Certified Mail Receipt 7001 0360 0003 3804 7328, “4, ON go Os STATE OF FLORIDA Ot, “7 ~*~) AGENCY FOR HEALTH CARE ADMINISTRATION Hy “yy A “ing py Ors ° Qo STATE OF FLORIDA, AGENCY FOR > toe, ‘es HEALTH CARE ADMINISTRATION, 03-47» o AHCA NO: 2003007398 Petitioner, 2003007520 v. MADISON HEALTH INVESTORS LLC d/b/a LAKE PARK OF MADISON, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA’), by and through the undersigned counsel, and files this Administrative Complaint against Madison Health Investors LLC d/b/a Lake Park of Madison, (“hereinafter “Lake Park of Madison”), 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 Lake Park of Madison, pursuant to Section 400.23(8)(b), Fla. Stat. (2002), 42 CFR 483.25{j), and Section 59A-4.1288, Florida Administrative Code (2002). The Agency also intends to impose a conditional rating effective September 17, 2003 through August 31, 2004, pursuant to Section 400.23(7), Fla. Stat. (2002) case no. 2003007520. JURISDICTION AND VENUE 2. This count has jurisdiction pursuant to Sections 120.569 . and 120.57, Florida Statutes, (2002). 3. Venue lies in Escambia County, Madison, 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 I, Florida Statutes, (2002), and Chapter 59A-4 Florida Administrative Code. 5. Lake Park of Madison, Inc. is a for-profit Florida corporation, Whose 120-bed nursing home is located at 1900 Country Club Drive, Madison, Florida. Lake Park of Madison is licensed as a skilled nursing facility license #SNF16360961; certification number 8921 effective 9/17/2003 through 8/31/2003. Lake Park of Madison 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 LAKE PARK OF MADISON FAILED TO MAINTAIN APPROPRIATE HYDRATION AS INDICATED IN RESIDENT CARE PLANS FOR 2 OF 6 SAMPLED RESIDENTS. DUE TO THE FACILITY’S LACK OF PROVIDING SUFFICIENT FLUIDS, RESIDENT #6 HAD BEEN DIAGNOSED AS BEING DEHYDRATED AND RESIDENT #1 HAD BEEN DIAGNOSED WITH MULTIPLE URINARY TRACT INFECTIONS AND FECAL IMPACTIONS, WHICH ARE INDICATIVE OF POSSIBLE DEHYDRATION. FEDERAL TAG F327-Quality of Care Section 42 C.F.R. 483.25(J) Section 59A-4.1288, Florida Administrative Code (2002) 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about September 16, 2003, AHCA conducted a complaint investigation at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) During a complaint investigation on or about September 16, 2003, Lake Park of Madison failed to maintain appropriate hydration as indicated in resident care plans for 2 of 6 sampled residents. Due to the facility’s lack of providing sufficient fluids resident #6 had been diagnosed as being dehydrated and resident #1 had been diagnosed with multiple urinary tract infections and fecal impactions, which are indicative of possible dehydration. 8. The above constitutes a violation of Section 42 C.F.R. 483.25(j}, requiring that the facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. @ @ 9. The violation alleged herein constitutes a class II deficiency, and warrants a fine of $2,500. 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 $2,500. The above constitutes a violation of Section 59A-4.1288, Florida Administrative Code (2002) requiring that nursing homes that participate in Tile 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(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 highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of @ e 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 II 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 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 licensure 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, MS #3, 2727 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. ceca tse 9° day ot Dporn Respectfully submitted this _3 day of bye GF™~_, 2003. Michael O. Mathis Fla. Bar. No. 0325570 Counsel for Petitioner, Agency for HealthCare Administration Bldg. 3, MSC#3 2727 Mahan Drive Tallahassee, FL 32308 (850) 921-0055 (office) (850) 921-0158 (fax) Barbara Alford Lealand McCharen Agency for Health Care Administration CERTIFICATE OF SERVICE I HEREBY CERTIFIY that a true and correct copy of the foregoing has been served by certified mail on ark day of Mov ? ther , 2003 to: Marlane Kay Williams, Administrator, Lake Park of Madison, 1900 Country Club Road, Madison, Florida 32340. uhrawtives— Michael O. Mathis, Esq.

Docket for Case No: 03-004686