STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2009006274 (Fine) 2009006277 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a CAPITAL HEALTHCARE CENTER, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Capital Health Care Associates, LLC, d/b/a Capital Healthcare Center (“Respondent”), pursuant to sections 120.569 and 120.57, Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine in the amount of $10,000.00, based upon one Class II deficiency and upon the citation of one Class I during the last inspection of the same facility and to impose conditional licensure status commencing May 7, 2009, and ending May 31, 2009. JURISDICTION AND VENUE Jd The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2008). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42 and Chapter 120, and Chapter 400, Part I, and Chapter 408, Part IT, Florida Statutes (2008). Filed December 3, 2009 1:20 PM Division of Administrative Hearings. 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities, more commonly referred to as nursing homes, in Florida and enforces the applicable federal regulations and state statutes and rules governing such facilities, Chs. 408, Part Ti, 400, Part H, Fla. Stat. (2008); and Ch. 59A-4, Fla. Admin. Code. The Agency is authorized to deny an application for licensure, revoke or suspend a license, and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or the applicable rules. §§ 408.813, 408.815, 400.121, 400.23. Fla. Stat. (2008). In addition, the Agency may impose an additional six-month survey cycle fine for certain classes of violations that take place within a specified period of time, assign conditional licensure status, and assess costs related to the investigation and prosecution of this case, §§ 400.19(3), 400.23(7), 400.121(8), Fla. Stat. (2008). 5. The Respondent was issued a license (License Number 1073096) by the Agency to operate a 156-bed skilled nursing facility located at 3333 Capital Medical Blvd., Tallahassee, Florida 32308, and was at all times material required to comply with the applicable statutes and rules relating to skilled nursing facilities. COUNT I 6. The Agency re-alleges and incorporates by reference paragraphs 1 through 5. 7. Under Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following...the.right to receive adequate and appropriate health care and protective and support services, inchiding social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan...the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints... § 400.022, Fla. Stat. (2008). 8. Under Florida law, in addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the Agency against a licensee: an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400,102(1), Fla. Stat. (2008). 9. On May 7, 2009, the Agency concluded an unannounced complaint survey of the Respondent and its Facility. 10. ~ Based upon observation, interview and record review of 5 sampled residents, the Facility failed to update an assessment at least quarterly for Resident #5 who developed a stage II pressure sore; failed to provide care and physician ordered treatment to existing pressure sores for Residents #1 and #4; and failed to anticipate, recognize and treat pain consistent with the comprehensive assessment and care plan for Residents #4 and #6. Resident #5 11. A visual observation of Resident #5 on May 6, 2009, at 6:45 p.m., revealed the Resident lying in bed on his or her back. 12. The bed had an alternating low air loss mattress. 13. The Resident had a pressure ulcer located on his or her coccyx. 14. The Resident had two stage II pressure ulcers, one on each side of the buttocks, measuring approximately 1 cm long x 1 cm wide and 0.5 cm deep. 15. A record review on May 6, 2009, revealed that Resident #5 had been admitted to the Facility on January 13, 2006. 16, A Braden scale dated December 14, 2008, revealed a total score of 16 (mild risk 15-18). . 17, There was no other assessment of the Resident. 18. According to the Facility’s Skin Care and Wound Management-Clinical Programs Manual, the Braden scale is used to identify factors for skin breakdown and is supposed to be completed quarterly. 19. The skin grid for bottom (sacral) was last dated April 16, 2009, and the wound measured 1 cm long x 1 cm wide x 0.3 cm deep with nothing else checked. 20. The weekly skin sweeps indicated as follows: March 2, 10, 17, 30, 2009, April 14, 21, 27, 2009, and May 5, 2009, all of which indicated no new skin impairments. 21. There were no weekly skin sweeps for the weeks of March 23, 2009, and April 6, 2009. 22, According to the Facility Skin Care and Wound Management-Clinical Programs Manual, skin sweeps are supposed to be conducted weekly to identify new skin impairments. 23. The nursing progress notes indicated as follows: On March 30, 2009, at noon, “observed small open area on lower left outer aspect of leg 1 cm x 1 cm measured, no drainage noted wound bed pink and red, no odor. Resident unaware it's there. New order per facility protocol. Attempted to notify responsible party with no avail. Will continue to monitor. Physician notified". 24. The physician orders for April 2009, dated April 3, 2009, indicated that there was no order for treatment to the lower left leg. 25. The treatment record for April 2009 indicated that there was no treatment to the lower left leg. 26. The physician orders for May 2009, which were not signed or dated by the physician, have an order to clean the outer aspect of Resident’s left lower leg with wound cleanser, dry with gauze, apply transdermal dressing every 72 hours. 27. There was no skin grid, weekly skin sweeps, assessment, monitoring, treatment, or care plan addressing the open area on the lower left outer aspect of Resident #5's leg. 28. The only Minimum Data Set (MDS) on the chart has an Assessment Reference Date (ARD) date of December 26, 2008. 29. During an interview with the MDS coordinator on May 6, 2009, at 9:00 p-m., it was confirmed there was no other MDS on the chart. 30. The MDS coordinator printed an MDS with an ARD date of March 20, 2009, and provided this to the surveyor at 9:16 p.m. stating this was not a signed MDS and she could not find the signed MDS and would look for it in her office. 31. During an interview with the MDS coordinator with the Director of Nursing (DON) in attendance on May 7, 2009, at 1:31 p.m., the MDS coordinator confirmed that she was still not able to locate the MDS for Resident #5. Resident #4 32. During observations of Resident #4 on May 6, 2009 at 4:59 p.m., it was revealed as follows: a. The Resident’s right outer ankle had a dressing dated May 6, 2009, with initials LG. The Unit Manager LPN put on gloves, removed old dressing and replaced the old dressing with the same gloves. A white creamy substance was observed on the ankle. The wound was approximately the size of a quarter. The wound bed was red, the margins were clean, and there was no infection noted. The nurse stated that the stage might be a “IL, however, the treatment nurse would know the stage. b, A wound was noted on right outer aspect of the Resident’s right foot. The wound was the size of pencil eraser, was dry, and located in a necrotic area. c. On the Resident’s left hip/ischeal area, there was a dressing dated May 6, 2009, with the initials LG. The size of the wound was approximately 5 cm long x 6 cm wide x 1 cm deep, stage IV with full thickness of skin loss with extensive destruction of muscle and supporting structures. A white creamy substance was noted when dressing was removed, The Unit Manager put on gloves, removed old dressing, gathered supplies to clean and redress the wound, The Unit Manager put on new gloves, cleansed wound with Cara Klenz and gauze and without changing gloves, placed Mesalt and Stratasorb over the wound. d. There was a wound on the Resident’s sacral area-approximately 8 cm long x 8 cm wide x 2 cm deep. It was classified as stage IV with full thickness of skin loss with extensive destruction of muscle and supporting structures. There was top right tunneling of approximately 1 cm. The area was cleansed with Cara Klenz. The left side appeared. to be bright red and inflamed and there was some granulation of the wound bed. Mesalt dressing and Strasorb were applied. There was significant undermining of the wound, where the wound extends under the skin edges so the pressure ulcer is larger at the base than it is at the skin surface. There appeared to be a new area of undermining at approximately 2 o'clock. The Unit Manager stuck her gloved pinky finger into the area and took out her finger and measured about 2 cm deep. This wound area had not been previously identified, or assessed, and there was no physician order to pack the area. The Resident was opening and closing eyes and attempting to mumble. 33. During interviews with RN Unit Manager and the LPN Unit Manager on May 6, 2009, at 6:18 p.m., while dressing changes were being performed, it was revealed that these nurses had no knowledge of the treatment for these pressure ulcers or how often the dressings were supposed to be changed. 34, Neither of these nurses had knowledge of the pressure ulcer on Resident #4's left ankle that was observed by the surveyor and the wound care nurse on the following morning. 35, When asked how they would know whether or not the Resident had pain during the dressing change, the LPN Unit Manager stated they thought the Resident did not speak, 36. | When asked if the Resident received pain medication prior to the dressing change, the LPN Unit Manager stated they could give the Resident something for pain, but was unaware if the Resident had ever received anything for pain prior to the dressing change. 37. During an observation of Resident #4 on May 7, 2009, at 11:26 a.m., with the wound care nurse, it was revealed that the Resident was lying on his or her right side, pillows in place for positioning. 38, The left ankle dressing was intact, but with no date or initials. 39, This pressure ulcer was not identified by the two Unit Managers on the evening before. 40. The dressing on the Resident’s left hip was saturated with bloody, serosanguinous drainage. 4l. The dressing on sacral area was saturated with bloody, serosanguinous drainage, which also saturated the adult diaper that had been on the Resident. 42. During an interview with the wound care nurse at this time, it was revealed that nurses are responsible for checking the dressings to determine if they are soiled or need to be changed. If so, the nurse then lets the wound care nurse know by putting the information in the 24-hour report or leaving the wound care nurse a note. The nursing assistant will tell the nurse if a dressing is soiled or needs to be changed. 43. The wound care nurse stated that she attends nursing class from 8-10 a.m. and then comes into work. The wound care nurse stated that she starts wound care on the C wing because the residents on C wing are at the Facility for therapy and she likes to get their dressing done first so that they can go to therapy. The residents on wing A and B wing are in their rooms . and thus they usually receive their treatments in the afternoon, 44, The wound care nurse further stated she tells the nurse on the wing what time treatment will be performed so that the nurse can premedicate the resident to allow the resident to be comfortable during the treatment. 45. The wound care nurse stated she always asks the nurse if the resident has been premedicated, and if not, she will ask the nurse to provide the resident pain medication and come back after a while. 46. When asked how Resident #4 communicates pain, the wound care nurse stated that the Resident moans or may move his or her hand to push the nurse away. The Resident seldom speaks. 47. The wound care nurse stated that she documents in the progress notes the times when she performs the treatment. 48. A record review on May 6, 2009, revealed that Resident #4 had a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of January 30, 2009. 49, Section G(A) was coded that the Resident was totally dependent on staff for care. 50. Section M1 indicated that the Resident had two stage II pressure ulcers and two stage IV pressure ulcers. 51, Section J2a coded 1-pain less than daily in the last seven days and section J2b coded 1-mild pain. 52. The physician orders for April 2009, signed and dated April 3, 2009, indicated Hydrocodone-APAP (acetaminophen) 7.5-500, one tablet 30 minutes prior to dressing, change one per day, do not exceed 400 mg APAP per day. 53, This order is on the May 2009 physician orders, however, the orders are not signed and not dated. 54. Hydrocodone with Acetaminophen (brand names Lortab, Lorcet, Vicodin) is an ' analgesic narcotic used for relief of moderate to severe pain. 55. The Medication Administration Record (MAR) for April 2009 revealed that this pain medication was given to the Resident at 9:00 a.m. every day in April except April 16, 2009, and April 19, 2009, when it was not given at all. 56, The MAR for May, which does not have a date but was confirmed by the DON as the MAR for May, indicates that the Resident received this medication on May 1-2, and 4-6, 2009, daily at 9:00 a.m. 57, The Resident did not receive the pain medication on May 3, 2009. This was cross checked with Resident #4's controlled drug record-individual patient's narcotic record. 58, The nursing progress notes indicated dressing changes on April 5, 2009, at 11:00 am., April 7, 2009, at 11:50 am., April 13, 2009, at 2:00 p-m., April 22, 2009, at 1:30 p.m., April 24, 2009, at 2:00 p.m., April 30, 2009, at 9:00 a.m., and May 1, 2009, at 10:00 a.m. 39. The Resident was not being given pain medication 30 minutes prior to wound care treatment in accordance with the physician orders. The physician’s order was to administer the pain medication 30 minutes prior to the dressing change. The medication was not given at all on April 16 and 19, 2009. On all other dates in April, the medication was given at 9:00 a.m. Under the Plan of Care dated March 5, 2009, it indicates to evaluate and/or pre-medicate the Resident prior to wound care. 60. The Braden scale for predicting pressure ulcer risk was dated November 9, 2008, and the score was 13. A total score of 13-14 indicates moderate risk. 61. According to the Facility Skin Care and Wound Management-Clinical Programs Manual, the Braden scale is used to identify factors for skin breakdown and is supposed to be completed quarterly. 62. The Resident's Braden scale had not been completed in almost 6 months. 63. The weekly skin sweeps beginning on December 13, 2008, revealed no new skin impairment, however, there were no weekly skin sweeps between January 17, 2009, and February 7, 2009 (3 weeks) and no weekly skin sweeps between February 7, 2009, and February 28, 2009 (3 weeks). 64, The last documented skin sweep was April 18, 2009 (3 weeks). 65. According to the Facility Skin Care and Wound Management-Clinical Programs Manual, skin sweeps are supposed to be conducted weekly to identify new skin impairments. 66. Under the Plan of Care, it stated: pressure ulcer dated February 11, 2009, indicated that the Resident had a stage III on left ankle, stage IIT on right ankle, stage IV on left ishium, and stage IV on coccyx. 67. . Measurements were dated April 17, 2009, and indicated 2 x 1.8 x 0.4 (no location); R 2.5 x 1 x 0.5; ishial 6.2 x 5.5.x 1; sacral 8x 7 x 2.2. 68. A note dated April 24, 2009 stated apply Maxorb Extra AG q (every) 72 hours to bilateral ankles and left hip and sacral. 69. Under the Plan of Care, it stated: pressure ulcer dated March 5, 2009, indicated the following: sacral 8 x 7 x 2.2 stage IV; left ishium 6.2 x 5.5 x 1 stage IV; left ankle 2 x 1.8x 0.4 stage IL; right ankle 2.5 x 1.4.x 0.3 stage II and 2.5 x 1 x 0.5 (no stage). 70. Anote dated April 22, 2009, stated: cleanse all wounds with normal saline, apply moist to dry to all ulcers every day for 1 week and then change to Mesalt dressings every day. 71, A noted dated April 29, 2009, stated: right and left ankle-apply Silvadene pack moist to dry clean, normal saline with border gauze every day and sacral and ischial-irrigate with normal saline, apply Silvadene pack with moist to dry-cover border gauze every day. 72. According to the Facility Skin Care and Wound Management-Clinical Programs Manual, the care plan is reviewed quarterly at a minimum, 73, According to the Facility Skin Care and Wound Management-Clinical Programs Manual, the skin grid-pressure is to be done weekly until the area is healed to document status of the pressure area. 74, The nurse is supposed to use one form per identified pressure area. 75. Resident #4 had only two grid-pressures performed, one for the coccyx dated April 13, 2009, and then again on May 6, 2009. | 76, From March 2, 2009, through April 13, 2009, the pressure ulcer measurements ‘were unchanged. 77. On April 13, 2009, there was no description of the wound. 78. On May 6, 2009, the wound was documented as stage IV, 8 cm x 5 cm x 2 cm, with no description of the wound. 79. The second skin grid that was performed was for the left ishial area beginning on March 24, 2009, to April 13, 2009, documented as a stage IV. 80. The next entry is May 6, 2009, stage IV, measuring 5 cm x 6 cm x 1 cm. 81. There are no skin grids for the pressure ulcers on ‘the left and right ankles. 82. The physician orders signed and dated April 3, 2009, state: cleanse bilateral ankles, coccyx and left ischium with wound care cleanse, apply Dakins 1/4 solution moist to dry dressings, cover with gauze and border gauze daily and as needed. 83. A verbal order dated April 22, 2009, stated: discontinue Silvadene dressing, start normal saline wet to dry dressing to all decubitus ulcers every.day for one week and then change to Mesalt dressing. 84. This order was not signed or dated by a nurse and there was no date when the physician signed the order. 85. A physician order dated April 24, 2009, indicated to apply maxorb extra AG+ every 72 hours and as needed to right ankle, sacral and left hip. 86. There is no order for the left ankle pressure ulcer. 87. A verbal order dated April 30, 2009, indicated to cleanse the sacral wound, ischeal wound and bilateral ankles with wound care cleanse, apply mesalt dressing or equivalent and cover with statosorb composite qod soiling. 88. This order is not dated by the nurse and not signed or dated by the physician. 89. During an interview with the DON on May 6, 2009, at 9:59 p.m., it was confirmed that there were no May 2009 orders in the medical record. 90. There were orders, however, they were not signed or dated. 91. The DON confirmed that there were no treatment orders, only medication orders. 92. The treatment record for Resident #4 for April 2009 revealed that physician ordered treatments were not provided to the bilateral ankles, ischeal/hip area, or coccyx area on April 5, 18, 19, and 24-27, 2009. . 93. During an interview with DON on May 7, 2009, at 1:00 p.m., it was revealed that there seemed to be systemic problems with obtaining physician orders, getting physician orders signed, and getting consults on the charts timely. 94, She stated that the only consult they could find for Resident #4 for a certain physician was March 11, 2009, but they knew the physician saw the Resident after that time and that the Resident was also seen by another physician and they could not find any documentation from that other physician. Resident #1 95. A review of the clinical record for Resident #1 revealed treatment orders to cleanse the Resident’s sacral area with wound cleanser, apply Hydrocolloid every 3 days and as needed, and PRN soiling with a start date of April 27, 2009. 96. Another treatment order was present that stated to cleanse the Resident’s right calf with wound cleanser, apply Hydrogel sheet, cover with bordered gauze and change every 3 days with a start date of April 25, 2009. . 97. During an interview with the LPN on May 6, 2009, at 8:10 p.m., it was revealed that Resident #1's dressings were typically changed by the wound care nurse on the day shift. 98, The 3-11 shift did not change Resident #1's dressings unless the Resident was incontinent and the dressings were soiled. ) 99, An observation of Resident #1's sacral wound and right calf revealed that neither 13 area had a dressing in place. 100. The sacral area was open, superficial, approximately 1 cm, with no drainage. 101. . The right calf had two areas, a 4 cm raised blister and a 3 cm lacerated area with a small amount of dried blood. 102. The LPN stated that all of the areas should have been dressed, but, could not say why the dressings were not on. 103. At that time, the LPN cleansed the wounds and applied the dressings as ordered. 104. A review of the Resident’s treatment record revealed that both dressings were scheduled to be changed on the 11-7 shift. 105. Both were initialed as completed, but the initials were marked through. 106. There was no documentation indicating whether the treatment was administered, ‘or whether the records were initialed in error. 107. The LPN stated the initials were those of the wound care nurse, 108. During an interview with the wound care nurse and review of the treatment record at on May 7, 2009, at approximately 12:15 p.m., it was revealed that the treatment nurse was going to do the dressing, but realized it was scheduled for 11-7 shift. 109. Thus, she scratched through her initials because she did not do the dressing. 110. When asked how it was decided who does the wound care, the floor nurse or the treatment nurse, the wound care nurse stated that she tries to look at them all, but as a rule she does the deep more complicated wounds and the floor nurses do the smaller ones and the skin tears. 111. A review of the most recent MDS assessment, reference date February 27, 2009, revealed that Resident #1 has a stage II pressure ulcer. 14 112. A current care plan revealed that the right lower leg and the sacral area were identified as having open areas. 113. The current treatment was included in the interventions, but those interventions were not followed by the staff. Resident #6 114. An observation with LPN Unit Manager performing wound care and the CNA assisting on May 6, 2009, at 7:00 p.m., revealed Resident #6 lying on his or her back. 115. The bed had an alternating low air loss pressure mattress. 116. The Resident has bilateral above the knee amputations. 117. The Resident had: a. A stage I pressure ulcer located in his or her upper mid-back, size approximately 1 cm long x 0.5 cm wide. The dressing was dated May 4, 2009, with initials LG. b. A stage II pressure ulcer located on his or her right buttock, dressing dated May 6, 2009 with initials LG. The Unit Manager removed the dressings with gloves. The wound was approximately 4 cm long by 3 cm wide. The wound bed area was red. The surrounding tissue was pink. There were no signs or symptoms of infection. 118. During treatment to the right buttock, Resident #6 yelled out in pain as the nurse cleaned right buttock wound. 119. The Resident was in pain and attempted to hit the nursing assistant and said "leave me alone." | 120. The surveyor asked the Resident if the treatment hurt and Resident said "yea." 121. The nurse was asked if the Resident was medicated for pain before the dressing change. 15 122. The nurse did not know and did not know if resident had pain medication ordered. 123, The physician orders for April 2009, were signed and dated April 3, 2009. 124, The May 2009 physician orders were not signed and dated by the physician. 125. There was no order for either April or May for Tylenol. 126, Both the April and May 2009 physician orders had an order for Hydrocodone - APAP, 10-500, one tablet per tube every 4 hours as needed for pain, not to exceed 4 grams of Tylenol in 24 hours. 127, Hydrocodone with Acetaminophen (brand names Lortab, Lorcet, Vicodin) is an analgesic narcotic used for the relief of moderate to severe pain. 128. The Resident had not received this medication; the resident did not receive any pain medication in April or May. . 129. There was no indication in the progress notes dated March 13, 2009, through the last note of April 28, 2009, that the Resident was assessed for pain prior to dressing change or treated for pain. Sanctions 130. The Respondent’s actions or inactions constituted a class II deficiency. 131. Aclass Il deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2008). 132. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more 16 class I or class I deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2008). 133. In this instance, the Agency is seeking a fine in the amount of ten thousand dollars ($10,000), as a patterned class II deficiency. On April 20, 2009, in an Administrative Complaint, the Agency cited the Respondent for one Class II deficiency for failing to provide adequate and appropriate health care when it failed to follow the plan of care for hand mobility and range of motion and implement treatment that resulted in decline in range of motion and contracture for 3 of the 7 sampled residents. Also, the Respondent was cited in the April 20, 2009 Administrative Complaint for failing to provide adequate and appropriate health care when it failed to provide proper foot care and treatment for 1 of 7 sampled residents. The lack of proper care caused harm to the Resident in the form of pain and drainage. 134. Under Florida law, as a penalty for any violation of this part, authorizing statutes, , or applicable rules, the Agency may impose an administrative fine. Unless the amount or aggregate limitation of the fine is prescribed by authorizing statutes or applicable rules, the Agency may establish criteria by rule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules. Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final order of the Agency and not subject to further appeal, the violator shall pay the fine plus interest at the rate specified in section 55.03, Florida Statutes, for each day beyond the date set by the Agency for payment of the fine. § 408.813, Fla. Stat. (2008). 135. Under Florida law, the Agency may deny an application, revoke or suspend a license, and impose an administrative fine, not to exceed $500 per violation per day for the violation of any provision of this part, part II of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: A violation of any provision of this part, part II of chapter 408, or applicable rules. § 400.121(1)(a), Fla. Stat. (2008). 136. Under Florida law, in addition to any other sanction imposed under this part or Part I of Chapter 408, in any final order that imposes sanctions, the Agency may assess costs related to the investigation and prosecution of the case. Payment of Agency costs shall be deposited into the Health Care Trust Fund. § 400.121(8), Fla. Stat. (2008). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $5,000.00. COUNT IL 137. The Agency re-alleges and incorporates by reference paragraphs 1 through 135. 138. A conditional licensure status means that a Facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the Agency, was not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. If the Facility has no class I, class IT, or class UI deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. § 400.23(7)(b), Fla. Stat. (2008). 139. Due to the presence of one or more state class II deficiencies, or class IIT deficiencies not corrected within the time established by the Agency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part IL, Florida Statutes, or the rules adopted by the Agency. 140. As a result of these deficiencies, the Respondent was subject it the assignment of 18 a conditional licensure status. 141. The Agency issued the Respondent a conditional license with an action effective date of May 7, 2009. A copy of the original certificate is attached as Exhibit A. 142. The Agency issued the Respondent a standard license with an action effective date of June 1, 2009. A copy of the original certificate is attached as Exhibit B. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assign a conditional licensure status on the Respondent as set forth above. . CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests a final order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 2. Imposes the above-referenced relief sought by the Agency. 3. Enters any other relief that is just and appropriate. Respectfully submitted this i 7 day of November, 2009. hk loigen D. Carlton Enfinger, I ea Florida Bar No. 793450 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 Telephone: 850.922.5873 Facsimile: 850.921.0158 The Respondent has the right to request a hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes, and to be represented by counsel or other qualified representative. Specific options for the administrative action are set out within the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served to: Thomas L. McDaniel, Administrator, Capital Healthcare Center, 3333 Capital Medical Blvd., Tallahassee, Florida 32308, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 9333, and Corporation Service Company, Registered Agent, 1201 Hays Street, Tallahassee, Florida 32301, by U.S. Mail on this f 7 day of November, 2009: Akt D. Carlton Enfinger, II, Bf. 20 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR June 16, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: HOLLY BENSON SECRETARY The attached license ‘with Certificate #15735 is being issued for the operation of-your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: . Agency for Health Care Administration Long Term Care Section, Mail Stop.#33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for status change to Standard. Sincerely, SPOON Agency for Health Care Administration ’ Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need ‘ ORIDA 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 OMPARE CARE Health Care In the Sunshine www.FloridaCompareCare.gov Visit AHCA online at http://ahca.myflorida.com soueinssy Append) WTeep] JO UoIsiacy ¢ 6007/0E/TT ‘ALVG NOILVUldXd JSNIOII 6007/10/90 ‘ALVC FAILOSIA NOLLOV HONVHO SNLVLS Sad 9S “TVLOL 80€ZE Td SASSVHVTIVL ‘GATE TVOICGAN TVIIdVO cece UEINAD PUVOHLIVEH TWLIdvo ‘SULMO]IOJ OY] oyeIed0 0} peztoyINe ST sesuaol] auf se pure “soymers EpHol ‘TI wed ‘Ody JeideyD ut pezuoune ‘uonenstanupy ereD yyeay Jog Aoussy ‘epuory jo ag am Aq perdope suorenSer pue soy oy yim poryjdusoo sey DTT ‘SALVIOOSSV FUVO HLIVAH TVLldvo eH ULIFUOD 0} SI STAT, CaAVANVIS HINOH ONISUON AONVUNSSV ALTIVND HLTH JO NOISIAIG NOLLVYLSININGY Fav HLTVaH YOd AONADV BPLIOL] JO 338}S # OSNADIT Secsl -#ALVOILLaaO FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ; CHARLIE CRIST HOLLY BENSON GOVERNOR SECRETARY June 16, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: The attached license with Certificate #15734 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for status change to Conditional. Sincerely, \S(-00K Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need 2727 Mahan Drive, MS#33 oa Visit AHCA online at Tallahassee, Florida 32308 Oe eRe GORE http://ahca.myflorida.com > www.FloridaCompareCare.gov 600C/0E/TT *ALVC NOILVUIdXd ASNAOTT 6007/L0/S0 ‘ALVC FAILOGISA NOLLOV AONVHO SNLVLS SGaa 9ST “IVLOL S0€7E Td “AASSVHVTIVL “GATE TVOIGAW TVLIdV9 €ee€ UYALNEO FAVOHLTVEH TW LdVoO ‘SUIMOTIO} SU} oye1edo 0} pezuoyNE ST sesusol] ot} se pue ‘saynjeis BpLIoLy ‘T] ued ‘Oop JaideyD wt pezuoune ‘uonensturmpy szeD Wyeey Jog Aoussy ‘eptio] JO ares atp 4q perdope suonejnder pue sanz aty yim paydwoo sey DT] ‘SHLVIOOSSV AAV HLIVAH TVLIdVO eM wayUo oF st SIT, AINOH DNISHOAN FONVANSSV ALITVNO HLTVAH JO NOISIAIG NOILVULSININGV AAV) HLTVaH YOd AONADV PLO JO 338}S 9O0ELOTANS *# ASNAOIT -# FLVOMILaO Postage Cortiied Fee Retum Recel (Endorsement Hoque Restricted Deliv (Endoreament Roaress Total Postage & toes Y Anis’ She ‘ mY Se Ses Bid SENDER: COMPLETE THIS SECTION ™ Complete Items 1, 2, and 3. Also complete item 4 If Restricted Delivery is desired, D Agent ! ™ Print your name and address on the reverse D Addresseo So that we can return the card to you. B. Recelved by ( Printed Nam Attach this card to the back of the maliplece, ecenyed by ( Panted Name) . as, or on the front if space permits, d be ~ D. Is delivery Address different from item 17d Yes 1. Article Addressed to: YES, enter delivery address below: CINo Thema, L MeDanf & iN Cohncadss 3. Service Type O CertitedMal OF Express Mall C) Registered O Retum Recelpt for Merchandise C Insured Mail Ocoo. Restricted Delivery? (Extra Fea) 7004 @a5q 0000 55a, 433 PS Form 381

Docket for Case No: 09-006609