Certified Mail Receipt (7004 1160 0003 3739 8637) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 0 S- Y % f —< Petitioner, AHCA NOS: 2005009159 y. 2005009160 AVANTE VILLA AT JACKSONVILLE BEACH INC. Respondent. _/ gj} sh Hd 82 AON g0 ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“Al HCA”), by and through the undersigned counsel, and files this Administrative Complaint against Avante Villa At Jacksonville Beach Inc. (hereinafter “Avante Villa At Jacksonville Beach Inc.”), pursuant to Section 120.569, and 120.57, Fla. Stat., (2005), and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines totaling in an amount of Twenty-One Thousand Dollars ($21,000.00), against Avante Villa At Jacksonville Beach, Inc., for one (1) class | deficiency, plus a 6-month survey cycle inspection, pursuant to Sections 400.23(8)(a), 400.19(3) and Section 400.141(8), Fla. Stat. (2005) and Section 59A- 4,122(1), Fla. Admin. Code (2005). The Agency also intends to impose a conditional rating effective October 14, 2005, through July 31, 2006, pursuant to Section 400.23(7), Fla. Stat. (2005) case no. 2005009160. : Wlic 4 2 oe i JURISDICTION AND VENUE 2 This Agency has jurisdiction pursuant to 400, Part II and Section 120.569 and 120.57, Fla. Stat., (2005). Duval County, Jacksonville, Florida, pursuant to Section 3. Venue lies in | 120.57, Fla. Stat., (2005); and 59A-4, Florida Administrative Code (2005), 28.106.207, Florida Administrative Code. (2005). PARTIES 4. AHCA is the regulatory authority’ responsible for licensure and enforcement of all applicable statues and rules governing nursing home facilities pursuant to Chapter 400, Part II, Florida Statutes, (2005), and Chapter 59A-4, Florida Administrative Code (2005). 5. Avante Villa At Jacksonville Beach Inc. is a for-profit corporation, whose 165-bed nursing home facility is located at 1504 Seabreeze Avenue, Jacksonville Beach, Florida. Avante Villa At Jacksonville Beach Inc. is licensed as a nursing home facility license #SNF10270961; certificate number 12902, effective October 14, 2005, through July 31, 2006, Avante Villa at Jacksonville Beach Inc. was at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I AVANTE VILLA AT JACKSONVILLE BEACH INC. FAILED TO PROPERLY MAINTAIN THE OUTSIDE GARBAGE RECEPTACLES AND THE INSIDE KITCHEN AREA, INCLUDING WALLS, CEILS, DOORS, PREPARATION AREA, DISHWASHER, THE PREPARATION SINK (FOUR SINKS) AND KITCHEN ay sd EQUIPMENT, IN SANITARY CONDITION. THESE UNSANITARY CONDITIONS PRODUCED NEGATIVE OUTCOMES DOING THREE OF FOUR DAYS OF THE SURVEY AFFECTING ALL FACILITY RESIDENTS. STATE TAG N110-PHYSICIAL ENVIRONMENT Section 400.141(8), Fla. Stat. (2005) ADMINISTRATION AND MANAGEMENT OF NURSING HOME FACILITIES Section 400.19(3), Fla. Stat. (2005) RIGHT OF ENTRY AND INSPECTION Section 400.23(8)(a), Fla. Stat. (2005) RULES EVALUATION, AND DEFICIENCIES; ’ LICENSURE STATUS Section 400.23(7), Fla. Stat. (2005) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS - Section 59A-4.122(1), F.A.C. (2005) PHYSICIAL ENVIRONMENT 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set _ forth herein. 7. On or about October.14, 2005, AHCA conducted an annual survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about October 14, 2005, Avante Villa at Jacksonville Beach Inc. failed to properly maintain the outside garbage receptacles and the inside kitchen area, including walls, ceilings, doors, preparation area, dishwasher, the preparation sink (four sinks) and kitchen equipment, in sanitary condition. These unsanitary conditions produced negative outcomes doing three of four days of the survey affecting all facility residents. The findings are: 1. During the initial tour on 10/11/05 at 9:50 am it was noted that two of three garbage receptacles did not have plugs to ensure that contaminated fluids could not leak out of the receptacle on to the ground. On 10/12/05 it was noted the facility had placed silver duct tape over the missing plugs. The tape remained through 10/14/05, the duration of the annual survey. = _ 2. Observation of the facility's kitchen during the initial totir on 10/ 11/05 at 9:40 am revealed the dry storage room had insects crawling on the ceiling, the dish room had small insects crawling on the walls, the ceiling in the dry storage room was bowed and cracked, the wall behind the cook's stations was missing and exposing pipes, the insulated food carts were opened and stored outside near the garbage dumpsters, the back door did not shut securely, the handle on the walk in refrigerator was broken allowing for the cool air to escape, and the convection oven door did not shut tightly allowing for hot air to escape. : 3. Review of the facility provided information "sanitizing temperature record’, sanitizing sink temperature record, and the Dishwasher temperature record" during the initial tour on 10/11/05, revealed that all three documents were recorded through the 13th of October for breakfast, lunch and dinner. Note the following dishwasher and sanitizing concerns: a. Review of the "dishwasher temperature log" revealed on the 10th and the 11th of October, the "temperature was 138 degrees F which does not meet the minimum standard of 140 degrees F per the manufactures recommendations which is posted on the side of the machine. When interviewed about what policy is followed when the temperature does not meet the minimum requirements, staff stated "I guess someone will call EcoLab". Kitchen staff interview revealed no one was aware if Ecolab had been called on the 10th or the 11th when the temperatures were low. : b. Observation of the preparation sink (four sinks) and the dish room noted the sanitizing sink, 4th sink, was filled and ready for us. Sheet pans were soaking. Interview with the CDM, Certified Dietary Manager, regarding checking for sanitizer, revealed the reference strip for color comparison could not be located. She indicated that she would order some. c. Observation and review on 10/11/05 at 10:00 am of the "Sanitizing Sink Temperature Record" that was taped to the wall showed that the PPM was recorded for breakfast and already recorded for lunch on 10/11/05 and for breakfast on 10/12/05. Interview with the CDM revealed that she was unaware that the temperatures had already been recorded’ for the next two days. 4. Observation of the steam table on 10/11/05 at 11:15 am during the temperature taking of the resident's lunch meal, revealed staff taking temperatures before alibrating the thermometer. An interview at this time, before recording the temperatures to ensure accuracy, revealed the staff taking the temperatures was unaware of how to calibrate the thermometer. we ~~ On 10/11/05, at 11:15 PM, lunch was being served to the staff and residents. Temperatures were ‘taken at point of service and the following temperatures were noted to be below or above the target temperatures of 140 degrees F and 41 degrees F: . . , a. Gravy at 139 degrees F; b. Low fat baked chicken at 128 degrees F; c. Squash at 138 degrees F; : d. Pepper steak at 118 degrees F; +e. Baked regular chicken at 110 degrees F; and f. Fruit cobbler at 50 degrees F. On 10/11/05 at 12:15 PM holding temperatures were recorded and the following foods were noted not maintained at 140 degrees F: a. Baked chicken in the dining room at 98 degrees F; b. Mashed potatoes at 115 degrees F; c. Gravy with pepper steak at 132 degrees F; d. Baked chicken 115 degrees F; e. Ground beef at 119 degrees F; and f. Puree meat at 138 degrees F. 5, Observations on the morning of 10/12/05 during preparation and service of the breakfast meal revealed the following: a. At 6:55 am, breakfast temperatures were recorded and the sausage patty, at point of service, was at 98 degrees F. Surveyor intervened to stop the service and share with the kitchen staff that the temperature of the sausage must reach 140 degrees F. b. At 7:10 am the holding temperature of the sausage patty was noted having dropped to 79 degrees F. It was revealed that some of the sausage was served to some residents. c. Holding temperatures were taken at 7:50 am and the milk was at 57 degrees F. 6. Observations of the kitchen area on the morning of 10/12/05 also revealed the following: a. Observation at 6:35 am noted the lunch meal, to be served at 11:15 am, was being prepared. Three deep half pans were on the stove cooking green beans, rice and a roast pork was cooked and sitting on the 4 compartment sink tray. b. Observation on 10/12/05 at 7:50 am, under the preparation tables, were 2 one gallon jugs of lemon juice, each jug containing approximately 1/4th of the product. The jugs were marked "Refrigerate after opening". Neither had been refrigerated and staff indicated that they were having fish for dinner. c. On 10/12/05 at 6:30 am it was noted that three cooked pork roasts were being sliced on the dirty pot/pan table. An interview with dietary staff at this time revealed they did not have any place else to slice the meat noting the small kitchen. The pork was observed to remain out in room temperature until 9:00 am when it was sliced and placed in.a “holding tank", the convection oven, where bread was rising. The convection oven was not on at this time. By the time the oven was turned on before the lunch ‘meal was served and the temperature was at 140 degrees F, the pork had been at room temperature for over 4 hours. In addition, this entree is considered a left over, it was not teheated to reach 165 degrees F. 7. On 10/13/05 the following was observed in the kitchen beginning at 6:00 am. a. At 6:00 am the individual containers of peanut butter were infested with insects. The dish room wall was also noted to have small insects moving up and down the walls. b. At 6:30 am the temperature of the ice cream freezer was recorded at 30 degrees F and upon close inspection it was noted that the individual cups of ice cream had melted. c. A review at 7:00 am of the temperatures from the evening’ meal of 10/12/05, the vegetables were documented at 35 degrees F. Interview with the CDM concerning the low temperatures and a new policy and procedure revealed that their new policy and procedure for recording temperatures had not been implemented. d. At 9:35 am it was noted in the pots and pans storage unit, the pans had. been placed on the metal shelf wet and were stacked together which does: not allow for air drying. 8. On 10/13/05 at 11:15 am during the temperature recording of the lunch tray line, it was revealed that the foods prepared in the oven had not been hot enough to serve. The puree greens were 85 degrees F and the soup was cold. It was revealed that the oven was not functioning properly. 9. On 10/14/05 at 7:10 am the temperatures were recorded and all foods potentially hazardous were either above 140 degrees F or below 41 degrees F. Therefore, it was noted that the potential for jeopardizing the health and safety of the facility residents was abated during the last day of the survey. 8. The regulatory provisions of the Fla. Stat. (2005), that are pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; licensure status. ~ (8)(a) A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is-necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class | violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. * * * 400.23 Rules; evaluation and deficiencies; licensure status. ~ (7) The agency shall, ar least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign ’a licensure status of standard or conditional to each nursing home. en 400.141 Administration and management of nursing home facilities. (8) Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. a 59A-4.122 Physical Environment. ~ (1) The facility shall provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. * * The violation alleged herein constitutes a class 1 deficiency, and warrants a 9. fine of $15,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $15,000. COUNT I SURVEY FEES TOTALLING $6,000 PURSUANT TO Section 400. 19(3), Fla. Stat. (2005), RIGHT OF ENTRY INSPECTION 10. ° AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. ‘Vi. The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class 1 deficiency, has been cited for two or more class II deficiencies arising from separate surveys.or investigations within a 60-day period, ‘or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class 1 or class I deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. The agency may adjust this fine by the change in the Consumer Price Index, based on the 12 months immediately preceding the increase, to cover the cost of the additional surveys. The agency shall verify through subsequent inspection that any deficiency identified during the annual inspection is corrected. However, the agency may verify the correction of a class II or class IV deficiency unrelated to resident rights or resident care without reinspecting the facility if are _ adequate written documentation has been received from the facility, which provides assurance that the deficiency has been corrected. The, giving or causing to be given of advance notice of such unannounced inspections by an employee of the agency to any unauthorized person shall constitute cause for suspension of not fewer than 5 working days according to the provisions of chapter 110. 12. The violation alleged herein constitutes a class I deficiency, and warrants a fine of $6,000. ‘ WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2 Impose a fine in the amount of $6,000. Respectfully submitted this attey of November 2005. Michael O. Mathis, Esquire Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Fla. Stat. (2008). 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 the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan’ Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney, Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served by gral f certified mail on J day of Tere bs, 2005 to Jeffrey H. Tomack, Administrator, Avante Villa At Jacksonville Beach Inc., 1504 Seabreeze Avenue, Jacksonville, Florida 32250. Ave indie Michael O. Mathis, Esquire 10 FIED MAIL fall Qniy;\No Insurance Coverage Provided) Postage Certiflad Fee Return Reclapt Fee (Endorsement Required) . HX lallvery Fee it Aequired} Thlal Postage & Fees | § sts RY Postmark ELAS . 7004 L460 0003 37359 &b37 a \SO Y Sag ENDER: COMPLETE THIS SECTION A. xX Complete itams 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired, Print your name and address on the reverse iA DO Agent Signature 1 yf ~ g 7 - Cadtressee so that we can return the card to you, Attach this card to the back of the mallpiece, or on the front If space permits. B. Received by ( Printed Name) D. . Aa feces if TJomosk, Achaiah yer » Villa Ae Jax. pach, , EN, SOY Seabreszn Ave. 5 ack sonville, L SA25° 2: Wwonke Ville, Ab Jockos sol, , ned. : ITYES, enter delivery address below: [No meee ee Certified Mail 0) Exprass Mail O insured Mat = 1.0.0. C. Date of livery. YI aS Js delivery address different from itsm 1? Yes ©) Registered CO] Return Receipt for Merchandise . Restricted Delivery? {Extra Fes) D Yes Article Number . (Transfer irom service label) 7004 1160 } Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1035

Docket for Case No: 05-004345