STATE OF FLORIDA QO « AGENCY FOR HEALTH CARE ADMINISTRATION ¥ he a Ww >, AGENCY FOR HEALTH CARE 4g. 9 “Ss ADMINISTRATION, Kise, y . vf ie er . aan iti ; Ct: \ oy Pas xs Petitioner, () { AKO | "O00. on vs. AHCA No. 2004008153 (Cond. Lic.) . AHCA No. 2004007273 (Fine) NORTH OKALOOSA HEALTH CARE 7003 L010 0002 6160 SOo44 eS NN ASSOCIATES LLC d/b/a/ SHOAL CREEK REHABILITATION CENTER 2003 1010 0002 blb0 soe eee Respondent. / ae ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA’” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against NORTH OKALOOSA HEALTH CARE ASSOCIATES LLC D/B/A/ SHOAL CREEK REHABILITATION CENTER (“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose upon Respondent a conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes, and an administrative fine of THREE THOUSAND DOLLARS ($3,000) pursuant to Section 400.23(8)(c), Florida Statutes JURISDICTION AND VENUE 2. AHCA, and the Division of Administrative Hearings upon a request for formal hearing, have jurisdiction pursuant to Sections 420.569 and 120.57, Florida Statutes. 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 1 of 8 PARTIES 4. AHCA 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 Il, Florida Statutes, and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. Respondent, NORTH OKALOOSA HEALTH CARE ASSOCIATES LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, SHOAL CREEK REHABILITATION CENTER (‘Facility’), is a 120-bed nursing home located at 300 South Hospital Drive, Crestview, Florida, 32539-6022. Respondent is licensed as a skilled nursing facility license #SNF130471012. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNT THE RESPONDENT FAILED TO STORE, PREPARE, DISTRIBUTE, AND SERVE FOOD UNDER SANITARY CONDITIONS CLASS III UNCORRECTED 42 CFR § 483.35(i) Section 400.23(7)(b), Florida Statutes, Section 400.23(8)(c), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provisions of the Code of Federal Regulations and Florida Administrative Code that are pertinent to this alleged violation, read as follows: (i) Sanitary conditions. The facility must -- (1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities; (2) Store, prepare, distribute, and serve food under sanitary conditions, and Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 2 of 8 (3) Dispose of garbage and refuse properly. 8. AHCA staff made Kitchen/Food Service observations on June 2, 2004, beginning at 12:15 p.m., with the Certified Dietary Manager (CDM) and the facility administrator present. During those observations, the AHCA staff found the following sanitation problems: a. The air conditioning/heating vents located in the ceiling directly above the food serving line were covered with dirt and lint, exposing foods on the serving line to contamination. b. Measurement of the chemical sanitizer in the manual dishwashing sink was recorded at one hundred (100) parts per million (PPM). The manufacturer's recommendation for sanitizer concentration is two hundred (200) PPM. The CDM was alerted to the problem and the sink was filled to the proper water level, allowing for the correct concentration of sanitizer to be added. A full steam-table pan was sitting in the sanitizing solution at the time of the measurement, indicating that the dietary staff had begun the manual dishwashing process before determining whether there was adequate sanitizer concentration. During an interview at approximately 1:15 p.m. on the same day, the dietary manager confirmed that the department staff members were not maintaining monitoring logs of the sanitizer concentration. Cc. Flies were observed flying around and landing on the microwave over directly adjacent to the resident tray-line as staff members were serving the noon meal. d. The disposable towel dispenser for the handwashing skink located between the stove and the ice machine was empty with no evidence of disposable drying towels available in the immediate area. e. The backsplash of the flat kettle (non-food contact area) located next to the deep fat fryer was dirty and splattered with dried grease and food residue. f. Observations of raw meat storage in the walk-in cooler revealed poultry being stored on the top of a portable rack. Ham was stored directly below the poultry and beef was thawing directly below the ham. g. A pitcher of juice dated May 7, 2004 was stored in the nourishment refrigerator located on the “B” hall nursing unit. 9. Respondent’s failure to store, prepare, distribute, and serve food under sanitary conditions is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference the substantive requirements of 42 CFR 483.35. AHCA classified this violation as a class III deficiency. Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 3 of 8 10. AHCA gave the Facility a mandatory correction date of July 2, 2004. 441. On or about July 12-15, 2004, AHCA conducted a revisit survey. The findings included the following: a. During the initial tour of the kitchen, at 8:50 a.m. on July 12, 2004, an opened cardboard box of beverage thickener was found on a lower shelf of a food preparation table. One flap of the box top extended beyond the edge of the food preparation area. The entire surface was covered with multi-colored spots of food droplets. The plastic inner bag of the box was torn open and the contents were exposed. The cup used to remove the thickener was resting on top of the thickener. b. On the initial tour of the kitchen, wet pots and pans were found nested and stacked one within another, preventing air-drying. Cc. During a later observation of the kitchen, at’ 12:02 p.m. on July 12, 2004, the thickener had been moved to a snap lid plastic container. The nested pots were checked and found to be dry. The dietary manager stated that he/she had dried all of them with a towel after the initial observation. d. At 8:15 a.m. on July 13, 2004, the administrator stated, “| know we missed it on the thickener and wet pans.” 42. The deficiency was uncorrected during the re-visit survey, and that re-visit survey occurred after the mandatory correction date. 43. AHCA classified this violation as a widespread class II deficiency. Pursuant to Section 400.23(8)(c), this classification constitutes grounds for the imposition of an administrative fine of THREE THOUSAND DOLLARS ($3,000). Section 400.23(8)(c) defines a class III deficiency as “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.” 14. Respondent's failure to store, prepare, distribute, and serve food under sanitary conditions is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference the substantive requirements of 42 CFR 483.35 and constitutes grounds for Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 4 of 8 the imposition of conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Count I. 2. Uphold the imposition of conditional licensure status. 3. Imposition of an administrative fine of THREE THOUSAND DOLLARS ($3,000). DISPLAY OF LICENSE Pursuant to Section 400.23(7), Florida Statutes, SHOAL CREEK REHABILITATION CENTER 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 “A”. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569 and 120.57, Florida Statutes. 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: Agency Clerk, Agency for Health Care Administration, Building 3, 2727 Mahan Drive, MSC #3, Tallahassee, Florida, 32308 RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 5 of 8 FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted on a , 2004. Joanna Daniels FL BAR #0118321 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (850) 922-5873 (850) 921-0158 (fax) CERTIFICATE OF SERVICE | hereby certify that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 129.569, £.S.A. form, have been forwarded by certified mail, return receipt requested on A, > ___, 2004 to: MR DANIEL W HEALY CT CORPORATION SYSTEM ADMINISTRATOR REG AGENT FOR SHOAL CREEK REHAB CTR N OKALOOSA HEALTH CARE ASSOC 300 S HOSPITAL DR LLC D/B/A/ SHOAL CREEK REHAB CTR CRESTVIEW FL 32539-6022 1200 S PINE ISLAND RD (CERT # 7003 1010 0002 6160 5044) PLANTATION FL 33324 (CERT # 7003 1010 0002 6160 5020) OANNA DANIELS Administrative Complaint 2004008153 & 2004007273 Certified Nos. 7003 1010 0002 6160 5044 & 7003 1010 0002 6160 5020 Page 6 of 8

Docket for Case No: 04-003801