ge ae STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . . vs. ; : CaseNos, 2010012041 (Fines) : 2010012043 (Cond.) SOUTH DAYTONA HEALTH CARE ASSOCIATES, LLC d/b/a OAKTREE HEALTHCARE, 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 South Daytona Health Care Associates, LLC, d/b/a Oaktree Healthcare (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $70,000.00 upon Respondent, pursuant to Section 400.23(8), Florida Statutes (2009) and a survey fee of $6,000 pursuant to Section 400.19, Florida Statutes (2009). The imposition of this fine is based on three Class I deficiencies. The Agency also intends to impose a Conditional rating effective May 7, 2010 ending June 26, 2010, pursuant to § 400.23(7), Florida Statutes (2009). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed February 25, 2011 9:58 AM Division of Administrative Hearings Swag 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), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4, Respondent operates a 65-bed nursing home, located at 650 Reed Canal Road, South Daytona, Florida 32119, and is licensed as a skilled nursing facility license number 1122096, 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 (Tag N71) RESPONDENT’S FACILITY FAILED TO COMPLETELY AND ACCURATELY ASSESS AND REASSESS RESIDENTS Fla. Admin. Code R. 59A-4.109(1) ISOLATED CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Fla. Admin. Code R. 59A-4,109(1), Florida law states: each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s % ¥ agg? functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3, Revised as appropriate to assure the continued accuracy of the assessment. 8. That from May 3, 2010 through May 7, 2010, the Agency conducted an unannounced licensure survey at the Respondent’s facility, 9. Based on observations, resident record review, and staff and resident interview, the facility failed to completely and accurately assess and reassess 2 of 36 sampled residents, Resident #17 and Resident #2 for repeated incidents that involved the residents' mood, behavior patterns and mental disease diagnosis that threatened the physical and mental well-being of at least 6 other facility residents, Residents #10, #45, #75, #80, #70 and #58. Resident #17 10. During an initial interview with Resident #17 on 5/3/10 at 1:20 PM, the resident revealed that an incident had occurred on 4/29/10 between he/she and a staff member. The resident further revealed that he/she felt he/she was talked to in a rude manner by the staff person during the incident. The resident further stated the police were called and he/she felt threatened by the police. 11. Avreview of Resident #17's clinical record revealed the resident was admitted to the facility on 10/14/09 due to a stroke. The resident was discharged to the hospital on 10/25/09 for being over sedated with Lortab and Kanax that was not provided by the facility. Resident #17 ie returned to the facility on 10/27/09 from the hospital with hospital information stating the resident had a history of bipolar disorder and schizophrenia. 12. Further review of the clinical record revealed a nurses note dated 4/29/10 revealing the resident had been gone from the facility and when he/she returned around 6:45 PM the resident became angry upon noticing that the television in his/her room was removed. The note further stated the resident was yelling in the hallway and went into the main dining room and angrily confronted a CNA, "verbally assaulting her and not letting up." The nurse intervened and "finally" got Resident #17 to return to his/her room. The note further states that a police officer ““attived, spoke to the nurse and to the resident and left. The note concludes with the Director of a Nursing (DON) being called and informed of the incident. 13. An interview on 5/4/10 at 3:13 PM with the CNA involved in the incident on 4/29/10 revealed Resident #17 was cursing and yelling and "got in my face" calling her names and pointing at her. The CNA further stated the nurse on duty was aware of Resident #17 yelling at her and did nothing at first. The CNA stated after yelling at her, Resident #17 started yelling at Resident #70 who shared a room with Resident #17. The CNA stated as she feared for her safety and no one was helping her, she called the police. 14. An interview on 5/4/10 at 3:28 PM with the nurse on duty on 4no/ 10, revealed he observed Resident #17 verbally threatening the CNA. He further stated he did not witness Resident #17 yelling at or threatening Resident #70. The nurse stated he had informed the DON that night what had happened. He further stated no one ever asked him anything about the incident after it occurred. 15. Aninterview with Resident #70 on 5/5/10 at 9:31 AM revealed he/she had shared a room with Resident #17 and 2 other residents since being admitted on 4/8/10. Resident #70 stated that Resident #17 would watch pornographic movies at night and that disturbed Resident #70. Resident #70 further stated that he/she had approached Resident #17 about the pornographic movies and that he/she didn't want to listen to them and would Resident #17 turn them of f. Resident #17 refused and one time came at him/her with a fist in his/chest and threatened hiny/her. Resident #70 stated he/she reported this to his/her nurse and the DON. Resident #70 further stated he/she went to a nurse and asked to be put in another room. A review of the nurse's notes for Resident #70, revealed the resident asked to be moved on 4/12/10. The resident stated that he/she again asked to be moved on 4/27/10 at his/her care plan meeting. Resident #70 further stated that on 4/29/10 Resident #17 came into the room in the evening and “threatened to ~~ 7 harm (the resident)" and blamed him/her for the removal of the television. Resident #70 said the nurse on duty was aware of Resident #17 threatening him/her on 4/29/10, Resident #70 also stated that he/she had been threatened with harm by Resident #17 on numerous occasions and the facility was aware of it. Resident #70 was removed from the room shared with Resident #17 on 5/1/10, 16. — Further review of Resident #17's nurses’ notes revealed on 4/6/10 the resident became agitated and began yelling down hallways and slamming doors. A nurse’s note dated 4/14/10 revealed the resident was watching pornographic movies at 2:00 am very loudly and when asked by the nurse to turn it down he/she became agitated and started yelling at the nurse. A nurse’s note dated 4/24/10 at 6:30 AM revealed the resident spoke loudly and in an aggressive manner towards a CNA. The note further stated Resident #17 yelled (he/she) couldn't stand Resident #70 and was "going to bug the hell out of (him/her) every time I can." 17... Areview of Resident #17’s clinical record revealed a Minimum Data Set Quarterly assessment tool dated 4/29/10 which revealed the resident was not coded for having any aN g behaviors. A review of Resident #17's Care Plan dated 11/12/09 revealed no plan or interventions for any inappropriate behaviors. The facility's admitting diagnosis dated 10/14/09 for Resident #17 included Bipolar disorder and Schizophrenia, paranoid type. | Resident #2 18. An interview with Resident #10 on 5/6/10 at 8:50 AM revealed that the resident was afraid of Resident #2, as the resident threatened others and was angry. 19. An interview with Resident #75 on, 5/6/10 at 4:05 PM revealed Resident #2 had "threatened me with a cane on numerous occasions." The resident further stated that he/she had "talked to the DON about the threats and was told the DON "would take care of it." Resident #75 stated Resident #2 still threatened the resident from time to time. Resident #75 further stated that Resident #2 was "backing (the resident) into a corner and J don't know what to do." Resident #75 lives next door to Resident #2. 20. An interview with Resident #80 on 5/6/10 at 4:09 PM revealed he/she had heard Resident #2 threaten Resident #75 and Resident #2 had threatened him /her also. The resident had a room 2 doors away and across the hall from Resident #2. The resident also stated that the facility was aware of Resident #2's behavior. 21. A review of the clinical record of Resident #2 revealed the resident's admit date to the facility was 12/4/09. The resident's quarterly MDS dated 3/7/10 coded the resident as having short term memory concern, modified independence for daily decision making, persistent anger, repetitive anxious complaints, and unpleasant mood in morning. The resident had a care plan for Bipolar Disorder with persistent anger with staff and other residents dated 12/24/09 with the following interventions: a. administer antidepressant medication, b. monitor for side effects, og c. use gentle touch, d. encourage (the resident) to ventilate (his/her) feelings and frustrations in a calm, manner, e, if(the resident) continues to yell separate from stressful situation, f. xefer to social service for concerns that (the resident) may have, g. refer to psych service, psych to follow per routine for dose reduction. 22. Resident #2 had a Care Plan for behavior management with the following interventions, on 1/22/10; Inappropriate "Bold " sexual behaviors: respond with'patience and understanding, respond calmly and firmly, adm antipsychotic med. The resident was also care planned for delusions as of 12/5/09 and aggression 12/4/09, The care plan did not address interventions to - " prevent aggression or to protect others from his/her aggression. 23, Further review of the clinical record revealed the resident received Risperdal 1 mg AM and 2 mg bedtime. Resident #2 was seen and counseled by the facility psychiatrist on 1/25/10 for inappropriate sexual behavior and was ordered Risperdal 0.5mg qid, Risperdal increased to 1 mg AM and 2 mg PM for psychosis. 24, A review of the social services notes dated 2/5/10 revealed 2 residents (Resident #75 and #80) went to her to inform her they are afraid of Resident #2 saying-they "feel threatened because of the things he/she says to them and the way that he/she looks at all of them." They stated he/she threatened them by telling them he/she was going to "kill them and knock off their _ heads." The social service person stated in notes that she had witnessed Resident #2's behavior on the back porch with him/her threatening to "kill her and knock her head off". Interview with the Social Services person on 5/6/10 at 10:06 AM revealed she went to the DON regarding Resident #75's and #80's complaint and was told it would be handled internally... gia Fd 25, Class “I” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429.19(2)(a), Florida Statutes 26. Class “T” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined. by ~ the agency, is required Tor correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. 27. The Agency gave a mandatory correction date of this deficiency of June 7, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $20,000 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 429,19(2)(a), Florida Statutes (2009). COUNT II (Lag N72) RESPONDENT’S FACILITY FAILED TO DEVELOP A COMPREHENSIVE CARE PLAN FOR INAPPROPRIATE BEHAVIOR Fla. Admin. Code R. 59A-4.109(2) ISOLATED CLASS I DEFICIENCY 28. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 29. That pursuant to Fla. Admin. Code R. 59A-4.109(2), Florida law states: the facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan. must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. 30. That from May 3, 2010 through May 7, 2010, the Agency conducted an unannounced licensure survey at the Respondent’s facility. 31. . Based on observations, resident record review, and staff and resident interview, the ' “facility failed to develop a comprehensive care plan for inappropriate behaviors for 2 of 36° sampled residents, Resident #17 and Resident #2 with interventions to protect vulnerable residents from physical and mental abuse inflicted by these residents. Resident #17 32. A review of the clinical record for Resident #17 revealed a nurse’s note dated 3/19/10 revealing a CNA found a resident (Resident #45) with "severe dementia" in the doorway of Resident #17's room. The note further stated Resident #45 verbalized "Please don't touch me there" and the only other person in the room was Resident #17. The nurse’s note stated that this information was passed on to the RN supervisor. An interview with the nurse on 5/4/10 at 3:06 PM revealed she was concerned about what resident #45 had said on 3/19/10 as the resident had never made any type of remark like that before. 33. A document provided by the facility entitled "Risk Management/Interview Documentation" revealed on 3/19/10 a CNA was walking down the hallway and saw Resident #17 standing in the middle of his/her doorway. It is the last room in the building. The CNA further stated in the document, that Resident #45 was inside the room near the doorway and ) heard Resident #45 state "No! Stop! Please don't touch me down there." The CNA then. instructed Resident #45 to follow her down the hallway to the dining room. 34. No evidence could be found that the incident on 3/19/10 was investigated by the facility, An interview with the DON on 5/4/10 at 5:01 PM revealed he did not investigate the incident on 3/19/10 because he was told that Resident #45 was dressed at the time of the incident and. Resident #17 denied touching the resident and therefore did not need to be investigated. . 35. Further review of the clinical record of Resident #17 revealed a nurses note dated 2/27/10 revealing a previous inappropriate situation when Resident #17 asked a CNA to "close door and “get on top of (the resident) and (the resident) would show her what to do." 36. A review of the clinical record for Resident 445 revealed a Minimum Data Set Annual (MDS) assessment dated 3/15/10. The resident was coded for disorganized speech, coded as independent in walking in corridor, moderately impaired in decision making, and both long and short time memory concerns. Resident #45 was diagnosed as having dementia and delusions. A review of Resident #45's nurses’ notes revealed a note dated 3/20/10 "up all night my shift 11- 7AM walking the halls. Another dated 3/21/10 2 am " resident pacing hallways, 4:00 am resident up ambulating independently on hallway without difficulty." A nurse’s note dated 3/14/10 4:00 PM "was wandering hallways and disturbing other residents." A review of Resident #45's care plan for wandering dated 3/15/10 revealed there were no specific interventions in the care plan that addressed measures to protect the wandering resident from going into other resident rooms unsupervised. 37. A review of Resident #17's clinical record revealed a Minimum Data Set Quarterly assessment tool dated 4/29/10 which revealed the resident was not coded for having any behaviors. A review of Resident #17's care plan dated 11/12/09 revealed no plan or 10 % 3. ) } interventions for any inappropriate behaviors. The facility's admitting diagnosis dated 10/14/09 _ for Resident #17 included Bipolar disorder and Schizophrenia, paranoid type. Resident #2 38. Resident #2 had a Care Plan for behavior management with the following interventions, on 1/22/10; Inappropriate "Bold" sexual behaviors: respond with patience and understanding, respond calmly and firmly, adm antipsychotic med. The resident was also care planned for delusions as of 12/5/09 and aggression 12/4/09. The care plan did not address interventions to prevent aggression or to protect others from his/her aggression. 39." A review of the clinical record of Resident #2 revealed a nurse's note dated 1/21/19. stating Resident #2 was observed by a CNA making verbal sexual advances to Resident #58 while putting his/her hands on Resident #58's thighs and shoulders. Further review of Resident #2's clinical record revealed the resident was care planned for inappropriate "bold" sexual behaviors on 1/22/10 with the following interventions: respond with patience and understanding, respond calmly and firmly and administer antipsychotic medications. The care plan did not address interventions to prevent inappropriate sexual behaviors or to protect vulnerable residents, Resident #2 was seen and counseled by the facility psychiatrist for inappropriate sexual behavior on 1/25/10. 40. A review of the clinical record of Resident #58 revealed the MDS Annual Assessment dated 2/15/10. The MDS coded the resident as having short term memory problems, moderately impaired decision making skills, sometimes understands others and sometimes understood, insomnia, and wandering 4-6 days/week. The resident has a diagnosis for Alzheimer's Dementia. VW 41. Further review of the clinical record of Resident #58 revealed an Activities note dated 12/10/09 which stated "lately Resident #58 had been spending time with (Resident #2), whom Resident #5 8 thinks was a family member. The note further stated that Resident #58 seeks out Resident #2 wanting to hold his/her hands. 42. A social service note dated 1/22/10, revealed the social service person notified Resident #58's family about the incident that occurred on 1/21/10 with another resident who was observed rubbing Resident #58's thighs. The note further stated the family was "angered" because they had witnessed Resident #2 "making cat calls" to Resident #58 and staff had told the family that . Resident #2 would rub Resident #58's arms ‘nd the staff were keeping an eye on Resident #58, ensuring that Resident #2 was kept away from Resident #58. The social service note was concluded with the DON being notified. 43. Resident #2 was observed throughout the survey on 5/3/10, 5/4/10, and 5/5/10 freely moving about the facility unsupervised. The resident was observed to be alert and oriented. 44. No evidence could be found that the facility acted in any manner to protect a cognitively impaired resident from inappropriate sexual touching by an alert and oriented resident. No evidence could be found that either Resident #2 or Resident #58 were care planned with interventions to protect either resident who was at risk, one of harming another and the other for not being protected from a known violator. 45. After an immediate jeopardy to the health and safety of residents had been identified to the facility on 5/5/10 in regards to the known inappropriate behaviors of Resident #2, Resident #2 was observed on 5/7/2010 at 8:47 AM attempting to exit the building through the front door that was locked. An aide was standing next to the resident, as the facility provided. 1 to 1 staff at 12 Naa” that time, but did not intervene to redirect until a nurse from the nurse's station directed her to do so. Resident #2 was within 3 feet of Resident #58. 46. Class “1” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429.19(2)(a), Florida Statutes 47. Class “T’ violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines present an, imminent danger to the clients of the provider or a substantial probability that death or serious T violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. 48. The Agency gave a mandatory correction date of this deficiency of June 7, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $20,000 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 429.19(2)(a), Florida Statutes (2009). COUNT MI (Tag N216) RESPONDENT’S FACILITY NEGLECTED TO IDENTIFY RESIDENTS WHO WERE INCLINED TO PHYSICAL HARM OR SEXUALLY ABUSE OTHER RESIDENTS; RESPONDENT’S FACILITY NEGLECTED TO DEVELOP SUCCESSFUL INTERVENTIONS TO PREVENT OCCURENCES PLUS RECURRENCE §400.102(1), Florida Statutes WIDESPREAD CLASS I DEFICIENCY 49. The Agency re-alleges and incorporates paragraphs one. (1) through five (5), as if fully set 13 forth herein. 50. That pursuant to §400.102(1), Florida Statutes, Florida law states: 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; 51, Based on observations throughout the facility, resident clinical record reviews including a closed record, staff and resident interviews, the facility neglected to identify residents who were inclined to physically harm or sexually abuse other residents, develop successful interventions to "prevent occurrences plus recurrence, monitor the residents behavior because of the likelihood that the residents could cause harm to other residents, and investigate allegations of abuse, threats of physical harm or possible sexual abuse. 52. The facility failed to assess and develop a care plan with appropriate interventions for 3 of 36 sampled residents, Resident #17 who resided on the West wing; Resident #2 who resided _ on the East wing; and Resident #88 who had recently been discharged. Resident #17 verbally ‘threatened to harm Resident #70 and exhibited sexually inappropriate behavior to Resident #45. Resident #2 verbally threatened the life of Resident #75, Resident #80 and staff on several occasions requiring a call to the local police department for intervention. While Resident #88 resided in the facility, the resident threatened other residents and staff with an object that could cause bodily harm to others. 53. The facility failed to provide needed services, care, and protection to prevent mental anguish and fear for their safety for 4 of 36 sampled residents, Residents #75, #80, #70, and #10 as each of these residents had been threatened in some way by Resident #17 and Resident p who were known to be independent and move freely throughout the building. There was no 14 reassessment or revision to the plans of care for Resident #17 or Resident #2 when the verbal abuse and threats to others occurred. Furthermore, the facility failed to protect cognitively impaired residents, Resident #45 and #58, from possible sexual abuse. 54. This resulted in placing all residents at risk for future occurrences of physical or mental abuse and created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. Resident #88 55. A review of a closed record revealed that Resident #88 was admitted on 1/23/10 for diagnoses of Chronic Renal Failure, Renal Dialysis Encounter, Hypertension, Diabetes Mellitus Il, and Anemia. Records from Florida Hospital, Admission H & P, stated the resident spent 39 days in jail and was Baker Acted to Lakeside Behavioral for an unknown number of days ina behavioral health center for Bipolar Disorder with Psychotic Features. Due to need for dialysis the resident was sent to Florida Hospital for dialysis and stilt under Baket Act from 1/06/10 to unknown date. The resident was not on behavioral medications on admission to this SNF, the PASSAR did indicate yes for Mental Illness with the only diagnosis on the PASSAR Renal Failure with Dialysis. The Behavior Data Collection completed upon admission did not reveal any behaviors. 56. On 2/08/10 at 1:00 AM the notes stated the resident was walking through the facility carrying a (approximately) 4 foot wooden stick, he/she was using the stick to remove Valentine's decorations, and items from the activities room and dining room; therefore pulling down some of the decor in the rooms. The resident refused to give the stick to nurse. The resident told nurse he/she wanted to return to their former "lifestyle" and crudely discussed explicit inappropriate sexual acts. On returning the resident to his/her room, the nurse found a syringe on the nightstand 2 ; } (not any type used in facility). Later a stethoscope and scissors were also removed from the room. The resident was freely walking the halls, restless and agitated in the nurses notes up to 6:45 am. 57, At 7:30 AM the Unit Manager called the attending physician. Between 8:30 to 9:30 AM nurses notes revealed "resident piercing own ear with the syringe", and the resident had "shaved their eyebrows". At 10:00 AM, a second call was made to the attending physician regarding these events. At 11:55 AM the attending physician (Baker Act certified) examined the resident and filled out the Baker Act paperwork. At 12:45 PM the resident was transported by law enforcement to a local hospital. While the behavioral acting out was self-directed, the incomplete assessment could have resulted in behaviors directed at other residents or staff resulting in serious bodily injury. 58. Areview of facility provided documentation completed by a registered nurse, RAC-CT, titled "Resident Census and Conditions of Residents" (CMS 672) completed form dated 5/3/2010, noted a census of 60 residents. The form revealed 43 residents of the facility had “documented psychiatric diagnosis (exclude dementias and depression)", 36 residents had dementia and 20 residents had behavioral symptoms. The document further revealed that only 11 residents were receiving a behavior management program or care plan designed to address behavioral symptoms such as wandering, being verbally abusive or being physically abusive. 59. Class “I” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. §429,19(2)(a), Florida Statutes 60. Class “I” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class _ I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, Js required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation. 61. ‘The Agency gave a mandatory correction date of this deficiency of June 7, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $30,000 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §429.19(2)(a), Florida Statutes (2009). . COUNT IV 62. The Agency re-alleges and incorporates paragraph one (1) through five (5) of this Complaint as if fully set forth herein. 63. The Agency re-alleges and incorporates Count I through III of this Complaint as if fully set forth herein. 64. Based upon Respondent’s cited State Class I 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 (2009). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing May 7, 2010 and ending June 9, 2010. COUNT V 65. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I through III of this complaint as if fully set forth herein. 66. Respondent has been cited for three (3) State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section 400.19(3), Florida Statutes (2009). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of six thousand dollars ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2009). 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 Counts J through II; (B) Recommend administrative fines against Respondent in the amount of $70,000; (C) Impose a conditional license commencing May 7, 2010; (D) Grant a six month survey cycle for a period of 2 years and a survey fee of $6,000; (E)Assess attorney’s fees and costs; and ' (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 18 Sage” “was #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 this 24th of January, 2011 ee Mer bbe ATES Ee €a2. D. Carlton Enfinger, II, Esq. Fla. Bar. No. 793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 412-3640 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7001 0360 0003 3808 3543 to: Facility Administrator Gus Murphy, Oaktree Healthcare, 650 Reed Canal Road, Dayton Beach, Florida 32119 and by U.S. Mail to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, ¢ Vv Florida 32301-2525 on January 24 3011: Ate. Fe D. Carlton Enfinger, Il Copy furnished to: Rob Dickson, FOM : FLORIDA AGENCY FOR HEALTH CARE ADMINSTRATION CHARLIE CRIST GOVERNOR November 17,2010 OAKTREE HEALTHCARE 650 REED CANAL ROAD SOUTH DAYTONA, FL 32119 Dear Administrator: ‘” ELIZABETH DUDEK INTERIM SECRETARY - The attached license with Certificate #16542 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 erzors 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, Ju cahkoreparn Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management LORIDA ,SOMPARE OARE Health Care in the Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 www.FloridaCompareCare.gov Visit AHCA ontine at ahca.myflotida.com TIOZ/OC/TI ‘ALVG NOILVUldxa O10Z/L0/S0 “ALV FAILOFAAT AONVHD SO.LVLS sdad 69 “IVLOL 611ZE Td “VNOLAVG HINOS dvOw IVNVO Gada 0s9 FAVOHLTVaAH ATALAVO -SupMoTyo} ayy ayerodo 01 pezioyne st eesuaor] 2y) se pu ‘somes epuoLy ‘TI ued “OOr saidey Ul peztioyne ‘uoLERsIUTUpY aleD yyeaH JOJ Aouesy ‘epuopy Jo ereig ay Aq pardope suonenBal pur soyny ou) wim poyduos sey OTT ‘SALWIOOSSV TUVO HLTIVaH VWNOLAVG HLNOS #G WIUTFUOD O} S} STL, qINOH DNISHAN AONVUNSSV ALITVNO HLTVGH JO NOISIAIG NOILVULSININGV avd HLTVdH YOdt AONEOV VPLIOL] JO 398IS CySOl “#ALVOMILEAO “ae 4 FLORIDAAGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST . ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY January 24, 2011 OAKTREE HEALTHCARE 650 REED CANAL ROAD SOUTH DAYTONA, FL 32119 Dear Administrator; _ The attached license with Certificate #16543 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, Juhrathors2eer Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure cc! Medicaid Contract Management LORIDA . f 2727 Mahan Drive, MS#33 OmMPARE DARE Visit AHCA ontine at Tallahassee, Florida 32308 Health Care in the Sunshine ahca.myflorida.com EF www. FloridaCompareCare.gov [ey JEBIN fe ee TTOC/OS/TT ‘LV NOILVUIdxa 0102/92/90 ‘ALVd FALLOSATT AONVHO SALVLS Saad 69 “IVLOL 61IZE Td ‘WNOLAVG HLNOS AVOU TVNVD Gaay 0S9 aAIVOHLIVIH FTALAVO :SuTMOTIO} OU} SyeIedo 01 pozLIOyME ST soSTISdT] 947 se pue ‘somjerg epLIopy ‘II Ved “OO JeadeyD ur pezuowne ‘onensmarupy ereD weap 104 Aoue8y “epuopy Jo arerg om Aq paidope suonemsel pur sop ou WMA porduoo sey DTT “SALVIOOSSV TUVO HLIVEH VNOLAVG HLNOS Wey WUGWOS 0} ST SPAT CavaNvis HINOH ONISHAN FONVUNSSV ALITVNO HLTVSH dO NOISIAIG NOILVULSININGY Fav) HLTVAR YOA AONADV VPLIOL] JO 3983S "USS, Postal Service CERTIFIED MAIL RECEIPT. : (Domestic Mail Only; No. Insurance Coverage Provided) : Postage Certified Feo 3 3808 3543 Return Recelpt Fee (Endorsement Required) o Restricted Dellvery Feo (Endorsement Required) [X= Total Postage & Fees re . SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 8. Also complete item 4 if Restricted Delivery Is desired. @ Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailiplece, or on the front if space permits. Received by ( Printed Name) Ve fects De D. Is delivery address diffarent from Item 1? LJ Yes if YES, enter delivery address below: C1 No 1. Article Addressed to: 3. Service Type Certified Mail £1 Express Mall C1 Registered D Return Recelpt for Merchandise ESQ Reach Carma Roeueh » ) insured Mail OC... Sg Xora Beuah FL Fav 4, Restricted Delivery? (Extra Fes) C1 Yes 7001 0360 0003 3408 3543 PS Form 38 February 2004 Domestic Return Receipt

Docket for Case No: 11-001018