L2-b75— STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 06-01-0087-NH vs. WINTER HAVEN HEALTH & REHABILITATION CENTER Respondent. a ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against , WINTER HAVEN HEALTH & REHABILTATION CENTER (hereinafter “Respondent” ) and alleges: te NATURE OF THE ACTION 1. This is an‘action to impose an administrative fine in the amount of fifty thousand ($50,000) dollars pursuant to ‘Sections 400.23(8), 400.102(1) (a), (d), 400.121(1) Florida Statutes. Jurisdiction 2. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida. Statutes. orem spmet ge oe foprprge se mere eed 3. venue lies in Polk County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. Parties 4, AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, ' Florida Statutes and Rules 59A-4, Florida Administrative Code. . 5. Respondent is a nursing home located at 202 “0” Street N.E. Winter Haven, Florida. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I FACILITY MUST ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS, F.A.C. ~ 59A-4.1288 adopting by reference 42 CFR 483.25(h) (2); § 400.022 1(1) Fla. Stat. (2001) CLASS I DEFICIENCY qe 6. AHCA re-alleges and incorporates (1) through (4) as if fully set forth herein. 7. The facility was cited for the deficiency set forth " oon below during a complaint investigation on or about March 28, 2001 and constitutes a Class I deficiency. ee a oe 8. During the complaint investigation, it was determined that the facility failed to provide supervision of a visually -impaired resident to ensure his safety. The system, employed by ee ee the facility to alert staff to a resident leaving the facility, failed to alert staff to the incident. Failure to provide this level of supervision, and the failure of the alerting system resulted in. the visually impaired resident exiting the facility without staff knowledge and sustaining injuries that may have contributed to his death after a fall. This is a violation of § 400.022 1(1) Fla. Stat. (2001) “which require residents to receive adequate and appropriate protective services and 59A-4.1288 F.A.C. adopting by reference 42 CFR 483.25(h) (2) which requires the facility to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This is a Class I violation for which the Agency is authorized to impose a fine in the amount of $25,000.00 pursuant to Sections 400.23(8) (a), 400.102(1) (a), (d), and 400.121(1) Florida Statutes... 9. The Respondent was givelf written notification of the cited deficiency and the time frame for correction. COUNT IT FACILITY FAILED TO BE DESIGNED, CONSTRUCTED, EQUIPPED AND MAINTAINED TO PROTECT THE HEALTH AND SAFETY OF THE RESIDENTS, PERSONNEL AND PUBLIC F.A.C. 59A-4.1288 ADOPTING BY REFERENCE 42 C.F.R.§ 483.70and § 400.102(1) (a),d) Fla. Stat. (2001) CLASS 1 DEFICIENCY 10. AHCA re-alleges and incorporates (1) through (4) as if fully set forth herein. eM Tree nme eee * seme aa A A a lll | | 11. During the complaint investigation on March 28, 2001, it was determined that prior to March 24, 2001 the facility’s physical environment included an unprotected change in grade at the southwest exterior area of the grounds created by a five foot high retaining wall without any barriers or guard to prevent a person from falling. This condition contributed to the death of a visually impaired resident which may have been prevented if barriers or guardrails had been in place. 12. The Respondent was given written notification of the cited deficiency and the time frame for correction. This is a violation of 59A-4.1288 F.A.C. adopting by Reference 42 CFR 483.70 which requires the facility to design, construct, equip and maintain the physical environment of the facility to protect the health and safety of the residents, personnel and the public. This is a ¢lass I violation for which the Agency is authorized to imbose a fine in the amount of $25,000.00 pursuant to Sections 400.23(8) (a), 400.102(1) (a), (d), and 400.121(1) Florida Statutes. WHEREFORE, AHCA intends to impose a fine of twenty-five thousand dollars ($ 25,000.00) for Count I and twenty-five thousand dollars $25,000.00 for Count Il against the respondent under Section 400.23(8)(c), Florida Statutes, for a total fine amount of fifty thousand dollars ($50,000) ° The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2001). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. ectfully submitted, Eileen O'Hara Garcia, AHCA - Senior Attorney 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 Seger py crap rem ore mp opcpeee OTT STR TET TE RR TT TIE reer I HEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt No. 2170 444 540, to Lexis Document Services, Inc 3953 WW Kelley Road Tallahassee, Fl 32311 Registered Agent for WINTER HAVEN HEALTH AND REHABILITATION CENTER., on the 0 day of November , 2001. Copies furnished to: Long Term Care Section Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Area 6 Office Agency for Health Care Administration. Hurston Tower South . V 400 W. Robinson Street, S309 Le Orlando, Florida 33701 Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Administrator Winter Haven health and Rehabilitation Center 202 ~~O'' Street N.E. Winter Haven, Florida 33881 Pir meee eee Sete BRE Sop pg ro SOT ESTER RT OR TC CRC RR pet ree PAYMENT FORM Agency for Health Care Administration Finance & Accounting P.O. Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents payment of the administrative fine imposed by AHCA. Facility Name AHCA No. cc: Eileen O'Hara Garcia Senior Attorney Agency for Health Care Administration 525 Mirror Lake Dr. St. Petersburg, FL 33701 SO RE WB a ce ee ee ne aan or de ee ee ee cee ee ee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: WINTER HAVEN HEALTH AND REHABILITATION CENTER = - AHCA No. 06-01-0087-NH ELECTION OF RIGHTS PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) ® 1 do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) @ 1 do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) 8 / do dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your 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. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. - if you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 8 Mediation under Section 120.573, Florida Statutes, is not available in this matter. Le SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: ee License. No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Eileen O'Hara Garcia, Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive North, Room 310J St. Petersburg, Florida 33701 Telephone: (727) 552-1437 Fax No. (727) 552-1440 eee eer COR FE RT eR TERR ee ae Pee eee Ne eee soe op pe pee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES " (To be used in conjunction with Election of Rights form — attached) : In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA’ or “Agency”), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you 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. OPTION 2. If you do not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes (1999) before the Agency. At the informal hearing, you 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, you should select OPTION 2 on the | Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes (1999). To obtain a formal hearing, 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., your 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. In order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-dne (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. 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Docket for Case No: 02-000675