STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2003008447 2003007503 PINELLAS PARK NURSING HOME, INC., d/b/a INTEGRATED HEALTH SERVICES OF PINELLAS PARK Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against PINELLAS PARK NURSING HOME, INC., d/b/a INTEGRATED HEALTH SERVICES OF PINELLAS PARK, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2002), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, in the amount of thirty-six thousand dollars ($36,000) pursuant to Sections 400.102(1) (a) and (d), 400.19 and 400.23(8) (a), Florida Statutes (2002) [AHCA Case No. 2003007503]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2002) [AHCA Case No. 2003008447]. 3. The Respondent was cited for the deficiencies set forth below as a result of a complaint survey conducted on September 24, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2002). 4. Venue lies in Pinellas County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2002), and Chapter 28-106, Florida Administrative Code (2002). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle c (as amended) ; Chapter 400, Part II, Florida Statutes (2002), and; Chapter 59A-4, Fla. Admin. Code (2002), respectively. 6. Respondent is a nursing facility located at 8701 - 49th Street North, Pinellas Park, FL 33782. Respondent is licensed to operate a skilled nursing facility pursuant to license HSNF1085096. At all relevant times, Respondent was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO ENSURE THAT ALL ALLEGED VIOLATIONS INVOLVING MISTREATMENT, NEGLECT, OR ABUSE, INCLUDING INJURIES OF UNKNOWN SOURCE, ARE REPORTED IMMEDIATELY TO THE ADMINISTRATOR OF THE FACILITY AND TO OTHER OFFICIALS IN ACCORDANCE WITH STATE LAW THROUGH ESTABLISHED PROCEDURES (INCLUDING TO THE STATE SURVEY AND CERTIFICATION AGENCY) . 42 CFR 483.13(c) (2) (2002), INCORPORATING BY REFERENCE Fla. Admin. Code R. 59A-4.1288(2002) CLASS I DEFICIENCY WIDESPREAD 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about September 24, 2003, AHCA conducted a complaint survey at Respondent’s facility. 9. Based on observation, interviews, and record review, Respondent failed to immediately report a suspected incidence of sexual abuse to the administrator of the facility, and other officials, including but not limited to, the local law enforcement agency, the State protective services agency, and the State survey and certification agency. Respondent also failed to thoroughly investigate the suspected incidence of sexual abuse for one of one residents (#1) who was found to have injury/bruising to the genitalia, thereby placing all 103 residents at risk and resulting in findings of Immediate Jeopardy to resident safety. Findings: Per interview with the Director of Nursing (DON) on September 24, 2003, at 12:55 p.m., and an interview on September 24, 2003, at 2:10 p.m., with the certified nurse's assistant (CNA) who provided care, the CNA "noticed" bruising to the pubic area of Resident #1 while providing incontinence care after the evening meal on September 18, 2003, at approximately 7:15 p.m. The CNA stated that she had been caring for the resident since 7:00 a.m. on September 18, 2003 and did not observe the bruising when showering the resident that morning, nor when she provided incontinence care earlier that afternoon. The CNA further stated that she immediately reported her observations to the licensed practical nurse (LPN) who was assigned to care for this resident and asked the LPN to "come see" the resident's injuries. The LPN refused the CNA's request. The CNA then sought the assistance of the nursing supervisor (NS) on duty who is also a licensed practical nurse. In an interview on September 24, 2003, at 2:10 p.m., this NS stated that she accompanied the CNA to observe the injuries sustained by Resident #1 on the evening of September 18, 2003. The NS noted the bruising at the resident's pubic area and determined that there was no bleeding or other apparent injuries. The NS did not document her findings or actions in the resident's clinical record, but stated that she completed an incident report and left a message on the attending physician's answering machine. The NS stated that she did not contact the facility administrator nor any other management staff member at that time, nor did she report the injury to local law enforcement, or the "abuse hotline" because she felt that the resident might have inflicted the injury upon herself by "rubbing" the area. Per Appendix Q of the State Operations Manual (SOM) for Long Term Care facilities, which was cited in an in-service on Abuse Prohibition given to staff by the facility on September 2, 2003, one of the signs/symptoms of sexual abuse is “bruises around the breasts or genital area". Per the facility's policy and procedure (undated) on Abuse Prohibition, the in-service given on abuse prohibition on September 2, 2003, “real or alleged” abuse is reported immediately to the administrator or nursing supervisor". Additionally, all facility employees sign an "Abuse Acknowledgement" form in which they acknowledge their understanding that it is mandatory that suspected abuse, neglect and exploitation of an aged or disabled adult must be reported to the "central abuse registry” (abuse hotline) as per Chapter 415.103-1(a)(4), F.S. In an interview with the DON (who also serves as the facility's risk manager) on September 24, 2003, at 12:55 p.m., and in an interview with the Unit Manager (UM), who is a registered nurse (RN), on Scptember 24, 2003, at 2:10 p.m., it was revealed that after having been made aware of the incident report completed on the previous evening, the DON and UM assessed the injuries of Resident #1 on September 19, 2003, at 9:20 a.m. The UM described the injuries as "dark blue bruising" at the left pubic area and left groin. The UM also noted "redness and swelling" of the labia, but that the resident was not in pain. The UM stated they did not call the resident's attending physician at that time, nor did they report their findings to local law enforcement, the State protective services agency, or the State survey and certification agency. The DON stated they thought that perhaps the resident's incontinence briefs were "too tight", but did not suspect possible sexual abuse, despite the nature and location of the resident's injury, nor was there evidence that the facility initiated an internal investigation into the cause of the resident's injury at that time. The DON and UM did not document their findings in the resident's clinical record at the time of their assessment, but rather in a late entry in the nurse's noted, dated September 22, 2003 at 9:00 a.m. (which was after the resident had been transferred to the hospital). In an interview on September 24, 2003, at 3:00 p.m., with the CNA who cared for the resident on September 19, 2003, during the 3:00 p.m. to 11:00 p.m. shift, and the "restorative’ CNA for that same shift, it was revealed that while both these CNA's were assisting each other in providing incontinence care to this resident, the restorative CNA noticed "purple" bruising on the resident’s pubic area and she insisted that the CNA report it to the nurse. During the interview, the CNA stated he did not remember seeing the bruising, but reported it to the nurse. Record review revealed that the 3:00 p.m. to 11:00 p.m. shift nurse on September 13, 2003 documented the resident's injuries at 7:15 p.m. as "Ecchymosis noted over anterior vaginal area. No cuts or trauma to tissue". This nurse also did not report the injuries to the facility administrator, local law enforcement, the State protective services agency, or the State survey and certification agency. Per nurse's notes dated September 21, 2003, interviews with the CNA and the weekend nursing supervisor (WNS), who is a registered nurse, on September 24, 2003, at 2:10 p.m., it was revealed that on September 21, 2003, at 10:45 a.m., while the CNA was providing "morning care" to Resident #1, she observed "dark deep purple" bruising at the pubic area "with green and yellow" bruising at the edges. The CNA stated that the resident, who does not often speak, began screaming "it hurts" while being turned, and the CNA noticed bruising inside the resident's labia and bruises "three inches" in size on both inner thighs. The CNA immediately notified her nurse, as she was unaware when the resident had sustained these injuries because "nothing had been documented”. In a nurse's note entry, dated September 21, 2003, at 10:30 a.m., the nurse caring for the resident documented assessing this resident's injuries after being called by the CNA. This entry notes that the resident had "bluish/purple - some yellow - bruising around vaginal area". The nurse immediately alerted the WNS and called the resident's attending physician at 10:50 a.m. to report the injuries observed on the resident's genitalia. During the interview, the WNS stated that she also observed the bruised pubic area with some yellowing of the bruise, and swelling, but did not know anything was noted before this and had the physician called, as while there had been no recent falls or accidents. She was concemed there could be a possible fracture. The nurse received orders to medicate the resident for pain and to send the resident to the hospital via 911 for evaluation. The nurse noted she notified the resident's family at 11:00 a.m. and that the resident was transferred to the hospital by emergency medical services (EMS) at 11:20 a.m. Review of the EMS patient care report, dated September 21, 2003, notes that EMS received a call from the facility on September 21, 2003 at 11:17 a.m. and arrived on scene at 11:22 a.m. and that the "patient had vaginal bruising since Thursday (September 18, 2003) that was noticed by facility staff’. EMS noted “severe bruising in suprapubic region" and that the patient's condition had been charted by facility staff, "however, not reported to police department". EMS documents that they notified authorities of a "possible" sexual assault. During the interview on September 24, 2003, at 2:10 p.m., the CNA who cared for the resident on September 21, 2003 confirmed that the "paramedics called law enforcement" and that when the DON arrived at the facility on September 21, 2003, the CNA told her that "something happened to this resident" and that she didn't think that the resident's "rubbing" would have caused the bruising. Resident #1 was observed at the hospital at 10:40 a.m. on September 24, 2003 at 10:40 a.m. The charge nurse uncovered the resident and revealed severe bruising, dark blue to yellow in color, that covered most of the mons pubis and labia. The labia was noted to be swollen. The charge nurse manually opened the labia to reveal a laceration, approximately 1 1/2 to 2 inches in length along the left labia minora. The charge nurse stated that Resident #1 was non-verbal, but during the vaginal examination, the resident moaned and yelled out "You're just playing with that"! It was noted that, upon examination by a gynecologist on September 26, 2003, in addition to external bruising and swelling, and a tear in the left labia minora, purulent discharge was observed in this resident's vagina. Per the gynecologist's consultation report, dated September 23, 2003, the professional opinion was that the resident experienced "some kind of traumatic event." While interviewing the DON on September 24, 2003, at 12:55 p.m. and 2:10 p.m., and the UM on September 24, 2003, at 2:10 p.m., several requests were made to the facility to provide evidence that they had initiated an investigation of the resident's injuries. No written documentation was produced, except for the incident report that the NS completed on September 18, 2003, after the initial discovery of the resident's bruised genitalia. The DON and UM explained that they felt that the bruising had to have been caused by the resident's self-inflicted tubbing (Note: There is no documentation in the clinical record of the resident's "rubbing" behavior. Further, it was noted during an observation of Resident #1 on September 24, 2003, at 10:40 a.m., that the resident’s hands are contracted) or perhaps by the use of a lift during transfers, although staff had not reported any falls or accidents involving Resident #1. The DON and UM also acknowledged that in "retrospect" the injuries to Resident #1 should have been reported immediately as mandated by State and Federal regulations, and the facility's policy and procedure on abuse prohibition. The DON stated that she conveyed her theories to the nurse-practitioner who had examined the resident at the hospital emergency room on behalf of law enforcement for possible sexual assault. The DON did not immediately pursue an internal investi gation of this resident's injuries, and stated her rationale was that the facility cooperated with law enforcement and the State protective services agency, and had been told that the nurse practitioner who examined the resident did not feel there was an indication of sexual battery, and therefore assumed the incident was resolved. 10. Respondent was provided a mandated correction date of September 27, 2003. 11. The above actions or inactions are a violation of Title 42, Code of Federal Regulations 483.13 (c) (2) (2002), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2002), which requires the facility to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 12. Pursuant to Section 400.23(8) (a), Florida Statutes (2002), the foregoing is a class I deficiency and as such, 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 I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the Agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 fora patterned deficiency, and $15,000 for a widespread Geficiency. 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 must be levied notwithstanding the correction of the deficiency. 13. A civil penalty is authorized and warranted in the amount of $15,000, as this violation constitutes a “widespread” Class I deficiency. 14. Pursuant to Section 400.23(7) (b), Florida Statutes (2002), the Agency is authorized to assign a conditional licensure status to Respondent’s facility. COUNT II RESPONDENT FAILED TO DEVELOP AND IMPLEMENT WRITTEN POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT, AND ABUSE OF RESIDENTS. SECTION 400.147, Fla. Stat. (2002), 42 CFR 483.13(c) (2002), INCORPORATING BY REFERENCE Fla. Admin. Code R. 59A-4.1288 (2002) CLASS I DEFICIENCY WIDESPREAD 15. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 16. On or about September 24, 2003, AHCA conducted a complaint survey at Respondent’s facility. 17. Based on observation, interviews and record review, Respondent failed to implement abuse prohibition policies and procedures for the components of reporting/response and investigation for one of five sampled residents (#1) who was found to have injury/bruising to the genitalia, thereby placing all 103 residents at risk and resulting in findings of Immediate Jeopardy to resident safety. Findings: Resident #1 is an elderly adult who suffers from organic brain syndrome (dementia), per the admission record dated November 5, 2002. The care plan dated March 21, 2003 and updated September 9, 2003, documents that the resident usually has non-verbal responses, but will occasionally make needs known with "simple words.” Per an interview with the Director of Nursing (DON) on September 24, 2003, at 12:55 p.m., and an interview on September 24, 2003, at 2:10 p.m., with the certified nurse's assistant (CNA) who provided care on September 18, 2003, this CNA “noticed" bruising to the pubic area of Resident #1 while providing incontinence care after the evening meal on September 18, 2003, at approximately 7:15 p.m. The CNA stated that she had been caring for the resident since 7:00 a.m. on September 18, 2003 and did not observe the bruising when showering the resident that morning, nor when she provided incontinence care earlier that afternoon. The CNA further stated that she immediately reported her observations to the licensed practical nurse (LPN) who was assigned to care for this resident and asked the LPN to "come see" the resident's injuries. The LPN refused the CNA's request. The CNA then sought the assistance of the nursing supervisor (NS) on duty who is also a licensed practical nurse. In an interview on September 24, 2003, at 2:10 p.m., this NS stated that she accompanied the CNA to observe the injuries observed on Resident #1 on the evening of September 18, 2003. The NS noted the bruising at the resident's pubic area and determined that there was no bleeding or other apparent injuries. The NS did not document her findings or actions in the resident's clinical record, but stated that she completed an incident report and left a message on the attending physician's answering machine. Physician's progress notes at the hospital, dated September 21, 2003, at 3:34 p.m., indicate that the physician was first notified on September 21, 2003. The NS stated that she did not contact the facility administrator nor any other management staff member at that time, nor did she report the injury to local law enforcement, or the "abuse hotline" because she felt that the resident might have inflicted the injury upon herself by "rubbing" the area. Per Appendix Q of the State Operations Manual (SOM) for Long Term Care facilities, which was cited in an in-service on Abuse Prohibition given to staff by the facility on September 2, 2003, one of the signs/symptoms of sexual abuse is "bruises around the breasts or genital area". Per the facility's policy and procedure (undated) on Abuse Prohibition, and the in-service given on abuse prohibition on September 2, 2003, "real or alleged” abuse is reported immediately to the administrator or nursing supervisor". Additionally, all facility employees sign an "Abuse Acknowledgement" form in which they acknowledge their understanding that it is mandatory that suspected abuse, neglect and exploitation of an aged or disabled adult must be reported to the "central abuse registry" (abuse hotline) as per Chapter 415.103-1(a)(4), F.S. In an interview with the DON (who also serves as the facility's risk manager) on September 24, 2003, at 12:55 p.m., and in an interview with the Unit Manager (UM), who is a registered nurse (RN) on September 24, 2003, at 2:10 p.m., it was revealed that after having been made aware of the incident report completed on the previous evening, the DON and UM assessed the injuries of Resident #1 on September 19, 2003 at 9:20 a.m. The UM described the injuries as "dark blue bruising" at the left pubic area and left groin. The UM also noted "redness and swelling" of the labia, but that the resident was not in pain. The UM stated they did not call the resident's attending physician at that time, nor did they report their findings to local law enforcement, the State protective services agency, or the State survey and certification agency. The DON stated they thought that perhaps the resident's incontinence briefs were "too tight” but did not suspect possible sexual abuse, despite the nature and location of the resident's injury, nor was there evidence that the facility initiated an internal investigation into the cause of the resident's injury at that time. The DON and UM did not document their findings in the resident's clinical record at the time of their assessment, but rather in a late entry in the nurse's note, dated September 22, 2003 at 9:00 a.m. (which was after the resident had been transferred to the hospital). Review of the facility's abuse prohibition policy and procedure (undated) states on Page 4 of 6 pages that the facility is to report incidents to the appropriate ancillary agencies and investigate incidents. That the responsible staff member is to interview residents and staff, document all interviews, including those with ancillary agencies, and that there is to be evidence that all incidents have been thoroughly investigated. In an interview on September 24, 2003, at 3:00 p.m., with the CNA who cared for the resident on September 19, 2003 during the 3:00 p.m. to 11:00 p.m. shift, and the “restorative” CNA for that same shift, it was revealed that while both these CNA's were assisting each other in providing incontinence care to this resident, the restorative CNA noticed "purple" bruising on the resident’s pubic area and she insisted that the CNA report it to the nurse. During the interview, the CNA stated he did not remember seeing the bruising, but reported it to the nurse. Record review revealed that the 3:00 p.m. to 11:00 p.m. shift nurse on September 19, 2003 documented the resident's injuries at 7:15 p.m. as "Ecchymosis noted over anterior vaginal area. No cuts or trauma to tissue". The nurse also did not report the injuries to the facility administrator, local law enforcement, the State protective services agency, or the State survey and certification agency. Per nurse's notes, September 21, 2003, interviews with the CNA and the weekend nursing supervisor (WNS), who is a registered nurse, on September 24, 2003, at 2:10 p.m., it was revealed that on September 21, 2003, at 10:45 a.m., while the CNA was providing "morning care" to Resident #1, she observed "dark deep purple” bruising at the pubic area "with green and yellow" bruising at the edges, The CNA stated that the resident, who does not often speak, began screaming "it hurts" while being turned, and the CNA noticed bruising inside the resident's labia and bruises "three inches" in size on both inner thighs. The CNA immediately notified the nurse, as she was unaware when the resident had sustained these injuries because “nothing had been documented". In a nurse's note entry dated September 21, 2003, at 10:30 a.m., the nurse caring for this resident documented assessing this resident's injuries after being called by the CNA. This entry notes that the resident had "bluish/purple - some yellow - bruising around vaginal area." The nurse immediately alerted the WNS and called the resident's attending physician at 10:50 a.m. to report the injuries observed on the resident's genitalia. During the interview, the WNS stated that she also observed the bruised pubic area with some yellowing of the bruise, and swelling, but did not know anything was noted before this and had the physician called, as there had been no recent falls or accidents. She was concerned there could be a possible fracture. The nurse received orders to medicate the resident for pain and to send the resident to the hospital via 911 for evaluation. The nurse noted she notified the resident's family at 11:00 a.m. and that the resident was transferred to the hospital by emergency medical services (EMS) at 11:20 a.m. Review of the EMS patient care report, dated September 21, 2003, notes that EMS received a call from the facility on September 21, 2003, at 11:17 a.m., and arrived on scene at 11:22 a.m. and that the "patient had vaginal bruising since Thursday (September 18, 2003) that was noticed by facility staff". EMS noted "severe bruising in suprapubic region” and that the patient's condition had been charted by facility staff, "however, not reported to police department". EMS documents that they notified authorities of a "possible" sexual assault. During the interview on September 24, 2003, at 2:10 p.m., the CNA who cared for the resident on September 21, 2003, confirmed that the "paramedics called law enforcement" and that when the DON arrived at the facility on September 21, 2003, the CNA told her that "something happened to this resident” and that she didn't think that the resident's "rubbing" would have caused the bruising”. Resident #1 was observed at the hospital on September 24, 2003 at 10:40 a.m. The charge nurse uncovered the resident and revealed severe bruising, dark blue to yellow in color, that covered most of the mons pubis and labia. The labia was noted to be swollen. The charge nurse manually opened the labia to reveal a laceration, approximately 1 1/2 to 2 inches in length along the left labia minora. There was also bruising on both inner thighs, from the top of the thigh to approximately 3 inches above the knee. The charge nurse stated that Resident #1 was non-verbal, but during the vaginal examination, the resident moaned and yelled out "You're just playing with that"! It was noted that upon examination by a gynecologist, on September 23, 2003, that purulent discharge was observed in this resident's vagina. While interviewing the DON on September 24, 2003, at 12:55 p.m. and 2:10 p.m., and the UM on September 24, 2003, at 2:10 p.m., several requests were made to the facility to provide evidence that they had initiated an investigation of this resident's injuries. No written documentation was produced, except for the incident report that the NS completed on September 18, 2003, after the initial discovery of the resident's bruised genitalia. The DON and UM explained that they felt that the bruising had to have been caused by the resident's self-inflicted tubbing (Note: There is no documentation in the clinical record of the resident's "rubbing" behavior. Further, it was noted during an observation of Resident #1 on September 24, 2003, at 10:40 a.m., that the resident’s hands are contracted), The DON thought the injury may have been caused by the use of a lift during transfer, although staff had not reported any falls or accidents involving Resident #1. The DON and UM also acknowledged that in "retrospect," the injuries to Resident #1 should have been reported immediately as mandated by State and Federal regulations, and the facility's policy and procedure on abuse prohibition. The DON stated that she conveyed her theories to the nurse-practitioner who had examined the resident at the hospital emergency room on behalf of law enforcement for possible sexual assault. The DON did not immediately pursue an internal investigation of this resident's injuries, and stated her rationale was that the facility cooperated with law enforcement and the State protective services agency, and had been told that the nurse practitioner who examined the resident did not feel there was an indication of sexual battery, and therefore, assumed the incident was resolved. During the investigation on September 24, 2003, at 6:00 p.m., the facility began re-in-servicing all staff on abuse prohibition, including facility policies and procedures, reporting responsibilities, supervision of residents, and identification of visitors to the facility. Additionally, the facility began assessing all residents for scratches, skin tears, bruises or swelling and stated that any findings not previously reported would be reported and investigated. 18. Respondent was provided a mandated correction date of September 27, 2003. 19. The above actions or inactions are a violation of Title 42, Code of Federal Regulations 483.13(c) (2002), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2002), which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents. 20. Pursuant to Section 400.23(8) (a), Florida Statutes (2002), the foregoing is a class I deficiency and as such, has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care ina facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the Agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last 13 annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 21. A civil penalty is authorized and warranted in the amount of $15,000, as this violation constitutes a “widespread” Class I deficiency. 22. Pursuant to Section 400.23(7) (b), Florida Statutes (2002), the Agency ig authorized to assign a conditional licensure status to Respondent’s facility. 23. Pursuant to Section 400.19(3), Plorida Statutes (2002), the agency shall assess a one-time fine, in the amount of $6,000, for each facility that is subject to the six-month survey cycle. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $30,000 civil penalty against Respondent ; c. Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2002); d. Assess the fine for the six-month survey cycle, pursuant to Section 400.19, Florida Statutes (2002); e. Uphold the conditional licensure status pursuant to Section 400.23(7) (b) (2003); and £. Grant any other general and equitable relief as deemed appropriate. NOTICE The Respondent is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2002). 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 attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Pictu D. 21D) Esquir , AHCA, Senior Attorney Fla. Bar. No. 0277200 Counsel for Petitioner 525-Mirror Lake Dr. N., #330G St. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail Return Receipt No. 7003 1010 0003 0279 3693, to National Corporate Research LTD, Inc., Registered Agent for IHS of Pinellas Park, 103 N. Meridian Street, Tallahassee, FL 32301, dated on December Lak 2003. Katrina D. Lacy, Esq Copies furnished to: National Corp Research, LTD, Inc. Registered Agent for IHS of Pinellas Park 103 N. Meridian Street Tallahassee, FL 32301 (U.S. Certified Mail) Kimberly Morrow, Administrator IHS of Pinellas Park 8701 - 49°® Street North Pinellas Park, FL 33782 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701 LICENSE #: SNF1085096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE SKILLED NURSING FACILITY CONDITIONAL This is to confirm that PINELLAS PARK NURSING HOME > of Florida, Agency For Health Care Administration, authorized in Cha ? authorized to operate the following: INTEGRATED HEALTH SERVICES OF PINELLAS PARK 8701 49TH STREET NORTH PINELLAS PARK, FL 33782 TOTAL: 120 BEDS Status Change ACTION EFFECTIVE DATE: 09/24/2003 LICENSE EXPIRATION DATE: 08/31/2004

Docket for Case No: 04-000383