OF- 0886 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA 4 AGENCY FOR HEALTH ADM| ISiON Us CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 2003008611 QUALITY NURSING HOME MANAGEMENT, LLC, d/b/a CROSS TERRACE REHABILITATION CENTER Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against QUALITY NURSING HOME MANAGEMENT, LLC, d/b/a CROSS TERRACE REHABILITTION CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on Respondent in the amount of five thousand dollars ($5,000) pursuant to Sections 400.23(8) (c), and 400.102(1) (a) Florida Statutes 2. The Respondent was cited for the deficiencies during the Annual and Life Safety Survey conducted on or about October 31, 2003. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4, Venue lies in Pinellas County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 1351 San Christopher Drive, Dunedin, Florida, 34698. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO OBTAIN PRIOR APPROVAL FROM AHCA PLANS AND CONSTRUCTION FOR A MODIFICATION, VIOLATING Fla. Admin. Code R. Rule 59A-4.133(2), 59A-4.133 (4) WIDESPREAD CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. An annual and life safety survey was conducted on October 31, 2003. 9. On that date, based on observation and interviews, the facility installed a touch-pad door locking system without prior approval from the AHCA Office of Plans and Construction. 10. A Class III widespread deficiency was cited against Respondent based on the findings below: During the entrance conference with the administrator on 10/28/03 at 7:45 a.m., it was revealed that all the doors to the facility were locked electronically to everyone exiting the facility and only employees had the code to unlock the doors. There was no evidence that the facility communicated the change in the modification to the building to receive the Agency’s approval required by the Florida Administrative Code. 11. This observation was cited as a widespread, State Class III deficiency and was to be corrected by December 1, 2003. 12. This is a violation of 59A-4.133(2) and 59A-4.133(4), Florida Administrative Code, which requires all contemplated additions, conversions, renovations, or alterations affecting the structural integrity, life or fire safety, or use of space of existing buildings shall be submitted in accordance with the requirements of Rule 59A-4.133(4) for approval or exemption from the plans review process. 13. The Agency seeks to impose an administrative fine in the amount of five thousand dollars ($5,000), based on one widespread Class III deficiency as authorized under Sections 400.23(8) (c) and 400.102({1) (a) Florida Statutes. CLAIM FOR RELIEF 0 bom, £ Biagucnd? WHEREFORE, AHCA requests this Court to order the Mag A olin: 4 be 2 HHS iy. "0 relief: A. Make factual and legal findings in favor of MapAR Wi ge on Count I; B. Impose an administrative fine of five thousand dollars ($5,000) for the violation cited in Count I against the Respondent under 59A-4.133(2) and 59A-4.133(4), Florida Administrative Code; Cc. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2002); and D. All other general and equitable relief allowed by law. NOTICE The Respondent is notified that it has a right to request an Administrative Hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election 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 Uf De submitted, Myo en O’ liye b Leg Mt fo lila en AHCA - Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (Fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been furnished to K.C. Cross, Registered Agent, Cross Terrace Rehabilitation Center, 440 Phippen Road, Dania, Florida, 33004, by U.S. Certified Mail, Return Receipt No. 7003 1010 0003 4303 8197,and to Patricia D. Angell, Administrator, Cross Terrace Rehabilitation Center, 1351 San Christopher Drive, Dunedin, Florida, 34698 on January / , 2004. Lily dA Copies furnished to: digg hi te li Set en O’ Hard’Ga Patricia D. Angell Administrator Cross Terrace Rehab Center 1351 San Christopher Dr. Dunedin, Florida 34698 (U.S. Mail) K.C. Cross Registered Agent Cross Terrace Rehab Center 440 Phippen Road Dania, Fl. 33004 (U.S. Certified Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330D St. Petersburg, (Interoffice) Fl 33701

Docket for Case No: 04-000526