STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 04 JAN 28 PM &:43 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 2003004854 2003009127 CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against CYPRESS MANOR HEALTH CARE ASSOCIATES,LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to assign a conditional licensure status to Respondent effective June 23, 2003, pursuant to Sections 400.23(7) (b) and 400.23(8)(c), and impose an administrative fine in the amount of three thousand dollars ($3,000) pursuant to Sections 400.23(8) (c) and 400.102 (1) (a) Florida Statutes. 2. The Respondent was cited for the deficiencies during a revisit conducted on June 23, 2003 to the Fire Life Safety State Re-licensure and Federal Recertification Survey conducted on May 20, 2003. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28- 106.207, Florida Administrative Code. PARTIES 5. 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. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ENSURE THAT ALL HAZARDOUS AREAS WERE SEPARATED BY ONE (1) HOUR FIRE RESISTIVE CONSTRUCTION VIOLATING Fla. Admin. Code R. Rule 59A-4.130 §§ 633.022, 633.025 Fl. Stat. (2003) UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. A Fire Life Safety Re-licensure and Federal Recertification Survey was conducted on May 20,2003. 9. On that date, based on observations made during the Fire Life Safety tour between 12 p.m. and 3:30 p.m., it was determined that the facility failed to ensure that all hazardous areas were separated by one (1) hour fire resistive construction. This, in the event of fire, could allow smoke, fire, and toxic gases to migrate through the facility. 10. A Class III deficiency was cited against Respondent based on the findings below: A resident room in the West Wing was converted into a storage room, which contained a high volume of combustibles. There is no separation between the now storage room and the resident rooms. The janitor closets on both sides of the facility were observed to have large diameter openings in them. The openings were filled with coaxial cable wire for cable TV. The wires were run through the penetrations from a cable TV distribution panel mounted on the walls of the two closets. The penetrations were not properly protected. 11. These observations were cited as a State Class III deficiency and were to be corrected by June 20, 2003. 12. On June 23, 2003 the Agency conducted a revisit of Cypress Community Care Center. 13. On that date, based on observations made during the June 23, 2003 Fire Life Safety tour, it was determined that the facility failed to ensure that all hazardous areas were separated by one (1) hour fire resistive construction. This, in the event of fire could allow smoke, fire, and toxic gases to migrate through the facility. 14. A State Class III widespread uncorrected deficiency was cited against Respondent based on the findings below: The janitor closets on both sides of the facility were observed to have large diameter openings in them including secondary penetrations on the abutting corridor wall. The Openings were filled with coaxial cable wire for cable TV. The wires were run through the penetrations from a cable TV distribution panel mounted on the walls of the two closets. The penetrations were not properly protected after being cited during the annual survey on 5/20/03. 15. These observations were cited as a State Class III widespread uncorrected deficiency. 16. The regulatory rule pertinent to the alleged violation in Count I of this case is Chapter 13, Section 13-3.2.1, NFPA 101 (1985), [made applicable to nursing homes pursuant to the provisions of Section 633.022 and Section 633.025, Florida Statutes] setting forth fire and life safety codes mandated for existing health care occupancies. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of three thousand dollars ($3,000), based on one widespread uncorrected Class III deficiency as authorized under Sections 400.23(8)(c) and 400.102(1) (a) Florida Statutes. COUNT II AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS COMMENCING JUNE 23, 2003 TO CYPRESS COMMUNITY CARE CENTER BASED UPON THE DETERMINATION THAT THE FACILITY WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) WIDESPREAD UNCORRECTED CLASS III DEFICIENCY § 400.23(7), Fla. Stat. 17. The Agency re-alleges and incorporates paragraphs (1) through (6) and (8) through (16) as if fully set forth herein. 18. Based upon Cypress Community Care Center’s one widespread uncorrected Class III deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7) (b), Fla. Stat. (2003). WHEREFORE, the Agency intends to assign a conditional licensure status to Cypress Community Care Center, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7) (b) commencing June 23, 2003. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose an administrative fine of three thousand Dollars ($3,000) for the violation cited in Count I against the Respondent under 59A-4., Florida Administrative Code; Cc. Recommend that the change of licensure status effective June 23, 2003, from Standard to Conditional be upheld; D. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2002); and E. All other general and equitable relief allowed by law. DISPLAY OF LICENSE Pursuant to Sections 400.062(5) and 400.23(7) (e), Florida Statutes, the Respondent, shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE The Respondent 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 Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ly submitted, Eileen|O’Hara Garcia, Esquire AHCA -}/Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (Fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been furnished to C T Corporation System, Registered Agent for Cypress Community Care Center, 1200 South Pine Island Road, Plantation, FL 33324 by U.S. Mail and to Bill Maggard, Administrator, Cypress Community Care Center, 7173 Cypress Drive S.W., Fort Myers, FL 33907, by U.S. Certified Mail, Return Recg 7003 1010 0003 4303 8838, on December , 2003. Cf ‘Hara Garcia, Esq. Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Mail) Bill Maggard Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907 (U.S. Certified Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330D St. Petersburg, Fl 33701 (Interoffice)

Docket for Case No: 04-000336