STATE OF FLORIDA 04 . Mey AGENCY FOR HEALTH CARE ADMINISTRATION AFR 5, . AGENCY FOR HEALTH CARE “a PAS a, "ey ADMINISTRATION, PP os CAs AHCA No.: 2004001926" AHCA No.: 2004001924 Return Receipt Requested: 7002 2410 0001 4237 0737 7002 2410 0001 4237 0744 7002 2410 0001 4237 0751 Petitioner, Vv. A.D.M.E. INVESTMENT PARTNERS, LTD, d/b/a OCEANSIDE EXTENDED CARE CENTER, Respondent ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the "undersigned counsel, and files this Administrative Complaint against A.D.M.E. Investment Partners LTD, d/b/a Oceanside Extended Care Center (hereinafter “Oceanside Extended Care Center”), pursuant to Chapter 400, Part IT, and Section 120.60, Fla. Stat. (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $4,000.00 pursuart to Section 400.23(8), Fla. Stat. (2003), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Oceanside Extended Care Center, pursuant to Section 400.23(7) (b), Pla. Stat (2003). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat, (2003), and Chapter 28-106, F.A.C. 4, Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Fla. Stat. (2003), and Rule 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat., (2003), and Chapter 59A-4 Florida Administrative Code. 6. Oceanside Extended Care Center is a 196-bed skilled nursing facility located at 550 9 Street, Miami Beach, Florida 33139. Oceanside Extended Care Center is licensed as a skilled nursing facility; license number SNF1171096; certificate number 11247, effective 11/17/2003, through 12/31/2003. Oceanside Extended Care Center 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. 7. Because Oceanside Extended Care Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. COUNT I OCEANSIDE EXTENDED CARE CENTER FAILED TO MAINTAIN STAIRWAYS AS REQUIRED Sections 5-2, 13-2.2.2, 13-2.2.3 NFPA 101 Life Safety Code Standard, as :incorporated by 59A-4.130, Florida Administrative Code (LIFE SAFETY CODE STANDARDS) UNCORRECTED CLASS III DEFICIENCY 8. AHCA" re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. Based on observation while touring the facility with the’ Maintenance Supervisor on 07/29/2003, the day of survey visit, it was noted that not all stairways were maintained as required. 10. A penetration of the wall separating the South stairwell from the hallway outside the laundry room was noted on the inside of the stairwell wall at ground level while touring with the Maintenance Supervisor in the afternoon on 07/29/03, the day of survey. This penetration could allow smoke to enter the stairwell, which would be used in an emergency. Correction Date: 08/29/03 11. Based on observation while touring the facility with the maintenance supervisor on 11/17/2003, the day of follow up survey visit, it was noted that stairways continued not to be maintained as required. we 12. Penetrations of the wall by conduits inside the south stairwell at the ground level were noted. These penetrations could allow smoke to enter the stairwell, which would hamper its use in an emergency. Uncorrected Deficiency. 13. Based on the foregoing, Oceanside Extended Care Center violated Sections 5-2. 13-2.2.2 and 13-2.2.3, NFPA Life Safety Code and Rule 59A-4.130, Florida Administrative Code, herein classified as ‘an uncorrected Class III deficiency pursuant to Section 400.23(8)(c), Fla. Stat., which carries, in this case, an assessed fine of $2,000.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). COUNT II OCEANSIDE EXTENDED CARE FAILED TO MAINTAIN ALL COMPONENT DEVICES FUNCTIONING IN THE MANNER INTENDED IN ORDER TO PROTECT OCCUPANTS AND WARN OF FIRE IN ANY PART OF THE BUILDING Sections 13-3.4.2, 13-3.4.3, and 13-3.4.4, NFPA 101 Life Safety Code, and Rule 59A-4.130, Florida Administrative Code (LIFE SAFETY CODE STANDARDS) UNCORRECTED CLASS III 14. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 15. Based on observation, performance testing of the alarm system and interview with the Maintenance Supervisor in the afternoon on 07/29/2003, the day of survey visit, it was determined that not all component devices of the alarm system were maintained and functioned in the manner intended in order to protect occupants and warn of fire in any part of the building. 16. The Maintenance Supervisor and his staff were observed testing the elevator recall for operation by activating a smoke detector in front of the elevators in the lobby on the ground floor, the elevator cars proceeded to the first floor which was the floor of simulated involvement. “The elevator car should have stopped and stayed on the second floor until released. This could cause occupants of the car to be exposed to fire. Further, while testing the alarm system for operation, linen carts were observed to be positioned so as to obscure the pull stations “on the North end of the hallway on the first and third floors. The staff reported at that time that the carts were only left there for a brief period of time. Pull stations should not be blocked on any occasion, for any length of time. Correction Date: 08/29/03 17. Based on observation, performance testing of the alarm system and interview with the maintenance supervisor in the morning on 11/17/2003, the day of follow up survey visit, it was determined that not all component devices of the alarm system were maintained and functioned in the manner intended in order to protect occupants and warn of fire in any part of the building. 18. The maintenance supervisor was observed testing the elevator recall for ‘operation by activating a smoke detector in front of the elevators in the lobby on the ground floor. The elevator cars proceeded to the first floor, which was the floor of simulated involvement. The elevator car should nave stopped and stayed on the second floor until released. The elevator coming to the first floor could cause occupants of the elevator car to be exposed to fire. Uncorrected Deficiency 19. Based on the foregoing, Oceanside Extended Care Center violated Sections 13-3.4.2, 13-3.4.3, and 13-3.4.4, NFPA Life Safety Code and Rule 59A-4.130, Florida Administrative Code, herein classified as an uncorrected Class III deficiency pursuant to Section 400.23(8)(c), Fla. Stat., which carries, in this case, an assessed fine of $2,000.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Oceanside Extended Care shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit wae CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess an administrative fine of $4,000.00 against Oceanside Extended Care Center on Counts I and II. Cc. ;,Assess and assign a conditional license status to Oceanside Extended Care Center in accordance with Section 400.23(7) (b), Florida Statutes. Dd. Grant such other relief as this Court deems is just and proper. ' Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Nelson E. Rodney. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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 pert, Uf freee, A. Naranjo ssistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52" Terrace Miami, Florida 33166 AGENCY. Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 5379 Street Miami, Florida 33139 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) lf EXHIBIT “A” 04 App 27 a a PY EL, Aopyiicgy | & Conditional License HLS Fe PAB RA License No. $N1171096 Certificate No. 11247 8S Effective date: 11/17/2003 Expiration date: 12/31/2003

Docket for Case No: 04-001579