STATE OF FLORIDA Tek, AGENCY FOR HEALTH CARE ADMINISTRATION 6. 4S * 7) Y STATE OF FLORIDA, AGENCY FOR a “? HEALTH CARE ADMINISTRATION, al dYy(7 See" Petitioner, AHCA NO: 2002045868 vs. KINDRED NURSING CENTERS EAST, LLC, d/b/a CARROLLWOOD CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against KINDRED NURSING CENTERS EAST, LLC, d/b/a CARROLLWOOD CARE CENTER (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose a conditional licensure status effective June 18, 2002, pursuant to Sections 400.23(7) (b) and 400.23(8) (b) Florida Statutes. The original conditional license is attached hereto as Exhibit “A”. 2. The Respondent was originally cited for the deficiency during the Complaint Survey conducted on or about June 18, 2002. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part ITI, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 15002 Hutchinson Road, Tampa, FL 33625. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I EFFECTIVE JUNE 18, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO THE RESPONDENT BASED UPON THE DETERMINATION THAT THE RESPONDENT FAILED TO ENSURE ADEQUATE SUPERVISION TO PREVENT AN ACCIDENT FOR ONE RESIDENT WHO DIED FROM A SIDE RAIL INJURY IN COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS I DEFICIENCY AT THE MOST RECENT SURVEY OF JUNE 18, 2002 Fl. Admin Code R.59A -4.1288 INCORPORATING BY REFERENCE 42 CFR 483.25(h) (2); §400.022 (1) (1) Fl. Stat. (2001) 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about June 18, 2002 a complaint investigation was conducted at the facility. 9. During that investigation, the particular findings regarding this deficiency include the fact that resident #1 was found on the floor sitting in an upright position at approximately 8:15am on 5/5/02 by a CNA. His head was wedged between the right upper side rail and the mattress with the resident’s chin pressed upward against the rail hyperextending the neck. The resident was without pulse or respiration. 10 Further findings include the fact that the fall resident assessment protocol of 4/9/02 revealed that Resident #1 was at risk for falls. 11. Based on the above actions or inactions the facility violated Fl. Admin Code R.59A-4.1288 incorporating by reference 42 CFR 483.25 (h) (2) which requires that the facility provide adequate supervision to prevent accidents; §400.022 (1)(1) Fl. Stat. (2001) which requires the resident receive adequate and appropriate health care and protective and support services consistent with the resident care plan and established practices within the community. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Recommend that the change of licensure status effective June 18, 2002, from Standard to Conditional be upheld; and Cc. Assess costs related to the investigation and prosecution of this case pursuant to §400.121(10) Florida Statutes. D All other general and equitable relief allowed by law. DISPLAY OF LICENSE Pursuant to §400.062(5) and §400.23(7) (e) Florida Statutes, KINDRED NURSING CENTERS EAST, LLC, d/b/a CARROLLWOOD CARE CENTER shall post the 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. NOTICE GI KINDRED NURSING CENTERS EAST, LLC, d/b/a CARROLLWOOD CAR CENTER is notified that it has a right to request an administrative hearing pursuant to §120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (two pages). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, St. Petersburg, Florida 33701. 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. Eileen O’Hara Garcia, Esquire AHCA — Senior/ Attorney Fla. Bar No. 504149 525 Mirror Lake Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to Cc T Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 by U.S. Mail and to Administrator, Carrollwood Care Center, 15002 Hutchinson Road, Tampa, FL 33625, by U.S. Certified Mail, Return Receipt No. % 0510 0003 FYI RIS , f October ABs 002. ¢ ; Wek Eileen 0’ Ha Garcia, Esquire Copies furnished to: / C T Corporation System Registered Agent for Carrollwood Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Mail) Administrator Carrollwood Care Center 15002 Hutchinson Road Tampa, Florida 33625 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (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) Fileen O’Hara Garcia-AHCA Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 €007Z/0E/r0 “ALLVC NOLLVUldxa ASNAOII Z00Z/1/90 ‘ALVG SALLOaSA NOLLOV aBueysd snieis ‘spaq Ocl WIM Gz9Ce Td “VdINVL GVO¥ NOSNIHO.LAH 70081 UELLNAO AWVO GOOMTIONAVO -Surmorjoy amp atezodo 0} peztoyne “OOP JaideyD ut pezHoynE suonenstunmpy ed weeH 104 KouaSy ‘epuloy,y JO a181¢ st aasuaor] ou) se pur ‘SaImIeIS epuops ‘II ued poyjduioo sey STI ‘LSVA SYALNAO ONISUAN CSYANDA yey) WLIJUOS 09 ST SHY. ayy Aq posdope suone[ngal pus soyns oy) YIM TVNOLLIGNOD ALITIOVA ONISHON aa TVIris ALIN BLIVaH GNV duvO GSOWNVW dO NOISIAIG NOLLVULLSININGY Fav HLTV dH wOd AONAOV EPLIOp,] JO BES S60LLOIANS ‘# HSNSOFT $188 *# ALVOLILYAO

Docket for Case No: 02-004417

Orders for Case No: 02-004417