AQ: 7 08/28/02 14:07 Fax L4 IOSY oor bio” VAG. 27.2002 1:26°M W0. 5h, aoe STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 7 . Petitioner, AHCA NO.: 2002020601 Ve, AHCA NO.: 2002026181 PALM COAST HEALTH CARE ASSOCIATES, LLC, d/b/a GRAND OAKS HEALTH AND REHABILITATION CENTER, Respondent. re at te _—__—_.__/ ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION ("AHCA"), by and through che undersigned counsel, and files this Administrative Comp‘aint against PALM COAST HEALTH CARE ASSOCIATES LLC, d/b/a GRAND OAKS HEALTH AND REHABILITATION CENTER, (“Grand Oaks Health and Rehabtitation Center”), pursuant ta Section 120.569, and 120.57, Fla. Stat. (2001), alleges; NA EOF THE (@) 1, This is an action to impose an administrative fine against Grand Oaks ea Health and Rehabilitation Center, pursuant to Seerion 400.23(8b), Fla. Star; 42 CER. 483.13(cM1)(), and Rule 594-4.1288, Flotida Administrative Code (2001), The Agency ny also intends to impose a conditional rating effective March 14, 2002 through November — 30, 2002, pursuant to Section 400.23(7), Fla. Stat. (2001) case no, 2002026181. 08/28/02 14:08 FAX | —— . oo2 5 P, © AUG. 27.2002 1:26PM NO. 454 3 SDICTIO 2. This Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat. (2001), 3. Venue lies in Flagler County, Palm Coast, 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 stanutes and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Fla, Stat, (2001), and Chapter 594-4 Florida Administrative Code. 5. Grand Oaks Health and Rehabilitation Center is a forprofit corporation, whose 120-bed nursing home is located at 3001 Palm Coast Parkway SE, Palm Coast, Florida, Grand Oaks Health and Rehabilitation Center is licensed as a skilled nursing facility license #SNF130470968, certificate number 8498, effective March 14, 2002 through November 30, 2002. Grand Oaks Health and Rehabilitation Canter was at all time material hereto, a licensed facility under the Ilcensing authority of AHCA, and requested to comply with all applicable rules, and statutes. COUNT] GRAND OAKS HEALTH AND REHABILITATION CENTER FAILED TO IMPLEMENT POLICIES AND PROCEDURES RELATED TO IDENTIFICATION OF RESIDENTS WITH ADVANCE DIRECTIVES AND INITIATION OF CARDIOPULMONARY RESUSITATION (CPR). STAFF WERE NOT KNOWLEGEABLE OF FACILITY POLICY AND DID NOT IMPLEMENT POLICY, FEDERAL TAG F224- RESIDENTS RIGHTS 42, CBR, 483.13(c) 50A-4.1288, F. A. C. 6. AHA realleges and tncorporates paragraphs (1) through (5) as if fully set forth herein, ‘08/28/02 14:08 FAX loos AUG. 27.2002 1:27PM NO.454 0 P,4 7. During an appraisal visit on or about Maxch 14, 2002, Grand Oaks Health r) and Rehabilitation Center failed to frotemen policies and procedures related to identification of residents with advance directives and initiation of cardiopulmonary resuscitation (con} Staft eas not knowledgeable of facility policy and did not implement policy. The above constitutes a violation of 42 CER. 483.13(c), requiring that the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. This is a class I] deficiency, Fine: $2,500.00. 8. The above also constitutes a violation of Section 400,23(8Xb), Fla, Stat. (2001), providing that a clase Il deficiencies are those which the agency determines has compromised the resident's ability to maintain or teach his or her highest practicable physical, mental, and psychosocial wellbeing, as defined by an accurate and comprehensive resident assessmenc, plan of care, and provision of services. A class TI 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 { 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 af the deficiency. This above constitutes a violation of Section 400.23(7), Fla, Stat. (2001), requires that the agency hall, at least every 15 months, evaluace all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules 08/28/02 14:08 FAX . . ood AUG. 27.2002 1: 279M NO.454 PL 5 adopted under this part as a basis for assigning a licensure status to that facility. The ageticy shall base its evaluation on the most recent inspection report, taking onto consideration * findings from other official reports, surveys, interviews, investigations, inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. (a) A standard licensure status meana that a facility has no claas I or class II deficiencies within the time established by the agency, {(b) A conditional licensure status means that a facility, dus to the presence of one more or more class | or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules edopted by the agency, If the facility has no class I, class 11, class Ill deficiencies at the ttme of the follow-up survey, a standard license statua tay be assigned. (c) Tn evaluating the overall quality of care and services and determining whether the facility will recelve a conditlonal or standard license, the agency shall consider the needs and limitations of residents in the facility and the Tesults of interviews and suzveys of a representative sampling of residents, families of residents, ombudsman council members in the planning and service ateag in which the facility Js located, guardians of residents, and staff of the nursing home facility. (d) ‘The curtent licensure status of each facility must be indicated in bold print on the facility of the license, A list of the deficiencies of the factlity shall be 08/28/02 14:09 FAX AUG. 27, 2002 . . . _ Moos 1:27PM . NO. 454.6 posted in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to that facility. Licensees teceiving a conditional licenaure status for a facility shell prepare, within 10 working days after receiving notice of deficiencies, a plan for correction of all deficiencies and shall submit the plan to the agency for approval. (e) Each licensee shall post iti license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. (f) The agency shall adopt rules that: 1. Batablished uniform procedures for the evaluation of facilities, 2, Provide criteria in. the areas referenced in patagraph (c) 3, Address other areas necessary for carrying out the intent of this section. WHEREFORE, AHCA intends to impose an administrative fine against Grand Oaks Health and Rehabilitation Center for violations of Section 400,23(7), and Section 400.23(8)(b), Fla. Stat. (2001), 594-4.1288, Florida Administrative Code, and 42. CER. 483.13(c)(DG), Grand Ouks Health and Rehabilitation Center is a skilled nursing facility in the State of Florida. 08/28/02 14:09 FAX ANG. 27,2002 1:27PM , NO. 454 PB, 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 Adiminiatration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael Mathis, Senior Attorney. RESPONDENT 18 FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A. HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT fd o08 7 IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT, AND THE ' ENTRY OF A FINAL ORDER BY THE AGENCY, Respectfully Submitted this oA day of Pruguak 2002, Leon County, Tallahassee, Florida. Michael ©, 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) Karen Swann Diane Grubbs Agency for Health Care Adniinistration 08/28/02 14:09 FAX AUG. 27,2002 1:28PM NO. 454, LHEREBY CERTIFY that a true and correct copy of the foregoing has been served oh by certified mail on oe day of Rugus t 2002 to: Gregory S. Roberts, NHA Executive Director, Grand Oaks Health and Rehabilitation Center, 3001 Palm Coast Parkway SE, Palm Coast, Florida 32137, Copies furnished to: Gregory 8. Roberts, NHA, Executive Director Grand Oaks Health and Rehabilitation Center 3001 Palm Parkway, SE Palm Coast, Flozida 32137 Agency for Health Care Administration Finance & Accounting Depattment P.O, Box 13749 Tallahassee, Florida 32317-3749 Michael O, Mathis, Esq, Karen Swann Area Office #4 Supervisor Agency for Health Cara Administration Divislon of Managed Care & Health Quality 921 N, Davis Street, A115 Jacksonville, Florida 32209 ihoo7 8 08/28/02 14:09 FAX . .. . Moos AUG. 27.2002 1:28PM No Ai 9 7) ee Ps Bo > Ay, eo ‘Syl STATE OF FLORIDA la) 0. AGENCY FOR HEALTH CARE ADMINISTRATION TR FON Rr, Grand Oaks Health & Rehab, Center Enforcement # 26203, 601 2002026181 (5 ELECTION OF RIGHTS REGARDING NOTICE OF INTENT TO DENY PLEASE SELECT ONLY 1 OF THE 3 OPTIONS . An Explanation of Rights is attached, OPTION ONE (1) G Ido not dispute the allegations of fact contained In the Notice of Intent and waive my right to object or to be heard. I understand that by waiving my rights, a final order will be issued that adopts the Notice of Intent and imposes the sanctions sought. OPTION TWO (2) (1 Ide net dispute aud I admit the allegations of fact in the Notice of Intent, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes (F.S.), at Which time, f will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) C Ido dispute the allegations of fact contained in the Notice of Intent and request a formal hearing, pursuant to Section [20,57(1), F.S., before an Administrative Law Judge appointed by the Division of Administrative Hearlngs. If you choose OPTION THREE (3), 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.), Section 28- 106.) 11, Florida Administrative Code (F.A,C.), and must state the material facts you dispute. Ju order to preserve the right to a hearing, the Election of Rights form, in this matter, must be received by the Agency for Health Care Administration within twenty-one (21) days from the date the Notice of Intent to Deny is received by licensee, If the election of rights form with the selected option is nat received by the Agency for Health Care Administration within twenty-one (21) days from the date of the receipt of Notice of Intent to Deny, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought. If you have elected either OPTION TWO (2) or THREE (3) above and you are Interested in discussing a settlement of this matter with the Agency, please also mark this black. 0 Mediation under Section 120.573, Florida Statutes, is not available in this matter, (Please sign a in urrent address.) Respondent (Licenace) Address. Liceise No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: AHCA Agency Clerk Office of the Gencra! Counsel Building 3, MS 3 2727 Mahan Drive Tallahassee, 1, 32308 Phone: 850/488-5861; Fax: 850/410-1512 or 850/414-5416 TDD 1/800/955-8771 08/28/02 14:10 FAX . ooo AUG, 27, 2002 1:28PM No454 oP, STATE OF FLORIDA __ AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC, 120.569, FLORIDA STATUTES (To be used with Election of Rights for Notice of Intent form — attached) In response to the allegations set forth in the Notice of Intent issued by the Agency for Health Care Administration (Agency), you must make one of the following elections within twenty-one (24) days - ftom the date of receipt of the Notice of Intent. Please mnke your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION ONE (1): H-you do not dispute the allegations in the Notice of Intent and watye your right to be heard, you should select Option 1 on the Elections of Rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Notice of Intent. You will be provided a copy of the final order. OPTION TWO (2): If you donot dispute any material fact alleged in the Notice of Intent (you admit each of them), you may request an informal hearing pursuant to Section 120,57(2), Florida Statutes, before the Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty belng © imposed for the violations set out in the Notice of Intent. For an informal hearing, you should select Option 2 on the Election of Rights form. , OPTION THREE (3): If you dispute the allegations set forth in the Notice of Intent (you do not admit them), you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. 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 28-106.111, Florida Administrative Code (F.A,C,), Section 28-106,201, Florida Administrative Cade (F.A.C and must state the material facts you dispute. In order to preserve the right to a hearing, the Election of Rights form, in this matter, must be received by the Agency for Health Care Administration within twenty-one (21) days from the date the Notice of Intent to Deny is received by licensee, If the election of rights form with the selected option is not received by the Agency’ for Health Care Administration within twenty-one (21) days from the date of the receipt of Natice of Intent to Deny, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought. Boro 14:10 FAX 08/28/02 11 P, NO, 454 | CERTIFICATE #: ; LICENSE #: _SNF130470968 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY SKILLED NURSING FACILITY & CONDITIONAL This {s to vonfirm that PALM COAST HEALTH CARE ASSOCIATES, LLC fas complied with the rales aud cognlations adopted by the State of Florida, Agescy For Health Care Administration, authorized in Chapter 400, Part iI, Florida Staintes, and as the licensee is authorized ta operate the following: GRAND QAKS HEALTH AND REHABILITATION CENTER 3001 PALM COAST PARKWAY SE PALM COAST, FL. 32137 with 120 beds. Change In Status ACTION EFFECTIVE DATE; 93/34/2002. LICENSE EXPIRATION DATE: _{1/30/2002., Deputy Secreiary, Yivision of Managed Care and Health Quality

Docket for Case No: 02-003654