STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION/;, ON, OY 3 ‘GF MEGS), AGENCY FOR HEALTH CARE OTA Oy ADMINISTRATION, ° Petitioner, i dy a -O195 vs. AHCA NO: 2002048917 DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH 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 DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH CARE CENTER, (hereinafter “Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2002), and alleges: NATURE OF THE ACTION 1. This is an action to assign a conditional license to DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH CARE CENTER, pursuant to Section 400.23(7), Florida Statutes (2002). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2002). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. DELTA HEALTH GROUP, INC., d/b/a MAITLAND HEALTH CARE CENTER, is a foreign profit company with a principal address of 2N Palafox Street, Pensacola, Florida 32501. 7. MAITLAND HEALTH CARE CENTER is a 180-bed skilled nursing facility located at 1700 Monroe Avenue, Maitland, Florida 32751. MAITLAND HEALTH CARE CENTER is licensed by AHCA as a skilled nursing facility having been issued license number SNF14280961 certificate number 9465, with an effective date of October 12, 2002 and an expiration date of December 31, 2002. 8. MAITLAND HEALTH CARE CENTER is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I EFFECTIVE OCTOBER 12, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO MAITLAND HEALTH CARE CENTER BASED UPON THE DETERMINATION THAT MAITLAND HEALTH CARE CENTER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS II DEFICIENCY AT THE MOST RECENT SURVEY OF OCTOBER 12, 2002. § 400.23(7), Fla. Stat. 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. CLASS II DEFICIENCY 10. On or about October 12, 2002, AHCA conducted an annual survey at MAITLAND HEALTH CARE CENTER. A class II deficiency was cited against MAITLAND HEALTH CARE CENTER based on the findings below. 11. Based on the observations, staff interviews, and clinical record reviews, the facility failed to maintain an environment free of physical and verbal abuse for one (1) resident (Resident #9) 12. Specifically: (a) Resident #9 was admitted to the facility in July of 2002 with diagnoses of Huntington's Chorea, Dementia, Psychosis, and Schizophrenia. Review of the Minimum Data Set Assessment completed 7/16/02 noted the resident to have short and long term memory loss and moderate cognitive loss. Behaviors indicated he/she was resistive to care. The resident also required assistance with dressing (ADL). The plan of care dated 8/12/02, for memory impairment documented a goal to maintain understanding of others as evidenced by continued ability to follow directions. The Approaches included, "follow the same routine for ADL's", and use a "calm voice and repeat if necessary." (b) During observation in resident #9's room, on 10/09/02 at approximately 3:00 PM, two Certified Nursing Assistants (CNA's) brought him/her into the room to change a soiled shirt. The roommate was in bed observing the staff and resident #9. The resident became somewhat resistive and sat him/herself down on the floor near the bathroom and then preceded to lie down on the floor. In very loud voices the CNA's told him/ her " Pull yourself up". CNA#1 began pushing him up. The other CNA #2 told CNA #1 to "leave the resident alone." Interview with the roommate during this interaction revealed that the CNA's that same morning was talking very loudly to the resident while coaxing him/her up. The resident was sleeping ina chair in the room. Resident #9's roommate also stated that he/she heard resident #9's head bump something that morning. The roommate was very upset at his/her observations of the treatment to his/her roommate. 13. Based on the foregoing, MAITLAND HEALTH CARE CENTER violated Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 CFR 483.13(b), and Section 400.022(1) (1), which require the facility to maintain and environment free of physical and verbal abuse, and provide adequate and appropriate protective and support services. 14. AHCA assigned a conditional licensure status to MAITLAND HEALTH CARE CENTER based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of one (1) class II deficiency at the most recent survey on or about October 12, 2002. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make actual and legal findings in favor of AHCA on Count I; 2) Uphold the issuance of the conditional license with an effective date of 10/12/02, a copy of which is attached hereto as Exhibit “A”; and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, MAITLAND HEALTH 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 MAITLAND HEALTH CARE CENTER hereby is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Flection 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 Michael P. Sasso, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, #330K, St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY ACHA. Respectfully submitted on this 23°? aay of December, 2002. YckaD f sesag— Michael P. Sasso, Esquire Fla. Bar. No. 0167363 525 Mirror Lake Drive North, 330K St. Petersburg, Florida 33701 (727) 552-1435 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE — eee eee I HEREBY CERTIFY that the original Administrative Complaint and Exhibit “A” has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0002 7109 5264 to James Richardson, Administrator, Maitland Health Care Center, 1700 Monroe Avenue, Maitland, Florida 32751 and a copy of the foregoing has been furnished via U.S. Certified Mail, Return Receipt No. 7002 2030 0002 7109-5271, to Sondra McCrory, Registered Agent for Maitland Health Care Center, 2 North Palafox Street, Pensacola, Florida acl 32501, on December 23 , 2002. Michael P. Sasso, Esquire COPIES TO: Sondra McCrory Registered Agent for Maitland Health Care Center 2 North Palafox Street Pensacola, FL 32501 (U.S. Certified Mail) James Richardson, Administrator Maitland Health Care Center 1700 Monroe Avenue Maitland, FL 32751 (U.S. Certified Mail) Michael P. Sasso, Esquire Agency for Health Care Administration 925 Mirror Lake Drive North, Suite 330K St. Petersburg, Florida 33701 Exhibit “A” CONDITIONAL LICENSE License # SNF14280961; Certificate #9465 Effective Date: 10/12/2002 Expiration Date: 12/31/2002

Docket for Case No: 03-000195