10/08/02 11:31 FAX STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMT STATE OF PLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2002025591 VSa LEE HEALTH CARE ASSOCTATES, Lic, d/b/a LEZ CONVALESCENT CENTER Respoadent. f ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and filea this Administrative Complaint againat LEE HEALTH CARE ASSOCIATES, LLC, d/b/a LEB CONVALESCENT CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE AcTION 1, This is an action to impose a conditional Licensure Status effective March 7, 2002 through May 1, 2002, pursuant to Sections 400.23(7) (b) and 400.23(8) (b), as the result of a Survey of the Respondent’s facility completed on or about March 7, 2002. During this survey, a Clags IZ deficiency for violation of Rule 58A-4.1288, Florida Administrative Code, and Section 400.022(1) (1) was cited, and a Clase III deficiency for fd (pel ON NdiG-b 2002 % ‘L390 10/08/02 11:31 FAX 003/014 violation of Rule 59A~4.118(2), an uncorrected Class IT deficiency. 2. The Raspondent was originally cited for the Class ITT deficiency (Tag 514) during the survey conducted on ov about January 22-24, 2002. JURISDICTION AND VENUS 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes, a. Vanue lies in Lee County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES 5. AHCA, is the enforeing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59a~4, Florida Administrative Cede, §, Respondent is a nursing homa located at 2826 Cleveland Avenue, Fort Myers, Florida 33901-6097, The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. £ ‘dl ON WdlS*% 000% ‘LOO 10/08/02 11:34 FAX @oaod/o14 COUNT I RESPONDENT FAILED TO ENSURE THAT A RESIDENT WHO IS FED BY A NASO-GASTRIC OR GASTROSTOMY TUBE RECELVED TH2 APPROPRIATE TREATMENT AND SERVICES To PREVENT ASPTRATION PNEUMONIA, DIARRHEA, VOMITING, DEHYDRATION, METABOLIC ABNORMALITIES, AND NASAL - PHARYNGHAT, ULCERS AND TO RESTORE, IF POSSIBLE, NORMAL HATING SKILLS VIOLATING RULE 59A-4.1288, Florida Administrative coeds, AND SECTION 400.022(1) (u), Florida Statutes GUASS IL DEFICIENCY 7, AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based on resident record reviews and interviews the Respondent failed to ensure that recommended and ordered tube feeding, to meet the nutritional needs of a Yesident (Resident #19). The Resident did not weceive the dorrect amount of tube feedings for seven (7) days that resulted in a four (4) pourid Weight loss. 9, The facility failed ta adequately assesa and monitor the physical condition of a resident, to prevent complications for a resident with a feeding tube (Resident #29), Reaident #25 received approximately 11-12 grams more Pretein than her estimated need, and approximately 1000 ac more fluids than her estimated need. The Resident was not assessed and monitored for Possible complications. pod vel ON WAL?’ 7ONZ ‘b ‘140 oo0s/o14 10/08/02 11:31 FAX Q COUNT IL RESPONDENT FAILED TO MATNTAIN CLINICAL RECORDS on RACH RESIDENT TIN ACCORDANCE WITH ACCEPTED PROFHSSIONAL STANDARDS AND PRACTICES THAT ARE COMPLETE: ACCURATELY DOCUMENTED; RHADILY ACCESSIBLE; AND SYSTEMATICALLY ORGANIZED . VIOLATING RULE 59A-4,1288 AND 59A-4.118(2) Florida Administrative Code CLASS ILL DEFICTENCY 10. AHCA re-allegas and incorporates (1) through (6) as if fully set forth herein, il. Based on resident record reviews and interviews the Respondent failed to maintain cemplete and accurate yYecorda for two (2) residente (Resident #9 and Resident #19), Specifically, there was no documentation that the medical administration record for Resident #9 and Resident #19 was being followed or indicate that the care and feeding of the residents were being Monitored, Further, nursing notes, meal consumption records, and the medical adminiatration record for both residents were Not accurate and complete, 12. The Agency seeks to impose a Conditional Licensure Status effective March 7, 2002 through May 1, 2002, based on uncorrected Class It and Clase rimr deficiencies ag authori zad under Sections 400,23(7) (b), 400.23 (8) (c) and 400.022(3), Florida Statutes, WdiS?% 2002 F “190 Booso14a 10/08/02 11:32 Fax gy CLAIM FOR RELIEF WHEREFORE, AHCA requests thig Court to order the following relief: A, Make factual and legal findinge in favor of the Agency on Count I and Count IZ; 5, Recommend that the change of licensure Status effeative March 7, 2002 through May 1, 2002, Erem Standard to Conditional be upheld; and c, All other general and equitable relier allowed by law, DISPLAY OF LICENSE Pursuant to Section 400.062(5) and Section 400, 23(7) (ea), Florida Statutes, Respondent shall post the license in a prominent place that ia in clear and unobstructed public view at or near the place where residents are being admitted to the facility, NOTICE Respondent ie notified that it has a right to request an adminietrative hearing pursuant te Section 120.865, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Blection of Rights (one Page). All requests for hearing shall be made to the attention of Michael Sasso, Senior Attornay, Agency for Health Care 9 ‘d PL ‘ON WdlG-h 0000 >» “190 Moo7/o14 10/08/02 11:32 PAX oo Administration, 525 Mirror Lake Dr. N., St. Petersburg, Plorida, 33701. RESPONDENT Is FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 4 HEARING WITHIN 21 DAYS OF RECEIPT OF Hrs COMPLAIN? Wrun RESULT IN AN ADMISSION OF THE PACTS ALLEGED IN TRE COMPLAINT AND THE ENTRY OF A FINwan ORDER BY THE AGENCY, Reapedt fully submitted, Michael Sasso, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive North gt. Petergburg, Florida 33701 I HEREBY CERTIFY that a copy hereof has been furnished to C. T. Corparation System, 1200 South Pine Island Road, Plantation, Florida, Return Recelpt No. 7001 2510 0007 5976 5as4 and to Administrator, Lee Convalescent Center, 4826 Claveland Avenue, Fort Myers, Florida, Return Receipt No. 7001 a510 90007 5976 5179, by u.g. Certified Mail on october of + 2002, e ee Mire Michael Sasso, Esquire Copies furnished to; C.T. Corporation System Registered Agent for Lee Convalescent Center 1200 South Pine taland Road Plantation, FL 33324 (U.8. Certified Mail) Ld Pl ON WdeS'? 2002 b ‘190 10/08/02 11:32 Fax Administrater Lee Convaleacent Center 2826 Cleveland Avenue Fort Myers, FL 33501-6097 (U.S, Certified Mail) Wendy Adama Agency for Health Care Administration 2727 Mahan Drive, Bldg #2 Ms #3 Tallahassee, FLL 322308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Michael Saseao AHCA — Senior Attorney $25 Mirror Lake Drive Suite 330K St. Petersburg, Fl 33701 8d P2L ON Woosroia NdlS"P 2000 % “LOO (00g/or4 FAX 11:32 10/08/02 COOCIOEIIT -ALVG NOELWUEXY ASNHOFI CHUCILO/ED “ALVG HALIDE NOILoy SUES uy este “SP2q OZT aim A609-106EE “Id “SUHAW D0 HONAAV GONVISATTO 9797 YHINIO INDOSTTVANOD aHT 2SurOT[O; O18 azerOTO OY aD Se Pe ‘sae EpHOLy ‘[[ weg ‘g op 4q poydope snopeniar pre soar ap tpt Peydwos seq TTT “TYNOLLIGNOD ALTTIOVA DNISHAN Ga TIDIs ALFIVNO HLTVaH ONV FVD GHOVNVIN 0 NOISIAIG NOLLVULSININGY myo HLTVAH AOA ADNADY BPLIOL] Jo a3eIg S6006CTANS <# ASNAOIT POPE “@ ELVOWLLATD 10/08/02 11:33 FAX Mo1osoi4 PAYMENT FORM Agency for Haalth Cara Administration Finance & Accounting P.O. Bom 13749 Tallahassea, Florida 32317-3749 Enclosed plaase find Check No, in the amowt of § ) which represents payment of the Administrative Fine imposed by AHCA, renee cee Facility Name AHCA No. gl ‘d p01 ON NdES*? 7002 ‘LOG a14/o14 11:34 Fax 10/08/02 “MOZOLAT ava NOLLVaIIXA SSNaoTT “COCO ELV FATA NOLLOY SoG Of eBay ‘sPeq Ocl Wyeth 4609-T06EE ‘Td “SHEAW La JONSAV ONVTSAATO 978z WARING INGOSTTVANGD ETT +2nLAoTOy 3p ayRsdo ©} peznoyme s} seqmecr OW) $8 Pie “SNES BELOL] “TL weg ‘OO sexiegD or pagyroque ‘UOPEROMUPY ate aOR IE Lavy “EPWOpy Jo ateyg "8 9 pesdope suonejnéax pue soma qi paydunco sey JT] SHLVISOSSV HavO RETVAN FoL ULSON OL AE STL, "IVNOLLIGNO ALITIOVA DNISMON GATIDIS AUTVNO BLIVAH UNV HAVO CHOVNVAAO NOISIAIG NOILVELSININGY Fav HLIVEH Yor AONEDV EPHOLT JO 3387 S6006ZTHNS :# HSNFOTI Fore *# FLYORILGAD 02 'P ‘190 20 —s x N

Docket for Case No: 02-004256