OB-/AP9 STATE OF FLORIDA “ee AS AGENCY FOR HEALTH CARE ADMINISTRATION . STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO.: 200107397 vs. S CITY OF MARIANNA, d/b/a = MARIANNA CONVALESCENT CENTER, ns Respondent. m3 = ES ae _J/ ; “2 ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against CITY OF MARIANNA, d/b/a MARIANNA CONVALESCENT CENTER, (“Marianna Convalescent Center”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Marianna Convalescent Center, pursuant to Section 400.23(8)(b), Florida Statutes; Section 42 CFR 483.10(b)(11)(b), and Rule 59A-4.1288, Florida Administrative Code (2001). JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. Venue lies in Jackson County, Marianna, Florida, pursuant to Section 120.57, Florida Statutes (2001), and Chapter 59A-4, Florida Administrative Code (2001). 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 Il, Florida Statutes, (2001), and Chapter 59A-4 Florida Administrative Code. 5. Marianna Convalescent Center is a for-profit corporation, whose 180-bed nursing home is located at 4295 Fifth Avenue, Marianna, Florida. Marianna Convalescent Center is licensed as a skilled nursing facility license #SNF1322096; certificate number 7764, effective August 30, 2001 through May 31, 2002. Marianna Convalescent Center was at all time material hereto, a licensed facility under the licensing authority of AHCA, and requested to comply with all applicable rules, and statutes. COUNT I MARIANNA CONVALESCENT CENTER FAILED TO IMMEDIATELY NOTIFY THE PHYSICIAN FOR THREE OF TWENTY-EIGHT RESIDENTS FOLLOWING SIGNIFICANT CHANGES IN THE RESIDENTYS’ HEALTH STATUS FEDERAL TAG F157- RESIDENTS RIGHTS 42 C.F.R. 483.10(b)(11)(b) 59A-4.1288, F. A. C. 6. AHCA tealleges and incorporates paragraphs (1) through (5) as if fully set forth herein. . 7. During a re-certification on or about August 12-15, 2001, Marianna Convalescent Center failed to immediately notify the physician for three of twenty-eight residents’ health status. The above constitutes a violation of 42 CER. 483.10(b)(11)(b), requiring that the facility must immediately inform the resident; consult with resident’s physician; and if known, notify the resident’s with the resident’s legal representative or interested family member when there is a significant change in the resident's physician; notify of mental, or psychosocial status in either lifethreatening conditions or clinical complications. . This is a class II deficiency. Fine: $2,500.00. 8. The above also constitutes a violation of Section 400.23(8)(b), Fla. Stat. (2001), providing that a class II deficiencies are those which the agency determines Has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5, 000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. WHEREFORE, AHCA intends to impose an administrative fine against Marianna Convalescent Center for violations of Section 59A-4.1288, Florida Administrative Code, and 42. C.F.R. 483.10(b)(11)(b). Marianna Convalescent Center is a skilled nursing facility in the State of Florida. Respondent is notified that they have a right to request an administrative hearing pursuant to 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; Michael Mathis, Senior Attorney. 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 Florida. Michael O. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner, Agency for HealthCare Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0055 (office) (850) 413-9313 (fax) Donah Heiberg Diane Grubbs Agency for Health Care Administration _— ee SSSR CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on [st day of Were __, 2002 to: Jonnie Cloud, Administrator, Marianna Convalescent Center, 4295 Fifth Avenue, Marianna, Florida 32446, Copies furnished to: Jonnie Cloud, Administrator Marianna Convalescent Center 4295 Fifth Avenue Marianna, Florida 32446 Agency for Health Care Administration Finance & Accounting Department P.O. Box 13749 Tallahassee, Florida 32317-3749 Michael O. Mathis, Esq. Donah Heiberg Area Office #2 Supervisor Agency for Health Care Administration 2727 Mahan Drive, Suite 1213 Tallahassee, Florida 32308

Docket for Case No: 02-001289

Orders for Case No: 02-001289