STATE OF FLORIDA ean AGENCY FOR HEALTH CARE ADMINISTRATION App ae Tog P ° Fy AGENCY FOR HEALTH CARE anly 405 ADMINISTRATION, is Petitioner, "Reb ee vs. Case No. 2004000725 2004000158 CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE 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 CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, in the amount of six thousand dollars ($6,000) pursuant to Sections 400.102(1) (a) and (d), and 400.23(8) (c), Florida Statutes (2003) [AHCA Case No. 2004000158]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2003) [AHCA Case No. 2004000725]. 3. The Respondent was cited for the deficiencies set forth below as a result of a complaint survey conducted on or about December 18, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2003). 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28-106, Florida Administrative Code (2003). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for the 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 (2003), and; Chapter 59A-4, Fla. Admin. Code (2003), respectively. 6. Respondent is a nursing facility located at 7173 Cypress Drive Southwest, Fort Myers, FL 33907. Respondent is licensed to operate a skilled nursing facility pursuant to license #SNF11160961. 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 PROVIDE A SAFE, FUNCTIONAL SANITARY AND COMFORTABLE ENVIRONMENT FOR RESIDENTS, STAFF AND THE PUBLIC. 42 CFR 483.70(h) (2003), INCORPORATING BY REFERENCE Fla. Admin. Code R. 59A-4.1288(2003) CLASS III DEFICIENCY UNCORRECTED 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about November 6, 2003, AHCA conducted a survey at Respondent’s facility. 9. Based on observations made during tour of the facility between 1:00PM and 4:30PM, it was determined that the facility failed to maintain a sanitary and comfortable environment for the residents. Findings: The air conditioning supply vents in resident rooms (307, 305, 301, 303, 121, 113 and 111) were dripping water. The corridor air conditioning supply vents near the courtyard entrance, central supply, the laundry, resident Room 211 and both vents in the activities room were dripping water. Soiled air conditioning supply and return vents were pervasive throughout the facility. Interview with the staff revealed that there are multiple roof leaks in response to the observation of small wet spots on ceiling tiles in various locations, including one resident room (Rm. 111). Supply air vent temperatures were taken, which revealed that the supply air to the common areas of the facility ranged from 57 degrees Fahrenheit to 78 degrees Fahrenheit, which supported the noticeable change in temperature to the surveyor from one area to another. Mold was observed in the activities room on the wall common to the corridor. Further investigation revealed that the wall was wet and had paint peeling from it. Inspection of the ductwork revealed that the duct above the lay-in ceiling was all wet and condensated. Mold was also observed in resident Room 303 on the vent, in the duct and in resident Room 111 on the ceiling tile. 10. Respondent was provided a mandated correction date of December 6, 2003. 41. On or about December 18, 2003, a survey was conducted at Respondent’s facility. 12. Based on observation, Respondent failed to maintain a sanitary and comfortable environment for the residents. Findings: Interview with the staff on November 6, 2003 revealed that there are multiple roof leaks in response to the observation of small wet spots on ceiling tiles in various locations including one resident room 111. This issue was left unaddressed, and considered not corrected. Mold was observed in the activities room on the wall common to the corridor. Further investigation revealed that the wall was wet and had paint peeling from it. Inspection of the ductwork revealed that the duct above the lay-in ceiling was all wet and condensated. This was left unaddressed and determined to be uncorrected. The facility Directed Plan of Correction was written as follows: 1. A written determination and cause or causes for problems noted by a Florida Licensed Mechanical Engineer (P.E.), 2. Recommendations for remediation and correction of all findings, including damage caused by multiple roof leaks, 3. An HVAC Test & Balance report to validate corrections and criteria for certification of the system; and 4. A review of the scope of work performed submitted to AHCA Office of Plans and Construction Supervisor of Mechanical Engineering. Number one was addressed and numbers two, three, and four were not completed. The facility Administrator and Regional Director stated that they were at the mercy of contractors and could not complete the Directed Plan of Correction. The facility was granted one 10-day extension at their request. 13. The above actions or inactions are a violation of Title 42, Code of Federal Regulations 483.70(h) (2003), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2003), which requires the facility to provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. 14. Pursuant to Section 400.23(8)(c), Florida Statutes (2003), the foregoing is a class III deficiency and as such results 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 civil penalty is authorized and warranted in the amount of $3,000, as this violation constitutes a “widespread” Class III deficiency. 15. During the annual survey of May 19-22, 2003, Respondent was cited for Tags F324 and F490, Class I deficiencies. Therefore, pursuant to Section 400.23(8) (c), Florida Statutes (2003), the fine amount is doubled to $6,000. 16. Pursuant to Section 400.23(7) (b), Florida Statutes (2003), the Agency is authorized to assign a conditional licensure status to Respondent’s facility, effective December 18, 2003. 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 $6,000 civil penalty against Respondent; c. Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2003); d. Uphold the conditional licensure status, effective December 18, 2003, pursuant to Section 400.23(7) (b) (2003); and e. 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 (2003). 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 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. Hitiua d. Katrina D. Lacy, Esffuire 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 0002 4667 0036 to Bill Maggard, Administrator, Cypress Community Care Center, 7173 Cypress Drive th S.W., Fort Myers, FL 33907-2994, dated on February ol 7 2004. bbicaad ce Katrina D. Lacy, AHCA, Senior Attorney Fla. Bar. No. 0277200 Counsel for Petitioner 525-Mirror Lake Dr. N., #330G t. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) Copies furnished to: Bill Maggard, Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Certified Mail) CT Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Mail) Katrina D. Lacy AHCA -— Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701 Aw a RSS. 1S Se . i Aa State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION + = DIVISION OF HEALTH QUALITY ASSURANCE — =O : CO CONDITIONAL , @ This is to confirm that CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC has complied with the rules and regulations , ed in Chapter 400, Part Il, Florida Statutes, and as the licensee is authorized to operate the fe ollowing: CYPRESS COMMUNITY CARE CENTER 7173 CYPRESS DRIVE S.W. FORT MYERS, FL 33907-2994 TOTAL: 120 BEDS CONDITIONAL ACTION EFFECTIVE DATE: 12/18/2003 LICENSE EXPIRATION DATE: 01/20/2004 Deputy Secrgyary, Division of Health Quality Assurance

Docket for Case No: 04-001190