STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. TANDEM HEALTH CARE OF VERO BEACH, INC., d/b/a TANDEM HEALTH CARE OF VERO BEACH, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty one (21) days from the receipt of this complaint, the Agency for Health Care Administration (hereinafter referred to as the “Agency") intends to impose an administrative fine in the amount of Fifteen Thousand ($15,000) Dollars upon Tandem Health Care (hereinafter referred to as "Respondent"). As grounds for this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over Respondent by virtue of the provisions of - Chapter 400, Part IL, Florida Statutes (F-S. 2. Respondent is licensed to operate at 1310 37" Street, Vero Beach, Florida 32960, as a nursing home in compliance with Chapter 400, Part Il, (F.S.), and Chapter 59A-4, Florida Administrative Code (F.A.C.) 3. On January 16, 2001, as a result of a complaint investigation conducted by personnel from the office of the West Pal Beach Office for the Agency for Health Care Administration it was found: (a) Tag F323. Quality of Care. Based upon interviews and observation on 01/16/01 it was revealed that the facility did no ensure that a safe hazard free environment was provided in that all residents, 47 of whom were incognitively impaired, had access to a pond which was adjacent to the facility and which represented an accident hazard. The findings include: (1) The facility had an alarm, which activate on all corridor exit doors and a keypad on the front and smoking area door. However, the facility did not have a lock or alarm device on the door leading from the restorative dining room to the cook out patio. This is an area to which the residents can easily have access. (2) According to the administrator, it was between 2-3 weeks ago that portions of a fence had been taken down to allow water pipes to be routed to the new building constructed. This left openings in the fence, which was surrounding the pound that adjoins the facility and also openings in the fence that surrounded the patio. It was through these openings that a resident who exited the building then entered the pond and subsequently was found expired in the water. (3) All residents in the facility had access to the restorative dining area and adjacent patio (4) The immediate threat was mitigated by the application of a padlock on 01/16/01 to the restorative dining room, which led to the patio. This is in violation of Rule 59A-4.1288, F.A.C, Class I deficiency, carrying in this instance a $5,000 fine. (b) Tag F324, Quality of Care. Based upon interview and record review on 01/16/01, it was revealed that the facility did not act to ensure that proper supervision was provided to all residents, in order to prevent accidents, including 47 of which had dementia. The findings include: (1) Resident #1 was an 80 years old individual with a diagnosis of dementia with agitation, depression-major, severe psychosis, atrial fibrillation, ventricular heart disease (VHD), Pulmonary Vascular Defect (PVD), insomnia, diabetic neuropathy, cerebral vascular (CVA), Chronic obstructive pulmonary disease (COPD), peptic ulcer, none insulin dependant diabetes mellitus. The resident according to the care plan and 2 MDS and behavior monitoring sheets did not wander and was allowed to do so throughout the facility. The resident was found to have exited the building unobserved on 01/16/01 and was then discovered in the pond near the facility. The resident, despite the - efforts of facility staff and emergency technicians could not be revived. (2) The resident was last seen by staff members at 6:45 a.m. on 01/16/01. The resident had received the morning meds from the nurse and then was assisted with washing and grooming by the nursing aide. As was in the resident’s care plan, the resident was then allowed to self occupy until breakfast. The resident would then walk throughout the facility or sit in the indoor courtyard area. As was the regular routine, the staff at around 7:45 a.m. went to find the resident and remind him/her that it was time for breakfast. The resident could not be located and a search was then initiated of the building, extending to the outside areas. The resident was found in the pond at approximately 8:15 a.m. The resident was face up with the head slightly out of the water. Efforts were made to revive the resident. The oral cavity was found to not be blocked but . full of water. The facility’s staff continued to try to revive the resident until relieved by the emergency technicians. They too were not successful and pronounced the resident as dead. @G) Review of the building by the administrator following this incident confirmed that all alarms were operational at the time. The building had an alarm which activates on all corridor exits doors and a keypad on the front and smoking area door. However, the facility did not have a lock or alarm device to the cookout patio. This is an area to which the resident could easily had walked into and then exited to the patio through this door. The resident then would have walked through openings in the fence that surrounded this patio and the fence that surrounded the pond. (4) According to the administrator it was between 2-3 weeks ago that portions of this fence had been taken down to allow water pipes to be routed to the new building. = (5) Due to the lack of a safe and secure environment being provided . and lack of increased vigilance or changed supervision during this period of construction the resident was able to exit from the building and subsequently expired. (6) All residents in the facility had access to the restorative dining area and adjacent patio. (7) The immediate threat was mitigated by the application of a padlock on 01/16/01 to the restorative dining room door, which led to the patio. This is in violation of Rule 59A-4.1288, F.A.C., Class I deficiency, carrying in this instance a $5,000 fine. (c) TagF454. Physical Environment. Based on observation and interview on 01/16/01 it was revealed that the facility did not ensure that the facility was designed and maintained in a manner to protect the health and safety of the residents. Findings include: (1) The building had an alarm, which activate on all corridor exit doors and a keypad on the front and smoking are door. However, the facility did not have a lock or alarm device on the door leading from the restorative dining room to the cookout patio. This is an area to which the residents could easily walk into. Although the patio area was fenced, approximately 2-3 weeks ago portions of this fence were removed. In addition, a portion of the fence that restricted access to a pond adjoining the facility was also removed. On 01/16/01 resident #1 was found in this pond, having expired. The resident had dementia and wandered through the facility and had access to this pond area as a result of the lack of an alarm on this restorative dining room exit to the patio and the openings in portions of the fences surrounding the patio and pond. (2) All residents in the facility had access to the restorative dining area and adjacent patio. (3) The immediate threat was mitigated by the application of a padlock on 01/16/01 to the restorative dining room door, which led to the patio. 4 This is in violation of Rule 59A-4.1288, F.A.C., Class I deficiency, carrying in this instance a $5,000 fine. 4. The above referenced violations constitute grounds to levy this administrative fine pursuant to Section 400.121, (F.S.), in that Respondent has violated the minimum standards, rules and regulations promulgated by the Agency under Chapter 400, Part II, (F.S.). ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED 5. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, (F.S.); to be represented by counsel (at its expense); to take testimony, to call and cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding, your request for an administrative hearing must conform to the requirements in Rule 28-106.201, (F.A.C.), and must state which issues of material fact you dispute. Failure to dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), (F.S.) 6. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY ONE (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. I HEREBY CERTIFY that a true and copy of the foregoing has been furnished by US. Certified Mail, Return Receipt Requested, to Floyd S. Steinberg, Administrator, Tandem Health Care of Vero Beach, 1310 37" Street, Vero Beach, Florida 32960 (7000 0520 0016 7234 4698), and to Tandem Health Care, Inc., 2040 Winter Springs Boulevard, Oviedo, Florida 32765 (7000 0520 0016 7234 4704) on i | “4 - f F > 2001. Patricia Feeney, Field Aon, ~ Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, FL 33407 Copy to: Alba M. Rodriguez, Assistant General Counsel Agency for Health Care Administration Manchester Building, 1st Floor 8355 N.W. 53rd Street Miami, Florida 3316 Nursing Home Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 . Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32399 NOTE: In accordance with the Americans with Disabilities Act, persons needing a special accommodation to participate in this proceeding should contact Alba M. Rodriguez, no later than fourteen (14) days prior to the proceeding or hearing at which such special accommodation is required. Alba M. Rodriguez may be contacted at 8355 N.W. 53rd Street, Miami, Florida 33166. Telephone: (305) 499-2165 or 1-800-955-8770 (voice) via Florida Relay Service.

Docket for Case No: 01-002770