May~07-2001 02:46pm — From-LEGAL 1-501-201-4801 T-246 =P.003/009 F252 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR © RETURN RECEIPT REQUESTED HEALTH CARE ADMINISTRATION, #7106657 3-2296-2089~ “8374 | Petitioner, vs. ; AHCA NO: 06-01-008. BEVERLY HEALTH & REHAB Ol- IE SERVICES, INC., d/b/a TAMPA HEALTH CARE CENTER, Respondent. / . ADMINISTRATIVE COMPLAINT YOU ARE HERERY NOTIFIED that after twenty-ane (21) days from receipt af this Complaint, the State of Florida, Agency for Health Care Administration (“Agency*) intends te impose an administrative fine in the amount of $700.00 upan Beverly Health & Rehab Services, Inc., d/b/a Tampa Health Care Center ("Tampa Health Care Center” or “Respondent’). As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. ‘The Agency has jurisdiction aver the Respandent pursuant to Chapter 400 Part i, Florida Statutes. 2. Respondent, Tampa Health Care Center, is licensed by the Agency to operate a nursing home at 2916 Hebana Avenue, Tampa, Florida 33614 and is obligated ta operate the nursing hame in compliance with Chapter 400 Part II, Florida Statutes, and Rule SQA-4, Florida Administrative Cade. . @d WASTIER TAaz ve "hey BEZS E29 G8 STA: ‘ON Xdd = ¢¢@A ASLNAD See HL TWSH UdHML ¢ Woe fay-O7-2001 02:48pm — From-LEGAL . 1-501-201-4801 T2468 «= P.004/008 = F252 ae : ‘ 3. On Auguet 6, 1998, a survey team from the Agency’s Ares. 6 Office conducted @ survey and the following Class Ill deficiency was cited. 3A. Pursuant to 42 CFR 483.13(c)(1)[i), the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and akuse of residerits and misappropriation of resident property. The facility myst pot use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This Tequirement was net met as evidenced by the follawing observations: _ . (1) Resident #108 had diagnoses of Quadrigiegia, diabetes, and renal insufficiency and was tatally dependent on staff for care and transfers. On March 31, 1998, this resident was showered late on the 3-11 shift, which was the facility practice. The certified nursing assistant ("CNA") who was assigned to care for the resident brought the resident back to the room ina shower chair and went to get help to pur the resident back to bed as she was ungble to do this by herself. The CNA sought help from twa other staff persons, a CNA, and the Nurse, Both.stated they were tao busy to help. The CNA then forget about the resident and the resident was Mp in the shower chair until approximately 7:00 am. when a day shift staff person arrived. The Charge Nurse admitted in investigative reports that she had not made monitoring rounds her whole shift, that she was te busy with other duties. This resident was left unattended, in a precarious situation, for at least six . “he facility violated Chapter 400,022(1){o}, F.S., for failing to - igure @ Tesident was free from mental and physical abuse, _ cofporal punishment, and extended involuntary seclusion in o.,.tRat one resident received neglect as a result af shortness of "taf, and the lack of monitoring supervision. fy HeCZIER 1G pa “AE —REZE ESZS LB ETA: “ON xud 2eRO MAINED TARO HITWSH can woe Sree mag appre rer May-07-2001 02:46pm © From-LEGAL 1-501-201-4801 7-246 «= P.005/008 = F-252 4. On Octaber 21, 1999, a survey team frora the Agency's Area 6 Office conducted a survey and the following repeat Class II deficiency was cited. | 4A. Pursuant wo 42 CFR 483.13(ci(1i{i). the facility must develop and implement written policies and procedures that probibit mistreatment, neglect, and abuse of residents and migzapprepriation of resident prepeity. The facility must not use yerbal, mental, sexual, or physical abuse, corporal punishment, or inveluntary seclusion. This requirement was not met as evidenced by the following gbscrvations; (1) Numerous family interviews revealed that a resident, whe required staff assistance for transfers fram the bed ta chair or bedside commode wia lift, was frequently left for several hours when the wansfers were requested. The resident was informed that transfers would cccur "when staff was ready” not when the resident requested assistance and that the Resident would "have to follow the staifs schedule". The same resident was left wet in bed for extended periods of time. : (2} A family interview revealed that a resident was observed being: given medications by a licensed nurse during a lif transfer. This occurred after the Resident requesicd the nusse return when the transfer was completed. (3) Based on observation, resident and staff interviews, clinical and clased record reviews, it was determined that the facility violated Chapter 400.022(t)}{o), F.S. and Rule 59A- 4.1288, for again failing to ensure a resident was free from mental and physical abuse, corporal punishment, and extended involuntary seclusion in that the facility did nor implement : written policies and procedures that prohibit mistreatment, - neglect, and abuse of residents and misappropriation of resident pfoperty which resulted in actual harm to & of 34 | residents.on the ¢ sample (#2, #7, #15, #17, #20, and #33). ; Pa WaS:fG Tage pA Aen Bf26 E825 9B FTA i ‘ON At = 4¢M ASNAD SCO HIINSH Bohl + woa= ae cr ree Administration, A ay-07-2001 2:48pm = From-LEGAL 1-501-201-4801 7-248 = P.O0G/I09 «= F252 5. Based on the foregoing, Tampa Health Care Center has violated the following: a) Tag F224 incorporates 42 CFR 483. 33(1)@, Section 400.022(1)}[0), F.S., and Rule SGA-4.1988, F.AC. © administrative fine imposed for this vepeat Violation is $700.00. 6. Phe above referenced violations constitute grounds ta jevy this civil penalty pursuant to Section 400.23(9}{c), Flarida Statutes, in that the above refercnced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation af a Nursing Hare. ; NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant te Section 120,57, Florida Statutes, to be represented by counsel lat its expense}, to take testimony, to call or cross-examine Witnesses, to have subpoenas and/or subpoenas duces tecum issued. and ta present written evidence or argument if it requests a hearing. In order ta abtain a formal proceeding under Section 120.57{1), - Florida Statutes, Respondent’ 3 Tequest must state which issues of material . Yaet are disputed. Failure to dispute material issues of fact in the request fora hearing, may be treated by the Agency as an election by Respondent - for an informal proceeding under Section 120. 57(2}, Florida Statutes. All requests for hearing should be made to the Agency for Health Care tion: Sam Power, Agency Clerk, Senior Attorney, 2727 ; Mahan Drive, Mail Stop # #3, Tallahassee, Florida 32308, “4 Sd WAS2:26 Take ra “heW ares S£25 S28 £ta : ON Mea eH ASUNSD Facd FL TSH dele. > WOAS ities el May-07-2001 02:47pm - From-LEGAL 1-501-201-4801 7-246 «= P.007/008 «= F~252 All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier's checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. all payment of fines should be sent to the Agency for Health Care Administratian, Attention: Christine T. Messana, 2727 Mahan Drive, Mati Stop #3, Tallahassee, Florida 32308-5403. ; RESPONDENT 15 FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF EECEIPT 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. | . Issued this _/7 tay of enel , 2001. Patricia Reid Cauiman FYeld Office Manger, Area #6 “ Agency for Health Care Administrarion <3 Health Quality Assurance - 6800 N. Dale Mabry Highway, Ste 220 Tampa, Florida 33614-3979 Si Hw2:28 TO? pa “RE ELK SEES WB ETA: “ON Md 2200 AENAD SRLD HIRSH ut = WOR: ec ihay-o7-2001 02:47pm = From-LEGAL 1-801-201-4801 T2468 «= P.008/009 = F252 a et ete ETT SENDERS RECORD gr name Gi wcasnn THEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrater, Tampa Health Care Center, 2916 Habana Avenue, Tampa, Florida 33614 on this the pode, of Meg —_. 2001. Christine T. NS 4. ~ Office of the General Caunsel Copies furnished ta: Christine T. Messana Senior Arto; Agency tor Health Care Adminisrration 2727 Mahan Drive, MS#3 Tallahassee, Florida 32308 Elizabeth Dudek, Acting Deputy Secretary Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Bi ing ' Tallahassee, Florida 32308-5403 Area 6 Office Gloria Collins, Finance & Accounting ed WeeZIEA TAGE Pa “ACY GE26 SEZS G8 STA: ON Xd 42GB NSLNSO FatO HI TGSH dol = HDad

Docket for Case No: 01-003154