STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2009008506 (Fines) 2009008508 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC,) © 2009008509 (Revoc.) . d/b/a Capital Healthcare Center, 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 CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capital Healthcare Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 400.121(1)(a) and 400.121(3)(d), Florida Statutes (2008), impose an administrative fine of fifteen thousand dollars ($15,000) based upon the citation for three (3) Class II deficiencies pursuant to § 400.102(1), Florida Statutes (2008). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing July 18, 2009 and ending September 3, 2009. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60, Florida Statutes, Chapter 400, Part I Filed January 5, 2010 11:51 AM Division of Administrative Hearings. and Chapter 408, Part II, Florida Statutes (2008), and Chapter 59A-4, Florida Administrative Code. 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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 IV, Subtitle C (as amended), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 156-bed nursing home, located at 3333 Capital Medical Blvd., Tallahassee, Florida 32308, and is licensed as a skilled nursing facility (License number 1073096). . 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7, Florida law provides the following: a. Section 400.102(1), F.S., “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: (1) an intentional or negligent act materially affecting the health or safety of residents of the facility...” b. Section 400.022(1)(n), F.S., “The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis. c. Section 400.121(1)(a), F.S., “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 licensce 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.” 8. The Agency conducted two complaint investigations in conjunction with a re-licensure survey starting on July 13, 2009 and ending July 18, 2009. 9. Based on observation, staff interview and record review the facility failed to provide care in a manner to enhance dignity and respect for 3 of 4 residents in the sa.m.ple, by not providing incontinent care resulting in harm for resident #208, use of insulting terms to describe resident #166, and for neglecting the emotional needs of resident #140. The facility failed to ensure 10 of 10 residents on the A wing were treated with dignity and respect for individual preferences during meals. 10. The findings regarding Resident #208 include: 11. Observation of resident #208 on 7/16/09 at 8:50 A.M., 9:15 A.M., 10:20 A.M,, 11:45 A.M. and 1:10 P.M. revealed the resident was in the Starlight progra.m. with 3 restorative aides. 12. Review of the sign in and out record where aides document when the residents are toileted revealed the resident had not been toileted since entering the progra.m. at 8:00 A.M.. 13. When interviewed at 1:10 P.M. Starlight progra.m. staff stated that they requested the staff on the unit to come and get the resident for toileting but they did not respond to the request. 14. Observation of incontinent care at approximately 1:30 P.M. revealed the resident smelled of urine, urine soaking resident’s pants and running down thighs, diaper completely saturated and a pool of urine on cushion in wheelchair, The resident's buttocks and groin area were red. 15. In an interview on 7/16/09 at 2:30 P.M. staff stated the resident requires extensive assistance with care, is incontinent of bowel and bladder and is toileted every two hours. The resident goes to Starlight which is a progra.m. for confused residents, and stays there all day. Staff maintained they check on the resident throughout the day. 16. Review of the 90 day minimum data set (MDS) dated 5/12/09 revealed the resident to need extensive assistance with toileting and incontinent of bowel and bladder. The assessment indicates the resident is on a scheduled toileting plan. 62. Review of the plan of care for 3/09 indicates the resident is incontinent of urine and is not a candidate for retraining. Approaches include to provide incontinent care as needed and to toilet prior to meals, activities and therapies. 17. Findings regarding Resident #166 include: 18. Jn an interview on 7/14/09 at 10:15 A.M. resident #166 stated “[A] week ago I overheard several aides telling a nurse it took 30 minutes to put me, my roommate and another resident to bed because I was fat. I was crying. I talked to the nurse about this and she tried to explain it away.” 19. In an interview on 7/15/09 at 5:30 P.M., the 3-11 shift aides and nurse stated the resident likes to stay up and they tell the resident nicely that they can stay up and they will get to her/him when we can. They stated resident #166 watches TV late and goes to bed around 10:00 P.M. - 11:00 P.M.. 20. The nurse remembered an incident when she was talking to several aides on the floor in ear shot of the resident. She stated she was trying to explain to the aides to share duties and team up to save time. She stated the aides were explaining that several residents require a lot of time to be put to bed and some are heavy. The nurse stated there was no intention to hurt the resident's feeling. 21. Findings for Resident #140 include the following: 22. ‘Interview with resident #140 on 7/14/09 at 11:02 A.M. revealed the resident to feel that the staff, particularly some of the nursing assistants, do not give him/her individual attention. "The staff are always talking around you. Sometimes when they leave my room they are talking to me and have their back to me and I don't hear a thing they say, especially if I don't have my hearing aid in. Then they may say 'I told you that before’. At one point when I was having lots of falls some nursing assistants said I was falling to get staff in trouble that I didn't like and I would never do that." 35. Findings regarding Wing A include: 36. Observation of 10 residents in the A Wing Day Room on 7/13/09 at 11:50 A.M. revealed clothing protectors were placed on all 10 residents without asking any of the residents if they wanted the clothing protectors placed or minded having the clothing protectors on. 37, Observation in the A Wing dining room on 7/15/09 at 5:40 P.M. revealed a resident to pull his clothing protector off as staff assisted him with his meal. The staff member immediately picked up the clothing protector, said "Now why did you pull your bib off" , and proceeded to replace the clothing protector on the resident. 38. The Respondent has the legal duty to treat residents courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis pursuant to s. 400.022(1)(n), E:S. 39, Therefore, the Agency has authority pursuant to § 400.102(1), F.S., to take action against the Respondent. 40. The above findings reflect Respondent’s failure to treat residents with dignity, thus the Respondent’s actions constituted a Class Il deficiency, pursuant of § 400.023(8)(b), Florida Statutes(2008). 41. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to’ §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT II 42. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I of this Complaint as if fully set forth herein. 43. Florida law provides the following: a. Section 400.102(1), F.S., “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: (1) an intentional or negligent act materially affecting the health or safety of residents of the facility...” b. Section 400.121(1)(a), F.S., “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 IL 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 IL of chapter 408, or applicable rules.” 44, The Agency conducted two complaint investigations in conjunction with a re-licensure survey starting on July 13, 2009 and ending July 18, 2009. 45. Based on observation, staff interview and record review the facility failed to provide incontinent care for resident #208 resulting in harm, failed to assess, care plan and treat excoriation for resident #53 which resulted in harm. The facility failed to assess, care plan and follow physician orders for weight loss for resident #240 which resulted in harm, failed to provide toileting asistance and prevent abuse for resident #140, and failed to provide care and services related to pain and pressure sore treatment to attain or maintain the highest practicable physical and mental well-being for resident #239. (5 of 26 sa.m.pled residents). 46. Findings for Resident #53 include the following: 47. Interview with resident #53 on 7/15/09 at 11:52 P.M. revealed resident to be complaining of itching under gown near arm. The resident stated that they tell staff all the time that it hurts and staff does nothing. 48. Observation with nurse at the sa.m.e found large areas of excoriation under both breasts. Review of quarterly assessment dated 5/23/09 made no mention of excoriation and the record lacked further assessment of excoriation. 49, Review of skin sweep dated 6/22/09 indicated redness under left breast. Review of further skin sweeps did not indicate excoriation. 50. Review of skin grid sheets lacked documentation of excoriation. 51. Review of treatment sheets for 6/09 and 7/09 lacked documentation of excoriated breast and treatment. Review of nurses notes for 6/09 and 7/09 lacked documentation of excoriation. 52. Review of the most current plan of care dated 5/27/09 lacked documentation of excoriation under breast or any revision. 53. In an interview on 7/15/09 at 11:30 A.M. wound nurse stated their policy if ‘anew area is found it is monitored and documented on the skin grid sheet or in the nurses notes. The nurses failed to assess, complete a care plan, or call the physician for treatment for excoriation under both breast. 54. Review of nurses notes dated 7/15/09 at 12 noon identified the excoriation under both breast with mild odor present and the resident complaining of itching with mild burning. The physician was called and orders received to apply antifungal crea.m. two times a day until healed. 63. Findings for Resident #240 include the following: 64, Observation of resident #240 between 2:00 P.M. and 3:00 P.M. on 7/16/09 during snack time revealed no milkshake was given. ) 65. The resident in an interview at the same time stated “I don't get milkshakes and I didn't get one this morning”. 66. Interview with staff on 7/14/09 at 12:43 P.M. indicated the resident does not receive a milkshake. 67, Restorative aide passing the snacks in an interview on 7/16/09 at 3:19 P.M. stated the resident was given a choice of other snacks and aide does not give her/him a milkshake. 68. Interview with kitchen manager on 7/16/09 at 3:19 P.M. indicated the aides on the unit keep track of the consumption of the milkshakes. 69. Aide on the unit interviewed at the sa.m.e time stated that they do not document the percentage taken by the resident, dietary staff perform that function. 70. The record lacked documentation of offering the shake and the amount consumed. 71. Review of physician orders directed that the resident recieve a regular diet with large portions and a health shake between meals for added calories due to risk of weight loss. 72. Record review of dietary notes indicated the resident was admitted 7/7/09 with a weight of 98 Ibs. The assessment indicated at risk for weight loss. 73. The resident was weighed again 7/14/09 which indicated a weight loss of 7.5 lbs in 7 days. Further record review after the 7/14/09 weight lacked further assessment or change in treatment or notifying the physician. Record review lacked a plan of care for potential weight loss. 74. Findings for Resident #140 include the following: 75. In an interview on 7/15/09 at 11:15 A.M. resident #140 revealed their toilet habits had completely changed since having a stroke several years ago. The resident now needs to be assisted to the bathroom after lunch and he/she needs the assistance of staff for that activity. 76. The resident stated that staff asked why he/she didn't go to the bathroom in the A.M. and said, "I bet you couldn't regulate your body". The resident also stated staff will at times close the room door to the hallway which scares the resident as he/she is unable to do anything once placed in the bed. The resident keeps two "football" type whistles by the bed to use to alert staff as they don't always come when the resident uses the call bell and the resident is totally dependent when in bed. Resident stated "[I]t's like being in prison. I can't do anything and when that door is closed it makes it worse". According to the resident these events usually occur on the 3-11 shift. 77. During another interview with the resident on 7/16/09 at 9:00 A.M. the resident felt he/she was humiliated by the treatment of staff not always assisting to the bathroom and on occasion has soiled self. The resident had tears in their eyes, and said he/she knew they required a lot of help and said "Do you think I would have it this way if I had any choice?" The resident also stated s/he had advised the new Unit Manager of her problems. 78. Record review of the resident's most recent full assessment dated 5/9/09 and care plan dated 5/14/09 revealed the resident to require limited assistance to toilet and to have left upper extremity flaccidy and left lower extremity weakness. The care plan did not include the resident's desire to be toileted after lunch, instead the plan stated "check for toileting needs Q2-3 hours as needed; toilet prior to meals, activities, therapies and as he/she requests”. The resident is also assessed as being continent of bowel. 79, Interview with the A-Wing Unit Manager on 7/16/09 at 9:40 A.M. revealed she knew nothing about the resident wanting to be toileted after lunch or to have her door always opened. 80. The resident's nursing assistant during an interview with on the sa.m.e day at 9:45 A.M. stated she was not aware the resident wanted to be toileted after lunch or to have her door always open. 81. Findings for Resident #239 include the following: 82. Resident #239 was observed at approximately 9:00 a.m. on 7/14/09, lying on their back in bed with the head of the bed up slightly. During an interview on 7/13/09 the resident stated that the pain in his/her bones had not quite gone away. Again, during the observation of wound care on 7/16/09 at approximately 8:45 a.m., the resident complained of heel pain to the surveyor. The treatment nurse entered the room just minutes prior to administering the wound care and asked if the resident was in pain. The resident stated "I think I'll make it." The nurse left and did not return with pain medication, nor did any staff provide pain medication to the resident prior to 10 the treatment. Later in the day at approximately 11:50 a.m. the resident stated that the heel still hurt, but had received a pain medication which helped some. 84, Review of the clinical record revealed an admission note dated 7/1/09 at 11:00 a.m., stating in part, that the resident told the nurse an area to the right heel is sore to touch. 85. An additional nursing note dated 7/08/09, reveals in part "Res. heel noted with dark soft place to R heel, painful to touch." 86. Review of the resident's record reveals a care plan for Discomfort and pain, initiated on 7/2/09. The pain is described as generalized, intermittent and no explanation of what exacerbates the pain is listed. What relieves discomfort/pain? Answer stated as Tylenol ES with the first approach to administer medications from pain management as ordered. Secondary approaches are listed as position to comfort - with no description in the care plan; encourage exercise/activity and to educate the resident to report the pain. 87. A history and physical from the previous hospital stay revealed the resident had chronic complaints of diffuse myalgias. 88. Review of the resident's medication administration record on 07/18/09, revealed the resident had received the pain medication on 7 occasions since admission on 07/01/09: 07/02, 07/08, 07/09, 0711, 07/14; 07/16 and 07/17. 89. Interview with a staff LPN on 07/18/09, revealed the standard procedure is to document effectiveness of the pain medication on a monitoring sheet. No pain medication monitoring sheets could be located for the resident. No documentation could be located for the effectiveness of the pain medications given. 90. This resident with diffuse and chronic pain did not receive monitoring and treatment to ensure his/her highest level of physical and mental comfort. 11 91. Observations of resident #239's skin on 07/16/09 at approximately 8:45 a.m. before and during wound care revealed the following: 92. Skin on the right heel: Large dark blister like area, flat, darker - close to black, at the end closest to the resident's outer ankle, edges of area red and bloody looking. Dressing removed prior to the observation contained a scant amount of brownish drainage. Measurement by treatment nurse: 7.5 cm. x 4.5 cm. Areas to the resident's buttocks: Left buttock, large nickel to quarter sized, irregular open . red/raw area - 2 smaller areas above the larger area, both red and raw looking. All with the appearance of stage 2 wounds. Right buttock - 1 irregular open red and raw area noted, approximately nickel sized. Appears as a stage 2 wound. Sacral area: The nurse lifted the left buttock, revealing a split in the sacral crease. The length of the split appeared as approximately 2.5 to 3 inches in length. The edges of the tissue just inside the split appeared yellowish in color, as if slough, the narrow slender , center appeared dark brown. Measurements of the sacral split conducted by the treatment nurse were stated as 7.5 cm. x 4.5 cm. by 0.2 cm. depth. The treatment nurse stated during an interview to the dressing changes that dressings are sometimes done at the preferred time for the residents and she was not certain as to when the dressing to resident #239's heel would be done. 93, On 07/16/09, just prior to observation of wound care for resident #239, the wound care nurse stated that new areas had "just opened up" and the resident previously had only had excoriation. She stated they had been treating only the sacral split. 94. Review of the resident's clinical record reveals: a. History and physical information from the immediately previous hospital stay, in part: Stage 2 pressure sore is noted underlying the sacral region. No other open lesions seen. 12 Admission assessments with conflicting information: b. Nursing data collection sheet 07/01/09: documentation reflects no history of skin breakdown and no current skin breakdown. Sheet completed by an LPN c. Initial weekly skin sweep dated 07/01/09: Darkened area to right bottom heel, excoriation redness to buttocks and buttock crease. No mention of sacral decubitis on either sheet. d. Skin sweep 7/06/09 - No new impairment e. Skin sweep 7/11/09 - New Skin Impairment - abrasion to inner thigh. f. Skin sweep 7/13/09 - No new skin impairment g. Skin sweep 7/16/09 - New skin impairment h. New areas identified on 7/14/09, 1:00 p.m. treatment nurse progress note: Noted with opened area to sacral upon skin assessment, area measured 5.5 x 4 x 0.3, with small amount of excoriation, edges intact, wound bed red, granulation, small amount of serous drainage. i, Then on 7/16/09: Skin Grid pressure: Rt. buttock visualized stage 2 pressure area 3 x 2.5 x 0.2 and Lt. Buttock visualized Stage 2 area 4.5 x 0.5 x 0.3. j. Nursing notes on 7/16/09 at 0600 record: Resident with reddish brownish drainage to r heel. Resident had blister to R heel. R heel cleaned with wound care cleanser, small open area noted. k. Progress notes: 07/01/09 at 11:00 A.M.: Redness noted to coccyx area, dark area noted to R. heel measuring 8 x 6 x U.S. The other skin concerns documented list surgical scars. Initial Braden Score (assessment for the risk of developing pressure sores): Score 15 - Residents are identified as at high risk with a score of 12 or below. 1. Minimum Data Set assessment dated 07/08/09, section M1 - Ulcers, identifies the resident as having 1 stage 2 skin breakdown and section M6. Foot Problems - none, other skin problems or leasions present - none. Plan of care for Pressure Ulcer form dated 07/01/09: float heels in bed, complete weekly skin sweeps. m. Other observations of the resident revealed the following: 07/14/09 1:50 p.m. - Up in wheelchair in his/her room, feet down, left foot on the floor, non- skid sock on and right foot propped on foot rest with his/hersock off exposing the heel. 108. Observation of the resident on 7/16/09 at 11:05 a.m., resident remains on his/her back in bed, head of bed up slightly, turned very slightly to the right and with his/her feet elevated. 07/16/09 at 2:00 p.m., resident remains in bed on his/her back, head of bed up. Left foot on mattress, right foot elevated slightly on a pillow. 7/16 at 4:15 p.m.observed lying on his/her back on bed with the head of the bed elevated, with his/her feet not elevated and heels lying on sheets at foot of bed, feet sticking out from under covers. m. 07/17 approximately 8:15 a.m. - On back in bed, head of bed slightly raised. 07/7/09 approximately 9:00 a.m. - Up in wheelchair, feet on bilateral footrests. 110. The above findings reflect Respondent’s failure to provide health and safety to residents, thus the Respondent’s actions constituted an uncorrected Class I deficiency, pursuant of § 400.023(8)(b), Florida Statutes (2008). n. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT It 95, The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I and II of this Complaint as if fully set forth herein. 96. Florida law provides the following: a. Section 400,102(1), F.S., “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: (1) an intentional or negligent act materially affecting the health or safety of residents of the facility...” b. Section 400.121(1)(a), F.S., “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 IL 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.” c. Section 415.102(1), F.S., "Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or is hkely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions. 97. The Agency conducted two complaint investigations in conjunction with a re-licensure survey starting on July 13, 2009 and ending July 18, 2009, 98. Based on observation and interview with resident and staff, the facility failed to protect 1 (#140) of 3 sa.m-pled residents from abuse to include feeling scared at times. The findings are: 99. Interview with resident #140 on 7/15/09 at 11:15 A.M. revealed the resident to say their toilet habits had completely changed since having a stroke several years ago. The resident now needs to be assisted to the bathroom after lunch and he/she needs the assistance of staff for that activity. The resident stated that staff asked why he/she didn't go to the bathroom in the A.M. and said, told one nursing assistant "I bet you couldn't regulate your body."The resident also stated staff will at times close the room door to the hallway and this scares the resident as he/she is unable to. do anything once placed in the bed. The resident keeps two "football" type whistles by the bed to use fo alert staff as they don't always come when the resident uses the call bell and the resident is totally dependent when in bed-"it's like being in prison--I can't do anything and when that door is closed it makes it worse". According to the resident these events usually occur on the 3-11 shift. 100. During another interview with the resident on 7/16/09 at 9:00 A.M. the resident felt he/she was humiliated by the treatment of staff not always assisting to the bathroom and on occasion has soiled self. The resident had tears in their eyes, and said he/she knew they required a lot of help and said "Do you think I would have it this way if I had any choice?" The resident also stated s/he had advised the new Unit Manager of her problems. 101. Record review of the resident's most recent full assessment dated 5/9/09 and care plan dated 5/14/09 revealed the resident to require limited assistance to toilet and to have left upper extremity flaccidy and left lower extremity weakness. 102. The care plan did not include the resident's desire to be toileted after lunch, instead the plan stated "check for toileting needs Q2-3 hours as needed; toilet prior to meals, activities, therapies and as he/she requests. The resident is also assessed as being continent of bowel. 103. Interview with the A-Wing Unit Manager on 7/16/09 at 9:40 A.M. revealed her to say she knew nothing about the resident wanting to be toileted after lunch or to have her door always opened. Interview with the resident's nursing assistant on the sa.m.e day at 9:45 A.M. revealed her to say she was not aware the resident wanted to be toileted after lunch or to have her door always open. 104. The above findings reflect Respondent’s failure to Protect a resident from abuse to include feeling scared at times, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.023(8)(b), Florida Statutes(2008). 105. The Agency provided Respondent with the mandatory correction date for this deficient practice of August 18, 2009. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT IV 106. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I, Ii and Ill of this Complaint as if fully set forth herein. 107. Based upon Respondent’s cited State Class II deficiencies, 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), Florida Statutes (2008). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2008) commencing July 18, 2009. COUNT V 108. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I, II, WI and [V of this Complaint as if fully set forth herein. 109. That the Agency may revoke any license under § 400.121(2)(a). 110. That the Respondent has been cited with three (3) Class II deficiencies pursuant to §§ 400.102(1), 400.022(1)(n), 415.102 and 400.23(8)(a), Florida Statutes (2008). 111. That based thereon, the Agency seeks the revocation of the Respondent’s license. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate a nursing home facility in the State of Florida, pursuant to §§ 400.121(1)(a) and 400.121(3)(d), Florida Statutes (2008). § 400.121(3)(d), F.S., authorizes the Agency to revoke the license of a nursing if the nursing home is cited for two Class I deficiencies arising from separate surveys or investigations within a 30-month period. Approximately six and a half months ago, or within a 30-month time period, on or about June 25, 2008, the Agency issued an Administrative Complaint (Agency Case Nos. 2008007399 and 200800400) which cited the Respondent with a Class I deficiency based on a survey separate from the survey at issue on this Administrative Complaint. Therefore, based on §§ 400.121(1)(a) and 400.121(3)(d), F.S., the Agency has proper statutory authority to revoke the Respondent’s license because the Respondent violated applicable rules and has been cited for two Class I deficiencies arising from separate surveys within a 30-month time period. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, IJ, I, IV and V; (B) Recommend an administrative fine against Respondent in the amount of $15,000; (C) Assign a conditional licensure status commencing July 18, 2009; (D) Assess attorney’s fees and costs; and (E) Grant the revocation of Respondent’s license; (F) Grant all other general and equitable relief allowed by law. 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 form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. : RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted December 3 » 2009. D. Carlton Enfin; Fla. Bar.0793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4161 to: Facility Administrator Thomas L. McDaniel, Capital Healthcare Center, 3333 Capital Medical Blvd., Tallahassee, Florida 32308, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4178 to: Owner 19 Capital Health Care Associates, LLC, d/b/a Capital Healthcare Center, 10210 Highland Manor Drive, Suite 250, Ta.m.pa, Florida 33610, and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4185 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301 on December _% , 2009: D. Carlton Enfinge Copy furnished to: Barbara Alford, FOM 20 FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR July 29, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: HOLLY BENSON SECRETARY The attached license with Certificate #15824 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, oon Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 GOMPARE CARE Health Care in the Sunshine F www.FloridaCompareCare.gov Visit AHCA online at http://ahca.myflorida.com 600Z/0E/IT -ALVG NOILVUdKs ASNAOIT 6007/81/20 “ALVC FALLOgdTA NOLLOV AONVHD SALVIS Saad 9ST -TVLOL S0€%E Td “AASSVHVTIVL “GATE TVDIGAN TVLIdVO Efe UALNAO AAVOHLTIVEH TW Ldvo ‘BuLMmojjoy ouj oyesodo 0} pazuoyne St sesusoq] OY} SB pur ‘soINIeIg BPHOL ‘Tl weg “OOP JerdeyH ut peznowne ‘uonensiurmpy erp yeoy 10,7 Aouasy “epuoyy jo ag op Aq pordope suonemser pue soni om wim parjdunoo sey OT] ‘SALVIOOSSV TUVO HLIVAN TVLdVO wy wUyUOS 07 st SALT TYNOILLIGNOD HINOH ONISUON FONVANSSV ALITVNO HLTVH JO NOISIAIC NOLLVULLSININGY FaVO HLTVaH YOd AONADV BPLIOL] JO 29kIS 960CLOTANS “# ASNAOIT vC8ST *#OLVOMILAaD FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR September 10, 2009 CAPITAL HEALTHCARE CENTER 3333 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 Dear Administrator: HOLLY BENSON SECRETARY The attached license with Certificate #15899 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, Qe Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need F COMPARE (ARE Health Care in the Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 {3 www.FloridaCompareCare.gov Visit AHCA online at http://ahca.myflorida.com eouemssy Anfend Tyee} Jo woIstaiq ‘ 600Z/OE/IT “ALWG NOILVUIEXa SSNIONI 600Z/£0/60 ‘ALWC AALLOSaIa NOLLOV AONWHO SALVLS SGag 9ST “TVLOL SOC@E Id “SASSVHVTIVL “GATE TVOIGEN TVLIdV Ccce YEINAD FAVOHLTVAH TVLdvoO BUIMOTIOT OU} arerado 01 pezuoune Si sasuisoy] OY] Se puke “sampeIg EPLOTJ ‘T] Ueg ‘OO Jerdey wi pezuomne ‘vonensturapy eed Yeap 10j Aouasy ‘epuoyy jo areis ou Aq perdope suogemsei pue spn oy] Yn paljduoo sey DTT ‘SAL VIOOSSV TUVO HLIVEH TVLIdVO 2m wo? 07 st SHEL AINOH DNISMAN FONVUNSSV ALITVNO HLTVAH AO NOISIAIC NOILVULSININGY Fav HLTVaH WOd AONADV BPLIOL] JO 98S SO0ELOIANS *# ASNAOIT ; “# ALVOMILYAD . STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Capital Health. Care’ Associates, LLC . os 9999008506 d/b/a Capital He altheare Center, ae “CASE NO™:" 2009008508" - - PO my - 2009008509 BLUCTI ION OF RIGHTS - This Election of Rights form ‘is attached. toa ‘proposed action: ‘by the Agency & for - Health Care Administration (AHCA). The title-‘may bé Notice of hitent to Impose a Late . Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308, Phone: 850-922-5873 Fax: 850-921-0158, PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___—Ss dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and IF request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administra... Hearings under Section 120.57(1), » .orida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. : 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4, A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that Iam duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC Postage Gertltied Feo Postmark Return Racelpt Fea ° Here (Endorsement Required) Resttloted Dallvery Fao (Endorsement Reqilred) or PO.Box.No, Biz 8g COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1, 2, and 3. Also complete re item 4 if Restricted Delivery Is desired. D Agent ™@ Print your name and address on the reverse D Addressee so that we can return the card to you. ™@ Attach this card to the back of the mailplece, or on the front if space permits. 1. Article Addressed to: Nae NS, Band Snohert AWemas VNC DBowia SBR 3 Sarg del Bd. * Of conten nal express Mall CI Registered C Return Receipt for Merchandise ‘Vathabhas SOS | FLBARAR Cl insured Mai! (01. G.0.0, Restricted Delivery? (Extra Fee) leturn Recelpt 102595-02-M-1540

Docket for Case No: 10-000018