OK-O3Ie STATE OF FLORIDA O AGENCY FOR HEALTH CARE ADMINISTRATION? STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No: 2007012981 vs. CARE CENTER OF ORMOND BEACH, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency” or “Petitioner’), by and through its undersigned counsel, and files this Administrative Complaint against CARE CENTER OF ORMOND BEACH, INC. (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of FIVE HUNDRED DOLLARS ($500.00), pursuant to Section 429.19(2)(c), Florida Statutes (2007) based upon the existence of one (1) uncorrected class III violation. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60 and 429, Part I, Florida Statutes (2007). 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable statutes, rules, and regulations governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes, Chapter 408, Part II, Florida Statues, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates an assisted living facility located at 1410 Hand Avenue, Ormond Beach, Florida 32174, and has been issued by the Agency a standard assisted living facility license (License # 10589). 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 7. Pursuant to Rule 58A-5.0181(1)(n) 1-3, Florida Administrative Code, each resident must have been determined to be appropriate for admission to the facility by the facility administrator. The administrator shall base his/her decision on: 1. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report. 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs; and 3. The ability of the facility to meet the uniform safety standards for assisted living facilities. 8. On or about September 17, 2007, the Agency conducted a survey of Respondent’s facility. 9. Based on facility and resident record review and staff interview, the administrator failed to follow their admission policy and admitted an inappropriate resident, for 1 of 4 sampled residents. 10. Resident #2 was unable to assist staff with transfers and was not appropriate to reside in an assisted living facility. The findings include: 11.‘ In review of the Admission/Discharge log, Resident #2 was admitted on 8- 31-07 and was discharged from the facility on 9-4-07, but actually was transferred to the hospital on 9-3-07. 12. _ In an interview with the Administrator and staff nurse on 9-17-07 at 10:30 a.m., Resident #2 was totally dependent on staff to be transferred from bed to chair. The nurse stated that the only thing that the resident was able to assist with was eating. 13. The Administrator stated that she did not want to admit the resident because he/she was not suitable for assisted living. The resident was totally dependent on staff for activities of daily living and they did not have the staff to take care of him/her. The Administrator and their management company did not want to admit the resident, but the owner insisted. 14. | The management company cancelled their contract due to the admission of this inappropriate resident. 15. The facility's Policy and Procedure revealed that they will only admit residents who are capable of living and functioning in a facility rendering this level of care (total dependence in transferring is not appropriate level of care). The Administrator has the responsibility for approval or rejection of all residents. 16. The resident's progress notes on 8-31-07 revealed that the resident was transported from wheelchair into bed with total assistance. On 9-1-07, progress notes revealed that while staff were attempting to assist resident to wheelchair with the assistance of 2 persons, they were unable to complete the transfer and eased the resident to the floor in a sitting position, leaning against the bed. The resident was later transported from floor to wheelchair with assist of four people. 17. The next day, the resident complained of shortness of breath and was transported to the hospital. 18. | The Agency provided a mandtatory correction date of October 17, 2007. 19. On or about November 1, 2007, the Agency conducted a survey of Respondent’s facility. 20. Based on facility and resident records review and staff interview, the administrator failed to follow their admission policy and admitted an inappropriate resident, for 2 of 4 sampled residents. The findings include: 21. ‘In review of the Admission/Discharge log, Residents #3 and #4 were admitted on August 20, 2007. The residents’ Form 1823 had a note that stated the residents must have 24 hour nursing care. 22. ‘In the area of Form 1823 where this question should be answered, the first response is Yes. This has been crossed out and No has replaced the original statement. There is no signature noting the change and the separate note has not been corrected. Resident #4 is an insulin dependent diabetic who requires two injections each day. This was covered by a Home Health Agency until November 1, 2007. 23. The facility has a standard license and the need for a licensed nurse to provide the injections lies beyond the facility's scope of services. In an interview with the Administrator and staff nurse on 11/1/07 at 11:30 a.m., they confirmed that the 1823's and the injection needs of the resident, negate the ability of the facility to care for the residents. 24. Based upon the above, the Agency determined that the Respondent failed to make to ensure that each resident must have been determined to be appropriate for admission to the facility by the facility administrator based on the pertinent mule, in violation of Rule 58A-5.0181(1)(n)1-3, Florida Administrative Code. 25. The Agency determined that this deficient practice was related to the Operation and maintenance of the facility or to the personal care of facility residents, and indirectly or potentially threatened the physical or emotional health, safety, or security of facility residents. 26. The Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2) (c), Florida Statutes. 27. The Respondent’s failure to ensure that each resident is appropriate for admission violates Rule 58A-5.0181(1)(n)1-3, Florida Administrative Code, as set forth in this count and constitutes grounds for the imposition of an administrative fine in the amount of FIVE HUNDRED AND NO/100 DOLLARS ($500.00), pursuant to Section 429.19(2)(c), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Respondent an administrative fine of FIVE HUNDRED NO/100 DOLLARS ($500.00) for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Grant such other relief as the court deems is just and proper. NOTICE OF RIGHTS Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120,57, Florida Statutes (2007). Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. | RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE OR REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ea. San SALMAN, ESQUIRE Florida Bar I.D. No. 30942 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 (850) 922-5873 - Telephone (850) 921-0158 or 413-9313 - Facsimile CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been fumished to Owner/Operator of Care Center of Ormond Beach, Inc., 1410 Hand Avenue, Ormond Beach, Florida 32174, Return Receipt No. 7000 0520 0024 8388 1761 by U.S. Certified Mail on this Ti aay of Tec €anbe,2007. —_) = < 4 y NY 9 ZA SALMAN, Copies To: Care Center of Ormond Beach, Inc. 1410 Hand Avenue Ormond Beach, Florida 32174 U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only;.No insurance Coverage Provided) Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees [ ‘Strest, Po No.; or PO Box No. LL Gentle Arcos : is. 7000 0520 O024 &388 1?bl oe State, Z1P+ 4 PS Form 3800, ee 2000 SENDER: COMPLETE THIS SECTION @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ™ Print your name and address on the reverse so that we can return the card to you. & Attach this card to the back of the mailpiece, or on the front if space permits. ! 1. Article Addressed to: | Care Caner of Orment i Pecech, FAC, {U)0 Hand Avenue Ormend Booch FC 3AM at's lame (Please ran Clearly) (To be completed by, mation) Cente cf Comend Beech. i @everse for Instructions Postmark Here pee. D Agent : Addressee _: C, Datd of Delivery D. ts delivery address different from item 1? (1 Yes If YES, enter delivery address below: + _C.No 3. Service Type CI Certified Mail OJ Express Mail CO Registered” ( Return Receipt for Merchandise. / Cl insured Mail, 11.0. i | 4. Restricted Delivery? (Extra Fee) 2 Yes : 2, Article Number (Transfer from service label} | PS Form 38114, February 2004 Domestic Return Receipt

Docket for Case No: 08-000312