STATE OF FLORIDA a AGENCY FOR HEALTH CARE ADMINISTRATION * STATE OF FLORIDA, AGENCY FOR Al HEALTH CARE ADMINISTRATION, . Petitioner, AHCA NO.: 2003007657 vs. 2003007973 NORTH OKALOOSA HEALTH CARE ASSOCIATES, d/b/a SHOAL CREEK REHABILITATION 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 NORTH OKALOOSA HEALTH CARE ASSOCIATES d/b/a SHOAL CREEK REHABILITATION CENTER, (“Shoal Creek Rehabilitation Center”), pursuant to Section 120.569, and 120.57, Florida Statutes (2003), alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Shoal Creek Rehabilitation Center, in the amount of One Thousand Dollars ($1,000) for one class III deficiency, pursuant to Section 400.23(8Xc), Fla. Stat. (2003), and Section 42 C.F.R. 483.10(b)(11). The Agency also intends to impose a conditional rating effective September 23, 2003, through November 30, 2003, pursuant to Section 400.23(7), Fla. Stat. (2003) case no. 2003007973. JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 3. Venue lies in Okaloosa County, Crestview, Florida, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 59A4, Florida Administrative Code (2003). 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 Il, Florida Statutes, (2003), and Chapter 59A-4 Florida Administrative Code. 5. Shoal Creek Rehabilitation Center is a for-profit corporation, whose 120- bed nursing home is located at 500 South Hospital Drive, Crestview, Florida. Shoal Creek Rehabilitation Center licensed as a skilled nursing facility license #SNF130471012; certificate number 9436, effective December 01, 2002 through November 30, 2003. Shoal Creek Rehabilitation Center was at all time material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I SHOAL CREEK REHABILITATION CENTER FAILED TO IMMEDIATELY NOTIFY THE PHYSICIANS OF 3 OF 5 SAMPLED RESIDENTS OF CHANGES IN CONDITION, AN ACCIDENT INVOLVING INJURY AND A DECISION TO TRANSFER A RESIDENT FROM FACILITY FOR EMERGENCY EVALUATION AND TREATMENT (#1, 3, 5). FEDERAL TAG F157- NOTIFICATION OF RIGHTS AND SERVICES Section 42 C.F.R 483.10 (b)(11) NOTIFICATION OF RIGHTS AND SERVICES 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7 On or about September 23, 2003, AHCA conducted a follow-up to a complaint investigation at Shoal Creek Rehabilitation Center. AHCA cited the facility based on the findings below, to wit: a.) On or about August 18, 2003, Shoal Creek Rehabilitation Center failed to inform the resident, consult with the physician and notify the resident’s legal representative of the significant change in resident #1 behavior and notify the resident’s legal representative of the resident’s discharge for 1 of 4 sampled residents. b.) During a follow-up visit on or about September 23, 2003, Shoal Rehabilitation Center failed to immediately notify the physicians of 3 of 5 sampled residents of change in condition, an accident involving injury and a decision to transfer a resident from facility for emergency evaluation and treatment (#1, 3, 5). 8. The above constitutes a violation of Section 42 C.F.R 483.11(b), requiring that a facility must immediate inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is a significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 9. The violation above constitutes a violation of Section 59A-4.1288, Florida Administrative Code (2003), which requesting that nursing homes that participate in Title XVHI 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. 9. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this administrative complaint. 2. Imposed a fine in the amount of $1.000. 10. The above constitutes a violation of Section 400.23(8)(c), Fla. Stat. (2003), requiring that a class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or 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 $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. Respondent is notified that they have a right to request an administrative hearing pursuant to 120.57, Florida Statutes (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, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael Mathis, Senior Attorney. RESPONDENT JS 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. Florida. Fla. Bar. No. 0325570 Counsel for Petitioner, Agency for HealthCare Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0055 (office) (850) 413-9313 (fax) Barbara Alford Lealand McCharen Agency for Health Care Administration CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served (3! day of Vprenba.. 2003 to: Daniel W. Healy, by certified mail on __ (3° Administrator, Shoal Creek Rehabilitation Center, 500 South Hospital Drive, Crestview, Florida 32539. Copies furnished to: David W. Healy, Administrator Shoal Creek Rehabilitation Center 500 South Hospital Drive Crestview, Florida 32539 Agency for Health Care Administration Finance & Accounting Department P.O. Box 13749 Tallahassee, Florida 32317-3749 wt aber Michael O. Mathis, Esq. Barbara Alford Area Office #2 Supervisor Agency for Health Care Administration Division of Managed Care & Health Quality 2727 Mahan Drive, Bldg# 3 Tallahassee, Florida 32308

Docket for Case No: 04-000021