Jun-11-2003 07:39am From-MARINER POST ACUTE NETWORK +6784436778 T-544 PP O17/038F-556 STATE OF FLORIDA he AGENCY FOR HEALTH CARE ADMINISTRATION” sy 7 aa {5 Fh , AGENCY FOR HEALTH CARE Cin Mtge ADMINISTRATION, 7008 03—q°uoo3 3804 4O32 Petitioner, AHGA NOY 2003002655 7001 G360 0003 3804 4oO44 vs. MARINER HEALTH CARE OF MACCLENNY, INC., D> 9 Sb/ D/BIA MARINER HEALTH CARE OF MACCLENNY, a> Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency’), by and through its undersigned counsel, and files this Administrative Complaint against MARINER HEALTH CARE OF MACCLENNY, INC., D/B/A MARINER HEALTH CARE OF MACCLENNY (hereinafter “MARINER’), pursuant to Chapter 400, Part Il, and Sections 120.569 and 120.57, Florida Statutes (2002), and alleges the following: NATURE OF THE ACTION 1. This is an action pursuant to Sections 400.121(10) and 400.23(7), Florida Statutes (2002): (a) to assign a conditional licensure status to MARINER based on one class | deficiency cited at a survey on or about March 3-7, 2003; and (b) to assess costs related to the investigation and prosecution of the case. The original conditional license effective March 7, 2003, is attached hereto as Exhibit “A” and incorporated herein by reference, MARINER'S licensure status was upgraded to standard effective April 15, 2003. EXHIBIT A - Jun-11-2003 07:38am From-MARINER POST ACUTE NETWORK +6784436778 7-544 (018/038 ~=—-F-556 JURISDICTION AND VENUE 2. This Tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. The Agency has jurisdiction pursuant to Chapter 400, Part I!, Florida Statutes (2002). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2002). PARTIES 5. The Agency is the regulatory authority responsible for the licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities pursuant to Chapter 400, Part Il, Florida Statutes (2002), and Chapter 59A-4, Florida Administrative Code. 6, Mariner Health Care of Macclenny, Inc. is a foreign for profit corporation with a principal address of One Ravinia Drive, Suite 1500, Atlanta, Georgia 30346. 7. MARINER operates a 120-bed skilled nursing facility located at 755 South Fifth Street, Macclenny, Florida 32063, having been issued license number SNF 1222096 by the Agency. 8. MARINER is and was at all times material hereto a licensed skilled nursing facility required to comply with all applicable laws and rules. Jun-11-2003 07:39am From-MARINER POST ACUTE NETWORK +678443677 1-544 P 019/038 = F-556 COUNT | EFFECTIVE MARCH 7, 2003, THE AGENCY ASSIGNED A CONDITIONAL LICENSURE STATUS TO MARINER BASED UPON THE DETERMINATION THAT MARINER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE CLASS | DEFICIENCY AT THE MOST RECENT SURVEY OF MARCH 4-7, 2003. 42 C.F.R. § 483.25(h)(1); Rule 59A-4.1288, Fla. Admin. Code (2002) Rule 59A-4.133(16)(d), Fla. Admin. Code (2002) § 400.23(7), Fla. Stat. (2002) 9. The Agency realleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. On or about March 4-7, 2003, the Agency performed a survey at MARINER. The Agency cited MARINER for a pattern class one deficiency based on the findings below. 11. MARINER failed to ensure that the resident environment remained as free of accident hazards as possible by failing to ensure that the temperature of hot water supplied to residents in lavatories, showers, and baths was within a safe temperature range (i.e., between 105 and 115 degrees Fahrenheit). 12. On or about March 4, 2003, an Agency surveyor observed and documented hot water temperatures using a calibrated thermometer. Jun-11-2002 07:38am From-MARINER POST ACUTE NETWORK +6784436778 7-544 PF 020/038 = F-556 13. On or about March 4, 2003, at about 10:00 a.m., an Agency surveyor recorded the following hot water temperatures in resident rooms: Room 117: 132° F at 9:40 a.m. and 126° F at 9:55 a.m. Room 112: 118° F Room 119: 118° F Room 121: 118° F Room 202: 122°F Room 204: 118° F Room 104: 122° F Room 105: 122° F Room 107: 124° F 14. On or about March 4, 2003, at about 10:00 a.m., an Agency surveyor recorded the hot water temperatures in the East wing shower room. The hot water temperature in the shower was 118 degrees Fahrenheit and the hot water temperature in the sink was 126 degrees Fahrenheit. 15, On or about March 4, 2003, at about 11:10 a.m., an Agency surveyor interviewed MARINER'S Maintenance Director. The interview revealed that MARINER recently purchased an electronic thermometer to document the water temperatures in the facility. The Maintenance Director and the Agency surveyor used the facility's electronic thermometer and the Agency surveyor's calibrated thermometer, respectively, to measure the hot water temperature in room 107. The Agency's calibrated thermometer showed a temperature of 120 degrees Fahrenheit. MARINER'S electronic thermometer showed a temperature of 113 degrees Fahrenheit, The Maintenance Director also measured the hot water with a non-electronic thermometer and the reading was 122 degrees Fahrenheit. After the temperature readings, the Maintenance Director told the Agency surveyor that the facility would no longer use the electronic thermometer to measure hot water temperatures. Jun-t+2003 07:39am From-MARINER POST ACUTE NETWORK +6784436778 T-544 PP 021/038 = F+556 16. On or about March 5, 2003, at approximately 8:30 a.m., an Agency surveyor interviewed Resident #1 who resided in the East wing. The resident said the water was extremely hot. 17. During the survey, MARINER'S Maintenance Director reduced the thermostat on the hot water heater but it did not solve the hot water problem. MARINER therefore shut off the water until the problem could be fixed. 48. On or about March 5, 2003, MARINER'S Maintained Director told the Agency surveyor that the hot water problem was due to a mixing valve which was open and mixing the laundry room/kitchen hot water at 140 degrees Fahrenheit with the water supplied to the residents’ rooms. 149. On or about March 5, 2003, at about 7:45 a.m., the Agency surveyors recorded hot water temperatures and all were within the standard range of 105 to 115 degrees Fahrenheit. 20. Based on the foregoing, MARINER violated: (a) 42 CFR § 483.25(h)(1) Via Rule 59A-4.1288, Florida Administrative Code, by failing to ensure that the resident environment remains as free of accident hazards as is possible; or (b) Rule S9A- 4.133(16), Florida Administrative Code, by failing to ensure that the temperature of hot water supplied to resident use lavatories, showers, and baths was between 105 degrees Fahrenheit and 115 degrees Fahrenheit. 21. The foregoing violation is a class one deficiency because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class | violation shall be abated or eliminated immediately. § 400.23(8)(a), F.S. (2002) wn Jun-11-2003 07:39am From-MARINER POST ACUTE NETHORK +6784436778 1-544? 022/038 = F-556 22. Section 400.23(7), Florida Statutes, provides in pertinent part the following: (7) 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 licensure status of standard or conditional to each nursing home. (a) A standard licensure status means that a facility has no class | or class !I deficiencies and has corrected all class II deficiencies within the time established by the agency. (b) A conditional licensure status means that a facility, due to the presence of one or more class | or class Il deficiencies, or class JI] deficiencies not corrected within the time established by the agency, is nat in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class |, class II, or class II! deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. 23. Pursuant to Section 400.23(7), Florida Statutes, the Agency assigned a conditional licensure status to MARINER based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of one class | deficiency at the most recent survey on or about March 4-7, 2002. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency on Count I; 2) Uphold the assignment of a conditional licensure status to MARINER for the time period March 7 to April 14, 2003: AND 3) Assess costs against MARINER related to the investigation and prosecution of the case. Jun-}1-2003 67:40am From-MARINER POST ACUTE NETWORK +6784436778 T-544 9-7 023/038 = F556 MARINER hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights form (two pages) and explained in the attached Explanation of Rights form (one page). All requests for hearing shall be made to the Agency, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308; Attention: Lealand McCharen, Agency Clerk. MARINER 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 THE AGENCY. THE REQUEST FOR HEARING MUST BE RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) DAYS FOLLOWING MARINER’S RECEIPT OF THE ADMINISTRATIVE COMPLAINT. Respectfully submitted, AA C. Qeorerl Lori C. Desnick, Esq. Assistant General Counsel Florida Bar No. 129542 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 922-8854 Fax: (850) 921-0158 dun-11-2003 07:40am From-MARINER POST ACUTE NETWORK +6784436778 7-544 P (024/038 = -F~556 CERTIFICATE OF SERVICE | HEREBY CERTIFY that one original Administrative Complaint and the original Conditional License has been served via Certified Mail, Return Receipt Requested, (return receipt #7001 0360 0003 3804 4032_)to Rebecca Tepper, Administrator, Mariner Health Care of Macclenny, Inc., d/b/a Mariner Health Care of Macclenny, 755 South Fifth Street, Macclenny, Florida 32063 and one original Administrative Complaint and a copy of the Conditional License has been served via Certified Mail, Return Receipt Requested, (return receipt # ?00) 0360 go03 3604 4049 i+) to CT. Corporation, Registered Agent for Mariner Health Care of Macclenny, Inc., d/b/a Mariner Health Care of Macclenny, 1200 South Pine Island Road, Plantation, Florida, 33324 on this 28th day of May 2003. Ax Co Qesvnele LORI C. DESNICK, ESQUIRE Jun-11-2003 07:40am From-MARINER POST ACUTE NETWORK +6784436778 T-544 -F 025/038 «= -F-556 EXHIBIT."A" Conditional License effective March 7 through July 31, 2003 (certificate #9990) Jun-t1-2003 07:40am From-MARINER POST ACUTE NETWORK 4678443677) T-544 FF 026/038 = F-556 “~ FUDRIDA AGENCY FOR HEALTH CARE ADMINSTRATION: . RHONDA MI. MEDOWS, MD, FAAFP, SECRETARY U Jy JEB BUSH, GOVERNOR : vs PH iy Wy "O93 MARINER HEALTH CARE OF MACCLENNY 755 SOUTH FIFTH STREET MACCLENNY, FL 32063 Dear Administrator: The attached license is being issued operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 LICENSE STATUS CHANGE TO CONDITIONAL Sincerely, yy, ency for Health Care Administration Division of Health Quality Assurance Enclosure cc: AHCA Area Office 04 Long Term Care Section file Medicaid Contract Management Certificate of Need Visir AHCA Online at 2727 Mahan Drive # Mail Stop #23 www fake state flus Taltahassze, FL. 32308

Docket for Case No: 03-002561