey team. observed during a tour with facility staff that the facility was not in compliance with the requirements of NFPA 101 Life Safety Code and NFPA-72 National Fire Alarm Code, posing an immediate and serious threat to the residents based on the following findings: 11.3 The fire alarm system required for Life Safety was not maintained and restored to service immediately and was not kept in normal condition for the proper operation. 11.4 The fire alarm system did not function or operate as required and could not be initiated to properly sound an alarm in the event of fire or emergency. 11.5 The fire alarm system could not give occupant notification automatically, without delay, upon operation of any fire alarm activating device. 11.6 The inoperable fire alarm system could not give automatic notification to the Fire Department in the event of fire or emergency. 11.7 The immediate jeopardy was noted as removed after the documentation, provided by the facility on January 29, 2003, evidenced that fire watch rounds were being initiated every 15 minutes as of January 28, 2003 at 7:15 p.m. The facility had been in contact with the St. Johns County fire marshal, who had provided the protocol necessary to constitute a proper fire watch in a long term care facility. 12. Based on ail of the foregoing, Westminster Woods violated: (a) 42 CFR 483.70(a) via Rule 59A-4.1288, Florida Administrative Code, and (b) 59A-4.130(2), F.A.C. by failing to be in compliance with the requirements of NFPA 101 Life Safety Code and NFPA-72 National Fire Alarm Code by failing to have a functional fire alarm system at all times and by, upon becoming aware that the fire alarm system was not functional, failing to immediately institute 15-minute fire watches and to make arrangements for the immediate repair of the non-functioning alarm system. 13. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing is a class | ..deficiency for which the imposition of a Statutory fine is authorized.because-it- presented a- - situation in which immediate corrective action was necessary because the facility's noncompliance was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the facility. 13.1. AHCA gave Westminster Woods a written mandated correction date of February 6, 2003, in accordance with Section 400.23(8)(b), Florida Statutes and the agency found that the immediate jeopardy had been removed prior to the end of the survey. SECOND CLASS | DEFICIENCY 14. On or about January 27-29, 2003 during an annual Survey conducted by AHCA at Westminster Woods, AHCA cited Westminster Woods for a second class | deficiency on the basis that the facility failed to meet the requirement that it be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public. Based on observations throughout the facility, staff interview and review of documentation provided by the facility, the facility failed to ensure that all residents were free from fire hazards and maintained safely from fire. AHCA surveyors observed that the fire alarm system for the second floor health care center was not functioning and the emergency exit stairwell was obstructed, preventing safe egress from the nursing unit. This poses a serious and immediate threat to the residents. The findings of the AHCA survey team included: 14.1. On or about January 28, 2003 at approximately 2:45 p.m. a fire drill was conducted by the AHCA fire life safety specialist at the health care center located on the second floor of the facility. It was evident that the fire alarm system was non-functional, There was no audible alarm and fire doors did not release. On or about January 28, 2003 at approximately 4:00 p.m. with the facility administrator revealed that the fire alarm system “went down” on the evening of January 26, 2003. The facility administrator stated that they were notified of the failure of the fire alarm system at approximately 8:15-a.m. on January 27, 2003- ee 14.2. Observations of the southeast emergency exit stairwell at approximately 2:00 p.m. on January 28, 2003 revealed that the exit was obstructed with construction and building equipment as well as flammable materials, preventing a safe and timely evacuation of the second floor in the event of a fire. Observation of the metal door at the bottom of the stairwell revealed it to be damaged, in that the top hinge was bent, causing the door not to shut completely. 14.3, On or about January 27, 2003 [the first day of the annual survey], the facility census was 58 residents, pursuant to observations of the residents and review of the facility. One (1) resident was bed fast and thirty-eight (38) of the residents were chair-bound, unable to take steps without extensive weight-bearing support. 14.4. The facility administrator stated that an hourly fire watch had been implemented in the health care center at approximately 4:00 p.m. on January 27, 2003. Before the survey team exited the facility on January 28, 2003, the facility was in the process of clearing the obstructed stairwell and had changed the fire watch to every 15 minutes. Review of the documentation provided by the facility revealed that the fire watch had begun at 4:25 p.m. on January 27, 2003 and continued hourly until 2:00 p.m. on January 28, 2003, when there was a 2 hour gap in documentation. The next notation was at 4:00 p.m. and rounds continued hourly until 7:15 p.m., when it was documented that fire rounds were made every 15 minutes. 14.5. On or about January 29, 2003 at 7:05 a.m. observations in the resident dining area revealed 18 residents in the room with staff serving the first seating for breakfast. The survey team noted that there was a pervasive hot mechanical odor and a high-pitched motor hum. Staff stated that someone had left a tray on the juice machine, causing the machine to overheat and burning out the fan. The juice machine was still plugged into the outlet. Staff stated that the dietary department was bringing extra .. pitchers to the unit to-fill with juice.and that-the machine would then be unplugged. The juice machine remained plugged into the outlet until 7:15 a.m. Review by the survey team of the fire watch log revealed documentation at 6:00 a.m. on January 29, 2003, the notation “OK” was written under the section entitled “comments”. At 6:15 a.m. it was noted “removed tray from top of juice machine in dining room”. 14.6. At 4:30 p.m. on January 29, 2003 the facility remained on fire watch rounds conducted every 15 minutes. Facility administration provided documentation of a proposal to replace the fire alarm system dated January 29, 2003. The facility also provided documentation from the St. John’s County fire marshal acknowledging notification that the facility's fire alarm system was out of service. The facility stated that they anticipated the fire alarm system would be operational on January 30, 2003. 14.7. The immediate jeopardy was noted as removed by the survey team after the documentation, provided by the facility on January 29, 2003, revealed that fire watch rounds were being initiated every 15 minutes as of January 28, 2003 at 7:15 p.m. and that the facility had been in contact with the St. Johns County fire marshal, who had provided the protocol necessary to constitute a proper fire watch in a long term care facility. 15. Based on all of the foregoing, Westminster Woods violated: (a) 42 CFR 483.70(a) via Rule 59A-4.1288, Florida Administrative Code, and (b) 59A-4.130(2), F.A.C. through its failure to ensure that the facility was equipped and maintained to protect the health and safety of residents, personnel and the public by failing to be in compliance with the requirements of NFPA 101 Life Safety Code and NFPA-72 National Fire Alarm Code by failing to have a functional fire alarm system at all times and by, upon becoming aware that the fire alarm system was not functional, failing to immediately institute 15-minute fire watches and to make arrangements for the immediate repair of the non-functioning alarm system. 16. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing is a class | ‘deficiency for which the imposition of a” statutory fine is authorized bécause it presented a situation in which immediate corrective action was necessary because the facility’s noncompliance was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the facility. 16.1 AHCA gave Westminster Woods a written mandated correction date of February 6, 2003, in accordance with Section 400.23(8)(b), Florida Statutes and the agency found that the immediate jeopardy had been removed prior to the end of the survey. 16.1. Based on the foregoing, on or about January 27-29, 2003 AHCA cited Westminster Woods for two (2) class | deficiencies and assigned the facility a conditional licensure status, in accordance with the mandates of Section 400.23(7)(b), Florida Statutes. The deficiencies were characterized by AHCA as widespread, in accordance with Section 400.23(8), Florida Statutes, in that they represented deficiencies that represented systematic failure that had the potential to affect a large portion of the facility's residents. 17. AHCA assessed a statutory fine against to Westminster Woods based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of two (2) uncorrected class | deficiencies at the most recent annual survey on or about January 27-29, 2003. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make actual and legal findings in favor of AHCA on Count |: 2) Impose a fine against WESTMINSTER WOODS in the amount of $36,000.00 and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). ae - Notice _ WESTMINSTER WOODS ON JULINGTON CREEK is hereby 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). 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, Mail Stop #3, Tallahassee, Florida, 32308. WESTMINSTER WOODS ON JULINGTON CREEK IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY AHCA. Respectfully submitted on this £F, Fla. Bar. No. 325821 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-5873 (office) (850) 921-9313 (fax) CERTIFICATE OF SERVICE | HEREBY CERTIFY that the original Administrative Complaint has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # Tl0b 455 12944 2044 826 ) to Donald. Wilson, Administrator,.Wesley Manor,.-Inc.-d/b/a Westminster Woods. on Julington Creek, 25 State Road 13, Jacksonville, Florida 32259 and that a true and correct copy of the Administrative Complaint has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # Tb 45°75 (244 2049 8274 ) to Keith T. Henry, Registered Agent for Wesley Manor, Inc. d/b/a Westminster Woods on Julington Creek, 80 West Lucerne Circle, Orlando, Florida 32801. COPIES TO: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, M.S. #9 Tallahassee, Florida 32308 (via interoffice mail)

Docket for Case No: 03-002568

Orders for Case No: 03-002568