APR-27-2804 @9:37 AHCA LEGAL DEPARTMENT P,.@2 CLP GS [SF STATE OF FLORIDA . AGENCY FOR HEALTH CARE ADMINISTRATION Me STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No: 2001041261 Return Receipt Requested A.D.M.E, INVESTMENT PARTNERS, #7000 1670 0011 4848 0418 LTD., d/b/a OCEANSIDE EXTENDED 7000 1670 0011 4848 0425 CARE CENTER, 7000 1670 0011 4848 0432 Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), and files this Administrative Complaint against A.D.M.E. Investment Partners, LTD, d/b/a Oceanside Extended Care Center (hereinafter “Oceanside Extended”) pursuant to 28-106.111, Florida Administration Code (2000)(F.A.C.), and Chapter 120, Florida Statutes (‘“Fla. Stat.”) hereinafter alleges: NATURE OF ACTION 1. This is an action to impose a civil penalty in the amount of two thousand ($2,000) dollars pursuant to Section 400.23 Fila. Stat. JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 3. Venue lies in Dade County, Florida, pursuant to 120.57, Fla. Stat., and Chapter 28, F.A.C. P,83 APR-27-2004 03:37 HCA LEGAL DEPARTMENT PARTIES 4. AHCA is the enforcing authority with regard to nursing home licensure pursuant to Chapter 400, Part Il, Fla. Stat. and Rule 59A-4, F.AC. 5, “Qceanside Extended” is a nursing home located at 550 9" Street, Miami Beach, Florida 33139 and is licensed under Chapter 400, Part II, Fla. Stat., and Chapter 59A-4, FAC. COUNT I OCEANSIDE EXTENDED CARE CENTER DID NOT ENSURE THAT THE ENVIRONMENT WAS SAFE, SANITARY AND FUNCTIONAL FOR RESIDENTS, STAFF, AND THE PUBLIC. 400.141(8), Fla. Stat. (PHYSICAL ENVIRONMENT.) CLASS TL 6. AHCA realleges and incorporates (1) through (5S) as if fully set forth herein. 7, During the survey of April 27, 2001 and based on observation and staff interview the facility did not ensure that the environment was safe, sanitary, and functional for residents, staff, and the public. 8. The following fixtures and equipment were not maintained in good repair: a. The commode in the bathrooms for rooms 402, 406, and 410 was loose. b. The ceiling bathroom light fixture in rooms 402, 404, and 414 was loose and separated from the ceiling. c. The bathroom light was out in room 318 and the bedside cabinet door was off and next to the cabinet for 318B. APR-27- 2004 89:37 AHCA LEGRL DEPARTMENT ros d. The bathroom door handle was loose for the bathroom in 410 and the room door handle was loose for room 403. e. Air conditioner covers were broken or missing in rooms 401, 415, and 2 outside room air conditioners. f. Ceiling in the first floor shower needs to be repaired. g. There was about a one-inch gap to the outside on the left side of the air conditioning between the unit and the wall frame in room 325. h. The area behind the sink in Room 325 had rotted wood. i. The bathroom door in 319 had a hole the size of a baseball. The base of the bathroom door was rusted in room 319. j. The over bed table in 315 had a chipped top exposing a porous surface. k. The air conditioning unit in 309 was missing the 2 side panels. The molding under the air conditioning was hanging. The bathroom doorknob was loose. The base of the doorframes in room 309 was rusted. The doorstep between the bathroom floor and the next room was missing. The faucet leaked when tumed on in the bathroom in room 309. 1. Bed 311A lacked a footboard. m. The base molding in 303 was hanging off near the corner of the room. n. The paper towel holder in the bathroom for 306 was on the floor. The base of the bathroom doorframes was rusted. w .64 APR-27-2084 99:37 SHCA LEGAL DEPARTMENT P.85 0. The bathroom doorframe in room 308 was rusted. and the base of the bathroom door frame was rusted. p. The air conditioning unit in 316 had broken vents. Tiles under the bathroom sink were pulling from the wall q. During the initial tour on 04/24/01, at 10:37 a.m., the high- backed armchair had multiple cracks in the vinyl upholstery in room 201. r. During the initial tour on 04/24/01, at 10:37 a.m., there were several bathroom faucet fixtures in rooms 201, 207, and 217 that were very corroded and had an accumulation of mineral deposition. The metal surface of the faucets were pitted. s. During the initial tour on 04/24/01, at 10:37 a.m, there was paint peeling from the ceiling of room 207. t. During the initial tour on 04/24/01, at 10:37 a.m., plaster was missing from the bathroom ceiling of room 217. u. During the initial tour on 04/24/01, at 10:37 a.m., there were pieces of small floor tile missing from the bathroom of room 210. v. Inresident's room 102, the bathroom call light cord was broken. w. In resident's room 106 window the mattress was too short for ‘the bed frame. x. In resident's room 111, the bathroom door had a hole on the door. y. Inresident's room 122 next to bed D, the AC cover plate was broken. APR-27-2084 O3:37 AHA LEGAL DEPARTMENT z. Inresident's room 125, the AC cover plated was missing. aa. In resident's room 107 the wall had a hole in the door knob location, and bb. Inthe resident's room 122 bed D two electrical cables were observed hanging from the over bed light. 9, The following fixtures and equipment were not kept a clean condition: a. Bathroom vents on the fourth floor were dirty. b. The caulking around the base of the commodes on the fourth floor was dirty. c. Repair work had been done in the bathroom for room 223 and construction debris including wallboard was left on the bathroom floor. d. The air conditioning face cover in Room 325 had black material. e. The side rail on 325 D bed was spotted with dried material and Tust f. The bathroom-ceiling vent in room 325 was covered with black material. g. The air conditioning vent cover had accumulated dust in room 325. Aresident stated the filter needed changing. h. The bathroom floor in room 319 had brown smeared material. i. The air conditioning vent in the bathroom of room 309 had black dusty material. APR-27-2084 09:37 AHCA LEGAL DEPARTMENT j. The doorstep going to the bathroom in 30] was stained a rust color. k. The air conditioning unit in room 301 had an accumulation of dust. L. The air conditioning cover on 302 had an accumulation of dust. m. The air conditioning unit in 308 was clogged with gray dust. n. During the initial tour on 04/24/01, at 10:37 a.m., the privacy curtains in rooms 209 and 217 were soiled with dark spots on them. 10. The following equipment were not maintained in safe condition: a. Following tour of the facility on 4/24/01, twelve (12) of eighteen (18) beds checked on the fourth floor were not secure and would move when pushed. Unsecured beds are a risk for patient falling. b. During the initial tour on 04/24/01, at 10:37 a.m., the mattress in room 203 A was at least 12" too short in the bed frame. There was at least a 12" space observed at the bottom of the mattress and footboard. Need to add—short mattresses, screen missing, etc. 11. During several days of touring the physical environment of the facility several items in need of repair needed to be corrected. 12. The facility was given until 05/27/01 to correct this deficiency. 13. The deficiency remained uncorrected as it was determined during the follow up conducted on 6/11/01 and based on observation and staff interview, the facility did not ensure that the environment was safe, sanitary and functional for residents, staff, and the public. APR-27-2084 @9:38 SHCA LEGAL DEPARTMENT 14. The following fixtures and equipment were found not to be maintained in good repair on the follow-up survey of 06/11/01: a. During the follow-up survey, the surveyor observations revealed the previously cited bathroom doorframe thresholds in rooms 308 and 309 with evidence of brown discoloration/stains consistent with rust. b. During tour, surveyor observations revealed the previously cited broken bedside table door in room 318B remained broken. c. During tour, surveyor observation revealed that the emergency cord in the toilet adjoining rooms 102 and 104 was only approximately 2 inches long and was not within 6 inches of the floor or readily accessible to residents. 15. The following equipment was not maintained in safe condition: a. During tour, surveyors were able to push beds in rooms 116, 117, 118,119 and 411, demonstrating that the beds were not secure and posed a fall risk for residents. All beds pushed were equipped with wheel locks, which were not engaged or were inoperarable. 16. During tour, it was observed that a warning sign was not posted at the entrance to room 423 that indicated oxygen was in use in the room. The resident was not in the room at the time of the tour but the surveyor observed that the oxygen was on. Foliowing the tour, staff found an oxygen warning sign and placed it on the door to the resident's room. APR-27-2004 63:38 _ ARCA LEGAL DEPARTMENT 17. Based on the foregoing, “Oceanside Extended” violated 400.141(8), Fla. Stat., herein classified as a Class II] violation, which carries, in this case, an assessed fine of $2,000. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the Court to order the following relief: A. Enter a Judgment in favor of the Agency for Health Care Administration against “Oceanside Extended” on Count I. B. Assess against “Oceanside Extended” a civil penalty of $2,000 for the Class III violation in Count I, in accordance with Section 400.23(8)(c) Fla. Stat. C. Award the Agency for Health Care Administration costs related to the investigation and prosecution of this matter as per 400.121(10) Fla. Stat. D. _ 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 Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 NW 53°? Street, Miami, Florida 33166; Nelson E. Rodney. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS APR-27-2084 83:38 SHCA LEGAL DEPARTMENT P.16 COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ERTIFICATE OF SERVICE 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 Requested to Richard Kjos Neal, Administrator, Oceanside Extended Care Center, 550 9™ Street, Miami Beach, Florida 33139, A.D.ME. Investment Partners, Ltd, 3737 W. Arthur, Lincolnwood, Illinois, 60645-4029, and to Martin W. Wasserman Registered Agent 999 Washington Avenue, Miami Beach, Florida 33139, on Py u C , 2002. Nelx6n Rodney Assistant General Counsel Agency for Health Care Administratjon 8355 NW 53” Street Miami, Florida 3316 Copy to: Nelson E. Rodney, Assistant General Counsel Agency for Health Care Administration Manchester Building 8355 NW 53" Street Miami, Florida 33166 Nursing Home Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Gloria Collins, Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, mail Stop #14 Tallahassee, Florida 32308 TOTAL P.16

Docket for Case No: 04-001599