2, £ 0 —C STATE OF FLORIDA F J LE QD AGENCY FOR HEALTH CARE ADMINISTRATION GENCY FOR HEALTH CARE a ‘ A REVISION OF ADMINISTRATION, ; Petitioner, vs. AHCA Case No. 08-01-0139-NH HHCI LIMITED PARTNERSHIP d/b/a HARBORSIDE HEALTHCARE-PINEBROOK, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against HHCI Limited Partnership d/b/a Harborside Healthcare-Pinebrook {hereinafter “Harborside-Pinebrook”), pursuant to chapter 400, part II, and section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to revoke Harborside-Pinebrook’s license to operate a skilled nursing facility, pursuant to Section 400.121(3), Florida Statutes (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to chapter 400, part II, Florida Statutes (2001). ~ 3B. Venue lies in Sarasota County, pursuant to Section 400.121(1) (e), Florida Statutes (2001). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities, pursuant to , chapter 400, part II, Florida Statutes (2001), and chapter 59A-4 Fla. Admin. Code. 5. Harborside-Pinebrook operates a 120-bed nursing home located at 1240 Pinebrook Road, Venice, Florida 34292. Harborside-Pinebrook is licensed as a skilled nursing facility, license number SNF14390962; certificate number 6784, effective February 1, 2001 through January 31, 2002. Harborside-Pinebrook was at all times material hereto a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable rules, and statutes. (nna ane ae LEER RST PON PRO EI is nasa mannan one COUNT I HARBORSIDE-PINEBROOK WAS CITED FOR AT LEAST TWO CLASS I DEFICIENCIES ARISING FROM SEPARATE SURVEYS OR INVESTIGATIONS WITHIN A 30-MONTH PERIOD 400.121(3) (d), Fla. Stat. 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Harborside-Pinebrook was cited in two separate surveys within a thirty (30) month period for at least two (2) class I deficiencies, to wit: On or about July 13, 2000, Harborside-Pinebrook was cited for four (4) class I deficiencies, pursuant to section 400.23(8) (a), Fla. Stat. ~ (2000); specifically: . 1) Failure to prevent the neglect of residents number 21, 10 and 19, and; 2) Failure to identify and assess the medical needs of residents number 19, 10, 12, 16, 9, 20, ‘25, and; 3) Failure to accurately complete, review and update care plans, which contributed to the actual harm of residents number 21, 19, 25, 3, 9, 2, 1, 10, 12 and 6, and; 4) Failure to follow physician’s orders, monitor resident. conditions and follow professional standards of practice for Gietary, mursing and physician services was cited for three (3) class I deficiencies, pursuant to section 400.23(8) (a), Fla. Stat. (2000); specifically: de hasliiegs dimen eee re to ‘prevent “resident ‘to resident nce of residents number 1, 2, 3 and 7, including but not limited to, the hospitalization of resident number 2, ~ and; ee geome Scr reer were 2) Failure to develop and update resident care pians to include specific intervéntions to prevent violent behaviors of residents number 1, 3 and 7, and; 3) Failure to assure protection of residents and staff from abuse, resulting in harm facility wide. The September 29, 2000 survey was within a 30- month period of the July 13, 2000 survey conducted by AHCA. The above constitutes a violation of section 400.121(3) (d), Fla. Stat. (2001), and requires revocation of Harborside-Pinebrook’s license to operate a skilled nursing facility. Section 400.121(3) (d), Fla. Stat. (2001) provides: (3) The agency shall revoke or deny a nursing home license if the licensee or controlling interest operates a facility in this state that: (d) Is cited for two class I deficiencies arising from separate surveys or investigations within a 30-month period. The licensee may present factors in mitigation of revocation, and the agency may make a determination not to revoke a license based upon a showing that revocation is inappropriate under the circumstances. . WHEREFORE, AHCA intends to revoke HHCI Limited Partnership’s license to operate Harborside-Pinebrook, a skilled nursing facility in the State of Florida, pursuant to section 400.121(3), Florida Statutes (2001); and assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Fla. Stat. (2001). Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; John F. Gilroy and Christine Tf. Messana, Senior Attorneys. RESPONDENT IS” FURTHER NOTIFIED THAT THE FAILURE 0 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 3 AGENCY. Respectfully submitted. Dated October a , 2001 Elizabeth Dudek Deputy Secretary _ Agency for Health Care Administration (Inter-office mail) William Roberts Acting General Counsel . Agency for Health Care Administration . (Inter-office mail) Polly Weaver Chief, Operations, MCHQ Agency for Health Care Administration (Inter-office mail) John F. Gilroy Senior Attorney Fla. Bar. ¥ 0454729 NAF), hnristine T. Messana. Senior Attorney Fla. Bar. No. 0153818 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) ~ “hae Tracey Cottle Chief, Facilities Regulation Counsel Agency for Health Care Administration {(Inter-office mail) Molly McKinstry Long Term Care Unit Manager Agéncy for Health Care Administration (Inter-office mail) Harold Williams Field Office Manager, Area 8 Agency for Health Care Administration (Inter-office mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the : foregoing has been served through a process server by hand delivery on October 3, 2001 to: HHCI LIMITED PARTNERSHIP d/b/a HARBORSIDE HEALTHCARE-PINEBROOK, 1240 Pinebrook Road, Venice, Florida 34292. pia Bote Fae STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: AHCA v. HARBORSIDE HEALTHCARE — PINEBROOK’ CASE NO. 08-01-0139-NH ELECTION OF RIGHTS PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. If you do not understand these options, please consult with your attomey or contact the Office of the General Counsel/Health Care Facilities Section of the Agency for Health Care Administration at the address/phone number listed at the bottom of this form. OPTION 1. Q 1 do not dispute (I admit) the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penaity imposed. OPTION 2. Q I do not dispute the allegations of fact contained in the Administrative Complaint: and » waive my right to object or to be heard. | understand: that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION 3. QI do dispute the allegations of fact contained in the Administrative Complaint and request this to be considered a petition for formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an - Administrative Law Judge appointed by the Division of Administrative Hearings. | If you have elected option one (1) or two (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 2 SEND NO PAYMENT NOW — REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. Mediation under Section 120.573, Florida Statutes, is not available in this matter. " (Please sign and fill in your current address.) Respondent (Licensee) ress: ~ Lig,No. Phone No. __; we : aan PLEASE ATTACH A COPY OF THE ADMINISTRATIVE COMPLAINT TO YOUR COMPLETED FORM AND MAIL TO: Christine T. Messana, Esquire, Senior Attomey, Agency for Health Care Administration, Office of the General Counsel, 2727 Mahan Drive, Mail Stop #3 (Note: Overnight Deliveries to same address) Tallahassee, FL 32308-5403. Telephone Number: (850) 922-8854; FAX (850) 921-0158; TDD 1-800-955-8771. i I he SRE abe EES — a a em RRS eR El ~ cr STATE OF FLORIDA _ AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES OR (To be used in conjunction with Election of Rights form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (‘AHCA” or “Agency”), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. if you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should-select OPTION 2 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penaity sought in the Complaint. You will be provided a copy of the final order. OPTION 2. If you do not dispute any material fact alleged in the Administrative Complaint (you admit each. of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes (1999) before the Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 1 on the Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes (1999). To obtain a _ formal hearing, select OPTION 3 on the Election of Rights. form. In order to obtain a formal Proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. _ In order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency'by filing within twenty-one (21) days from the date twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. fr Bs i

Docket for Case No: 01-004124