STATE OF FLORIDA on i ! one) AGENCY FOR HEALTH CARE ADMINISTRATION Fie fos Fo AGENCY FOR HEALTH CARE i004 BEC 27 P 2: 2y ADMINISTRATION, 7 . Petitioner, { ! vs. Case Nos. 2004009447 2004009446 PLANTATION BAY HEALTH CARE - ASSOCIATES, LLC, d/b/a PLANTATION -~ [ Ul AO BAY REHABILITATION CENTER, a Ou _ Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against PLANTATION BAY HEALTH CARE ASSOCIATES, LLC, d/b/a PLANTATION BAY REHABILITATION CENTER, (hereinafter Plantation Bay), pursuant to §§ 120.569, and 120.57, Fla. Stat. (2003), and alleges: NATURE OF THE ACTION This is an action to change Plantation Bay’s licensure status from Standard to Conditional, commencing June 15, 2004 and ending July 20, 2004, and to impose an administrative fine in the amount of $1,000.00 based upon one cited uncorrected Class III deficiency for Plantation Bay's failure to ensure that the resident environment remains as free of accident hazards as is possible. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title [V, Subtitle C (as amended); Chapter 400, Part II, Fla. Stat., and Fla. Admin. Code R. 59A-4, respectively. 4. Plantation Bay operates a 120-bed nursing home located at 401 Kissimmee Park Road, St. Cloud, Florida 34769, and is licensed as a skilled nursing facility, license number SNF16340962. 5. Plantation Bay was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was tequired to comply with all applicable rules, and statutes, COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25(h)(1) and Fla. Admin. Code R. 59A-4.1288, Plantation Bay must ensure that the resident environment remains as free of accident hazards as is possible. 8. On or about May 6, 2004, the Agency conducted a Recertification Survey of Plantation Bay. 9. Based upon observation and staff interview, the facility failed to ensure that the residents’ living environment remained free from potential accident hazards, including the improper placement and access to an electric shaver and after shave lotion both of which were accessible to confused residents on 1 of 2 wings (the South wing). 10. During the initial tour of the facility on May 3, 2004, at about 10:15 a.m., on the South wing in room # 206, the Agency observed an electric shaver, which was plugged into the electrical outlet and hanging all the way to the floor, and a bottle of after-shave, which was left out on the sink in the bathroom, both of which were accessible to confused residents. 11. When facility staff were interviewed regarding why the electric shaver, which was not being used by staff, was plugged into the outlet and hanging all the way down to the floor, a staff member indicated that he/she was unaware of why and proceeded to unplug it and put it away. After Agency intervention, the bottle of after-shave lotion was also removed and placed in a safe place. 12. The Agency determined that these conditions or occurrences have the potential to compromise the resident's ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services, and cited these deficient practices as a State Class If deficiency. 13. The Agency provided Plantation Bay with a mandatory correction date of May 27, 2004, for this deficient practice. 14. On or about June 15, 2004, the Agency conducted a follow-up visit to the Recertification Survey of Plantation Bay. 15. Based upon observation and staff interview, the facility failed to ensure that the residents’ living environment remained free from potential accident hazards. 16. Observation during the initial tour of the North wing on June 15, 2004, at about 10:25 a.m., revealed multiple accident hazards. 17. The Agency observed one (1) large putty knife and one (1) can of KO odor counteractant on top of an unattended housekeeping cart sitting in the hallway. 18. Wandering cognitively impaired residents were observed in the vicinity of the unattended housekeeping cart. 19. Interview with the housekeeping staff and the North wing unit manager, who were on duty on the same date and time of the above observations, revealed that the unlocked putty knife and odor chemical should be locked away in the housekeeping cart. 20. Two (2) pair of large scissors were observed stored on top of Resident # 7's bed and the his/her room door was observed open to the hall. 21. Interview with the charge nurse on the 7-3 shift and record review of the facility matrix validated that Resident # 7 had a diagnosis of cognitive impairment and revealed that other residents, who also were observed to be in the vicinity of the unattended scissors, had cognitive impairment and mental illness (MI). 22. During the interview with the 7-3 charge nurse, he/she confirmed the observations and immediately locked the accident hazards away. 23. The Agency surveyor observed that the equipment room was unlocked and opened. 24. The equipment room contained multiple oxygen cylinders, one of which was unsecured and stored standing on the floor. 25. Wandering residents with cognitive impairment and mental illness were observed in the vicinity of the unlocked oxygen room. 26. Interview during the survey on June 15, 2004, with the 7-3 charge nurse confirmed the observations and confirmed that the door should be locked at all times. He/she immediately locked the door. 26. The Agency surveyor observed Albuterol sulfate inhalation solution, 0.083%, 3 milliliters (mL) and two (2) 0.9% normal saline 5 cc (cubic centimeter) bottles which were left unattended on top of the nursing station on the North wing. 27. Further observation revealed two (2) additional 0.9% normal saline 5 cc bottles. One of the bottles was observed on the night stand in room 102-A, and the second was observed in room 133-A on the table by the television. 28, In addition, one (1) large bottle of sterile water was observed on top of the night stand in room 105-A. 29. The Agency determined that these conditions or occurrences have the potential to compromise the resident’s ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services, and cited these deficient practices as an uncorrected State Class III deficiency. 30. | The Agency provided Plantation Bay with the mandatory correction date of July 6, 2004, for this deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Plantation Bay, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003) COUNT IT 31. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (30) as if fully set forth herein. 32. Based upon Plantation Bay’s cited uncorrected State 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 Plantation Bay. a skilled nursing facility in the State of Florida, pursuant to § 400.23(7)(b), Fla. Stat., commencing June 15, 2004 and ending July 20, 2004. Respectfully submitted this | pit day of November 2004. Kunbwd VeusendeT Pusey Kimberly. Nicewonder-Murray ) Fla. Bar. No. 571628 Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1435 (office) 727.552.1440 (fax) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2003), Respondent shall post the most current license ina prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-58 73. 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. CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail, return receipt no: 7003 1010 0003 0299 1686 on November , 2004 to: Millie Benham, Administrator, Plantation Bay Rehabilitation Center, 401 Kissimmee Park Road, St. Cloud, Florida, 34769, and U.S. Mail to C.T. Corporation System, Registered Agent, Plantation Bay Rehabilitation Center, 1200 South Pine Island Road, Plantation, Florida, 33324. Kunbaly Hecaverele/ Tune) Kimberly M. Nicewonder-Murray, Esquire Copies furnished: Millie Benham C.T. Corporation System Kimberly M. Nicewonder- Administrator Registered Agent for Murray, Esquire Plantation Bay Plantation Bay Senior Attorney 401 Kissimmee Park Road 1200 South Pine Island Road Agency for Health Care St. Cloud, Florida 34769 Plantation, Florida 33324 Administration (US. Certified Mail) (U.S. Mail) 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office 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. 2004009446 Plantation Bay Rehabilitation Center 2004009447 Facility Name AHCA Case No.

Docket for Case No: 04-004630