STATE OF FLORIDA ne AGENCY FOR HEALTH CARE ADMINISTRATION i i i STATE OF FLORIDA, AGENCY FOR 03 APR 28 PH y: HEALTH CARE ADMINISTRATION, * 3h BIVIS.S,; <.- Petitioner, AHCA NO: 2003001032 OHS FR VE v. 2003001541 {EATINGS OO. [SOY DELTA HEALTH GROUP, INC., d/b/a BRYNWOOD CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned’ counsel, and files this Administrative Complaint against DELTA HEALTH GROUP, INC., d/b/a BRYNWOOD CENTER, (hereinafter “Brynwood Center”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2002), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Brynwood Center, pursuant to Sections 400.23(8)(b), Fla. Stat. (2002), 42 C.F.R. 483.25(h)(2), and Sections 59A-4.1288, Florida Administrative Code (2002). The Agency also intends to impose a conditional rating effective January 30, 2003 through December 31, 2003, pursuant to Section 400.23(7), Fla. Stat. (2002) case no. 2003001541. Brynwood Center was issued a standard license effective March 3, 2003 through December 31, 2003. JURISDICTION AND VENUE 2. This count has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, (2002). 3. Venue lies in Jefferson County, Monticello, Florida, pursuant to Section 120.57, Florida, (2002), and Chapter 59A-4, Florida Administrative Code. PARTIES 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 II, Florida Statutes, (2002), and Chapter 59A-4 Florida Administrative Code. 5. Brynwood Center is a for-profit Florida corporation, whose 97-bed nursing home is located at 1656 Jefferson Street, Monticello, Florida. Brynwood Center is licensed as a skilled nursing facility license #SNF10680961; certification number 9827 effective March 3, 2003 through December 31, 2003. Brynwood Center was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable rules, and statutes. COUNT I BRYNWOOD CENTER FAILED TO PROVIDE ADEQUATE SUPERVISION AND PROPER APPLICATION OF ASSISTIVE DEVICES TO PREVENT AN ACCIDENT FOR ONE OF TWENTY-ONE RESIDENTS. (RESIDENT #18) FEDERAL TAG F324-QUALITY OF CARE Section 42 C.F.R. 483.25(h)(2) QUALITY OF CARE Section 400.23(8)(b), Fla. Stat. (2002) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 59A-4.1288, Fla. Admin, (2002) EXCEPTION 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about January 30, 2003, AHCA conducted an annual survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) Respondent was cited for (Tag F324) during a recertification survey on or about April 25, 2002, Brynwood Center failed to provide adequate supervision of 1 (#11) of 23 sampled residents to prevent the potential for accidents due to lack of necessary supervision. i b.) During an annual survey on or about January 30, 2003, Brynwood Center failed to provide adequate supervision and proper application of assistive devices to prevent an accident for one of twenty- one residents. (Resident #18). ug. The above constitutes a violation of Section 42 C.F.R. 483.25(h)(2), requiring that each resident receives adequate supervision and assistance devices to prevent accidents. 9. The violation alleged herein constitutes a class II deficiency, and warrants a fine of $5,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $5,000. The above constitutes a violation of Section 400.23(8)(b), Fla. Stat. (2002), providing that a class II deficiency is a deficiency that 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 I] 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. The violation above constitutes a violation of Section 59A-4.1288, Florida Administrative Code (2002), which requesting that nursing homes that participate in Title XVIII] or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non- certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. The above constitutes a violation of Section 400.23(7), Fla. Stat. (2002), requiring that the agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licérisure status of standard or conditional to each nursing home. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Fla. Stat. (2002). 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, 27277 Mahan Drive, Tallahassee, Florida, 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMINISTRATION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. oh ae Respectfully submitted this at “day of , 2003. A Athy apy Nie Michael O. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner Agency for Health Care Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, FL 32308 (850) 921-0055 (office) (850) 413-9313 (fax) Donah Heiberg Lealand McCharen Agency for Health Care Administration 1 ' CERTIFICATE OF SERVICE I HEREBY CERTIFIY that a true and correct copy of the foregoing , th has been served by certified mail on Qe day of Merah __, 2003 to: Dawn Edwards, Administrator, Brynwood Center, Rt. 1 Box 21, Monticello, Florida 32344. ' , LALA RA PDEA ADA Han Michael O. Mathis, Esq.

Docket for Case No: 03-001504