vik, STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR DEPAR TIE: HEALTH CARE ADMINISTRATION, Petitioner, v. BEVERLY ENTERPRISES FLORIDA, INC., d/b/a BEAUCLERC MANOR, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA’), by and through the undersigned counsel, and files this Administrative Complaint against Beverly Enterprises Florida, Inc. d/b/a Beauclerc Manor, (hereinafter “Beauclerc Manor”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Beauclere Manor, pursuant to Section 400.23(8)(b), Fla. Stat. (2001), and Section 59A-4.1288, Florida Administrative Code, and Section 42 483.25(c). JURISDICTION AND VENUE 2. This count has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, (2001). oer oer Bh 3. Venue lies in Duval County, Florida, pursuant to Section 120.57, Florida, (2001), and Chapter 59, Florida Administrative Code. 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 Florida Administrative Code. 5. Beverly Enterprises Florida, Inc., d/b/a Beauclerc Manor is a for-profit Florida corporation, whose 120-bed nursing home is located at 9355 San Jose Boulevard. Beauclerc Manor is licensed as a skilled nursing facility license #SNF 1047096; certification number 7601 effective 10/01/2001 through 9/30/2002. Beauclerc Manor 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. COUNT I BEAUCLERC MANOR FAILED TO ENSURE RESIDENTS, WHO WERE ADMITTED WITHOUT PRESSURE SORES FEDERAL TAG F314-Quality of Care 42 C.F.R. 483.25(c) STATE -TAG Exception 59A-4.1288, Florida Administrative Code 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about August 23, 2001, Beauclerc Manor failed to ensure that residents, who were admitted without pressure sores, did not FT REM BRET huts. sheen wo Riis, develop them after admission. The facility did not monitor or provide weekly skin assessments, implement care plans, document procedures during wound care that include measurements of pressure sores that would indicate an increase or decrease in size, document nursing notes that would address the progress of the open areas, and therapy notes indicating assessment and appropriate treatment to prevent the development of avoidable pressure sores which resulted in actual harm. This is a class II deficiency. Fine: $2,500.00. The violation above constitutes a violation of Section 59A-4.1288, Florida Administrative Code (2001), which requesting that nursing homes participating in Title XVII or XIX must follow certification rules and regulations found in 42C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non- certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. The above also constitutes a violation of Section 400.23(8)(b), Fla. Stat. (2001), requiring a class II deficiencies are those which the agency determines have a direct or immediate relationship to the health, safety, or security of the nursing home facility residents, other than class I deficiencies. A class II fer rae prriee ore See Re rome oo deficiency is subject to a civil penalty in an amount not less than $1,000 and not to exceeding $10,000 for each and every deficiency. A citation for a class II deficiency shall specify the time within which the deficiency is required to be corrected. If a class II deficiency is corrected within the time specified, no civil penalty shall be imposed, unless it is a repeated offense. WHEREFORE, AHCA intends to impose an administrative fine against Beauclerc Manor related to the survey of August 23, 2001 and prosecution of this case, pursuant to section 59A-4.1288, Florida Administrative Code (2001), and 42 C.F.R. 483.25(c), (2001). Beauclerc Manor is a skilled nursing facility in the State of Florida. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, 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; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMINISTRATION OF THE FACTS ceege grep ype Seger rene ome elt ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this oe th, of Leds LZ. , 2001. NV WW ante Michael O. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, FL 32308 (850) 921-0055 (office) (850) 413-9313 (Fax) Karen Swann Diane Grubbs Agency for Health Care Administration CERTIFICATE OF SERVICE I HEREBY CERTIFIY that a true and correct copy of the foregoing has been served by certified mail on 21 ser of Leds bo , 2001 to: Kenyonn Demps, Administrator, Beauclerc Manor, 9355 San Joes Boulevard, Jacksonville, Florida 32257. Nari nna Michael O. Mathis, Esq. en a ae

Docket for Case No: 02-000042