STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, 6 & , ff 34 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008006790 (Fine) 2008006791 (CL) 2900 TWELFTH STREET NORTH, LLC d/b/a LAKESIDE PAVILLION REHABILITATION AND NURSING CENTER, Respondent. . / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against 2900 TWELFTH STREET NORTH, LLC d/b/a LAKESIDE PAVILLION REHABILITATION AND NURSING CENTER (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This: is an action against a skilled nursing facility to impose an administrative fine of TWENTY THOUSAND DOLLARS ($20,000.00) pursuant to Section 400.23(8)(a), Florida Statutes (2007), based upon two (2) Class I deficiencies; to assess a survey fee in the amount of SIX THOUSAND DOLLARS ($6,000.00) based upon Respondent being cited for two (2) Class I deficiencies pursuant to Section 400.19(3), Florida Statutes (2007), and to assign conditional licensure status beginning on March 12, 2008, and ending on April 21, 2008, pursuant to Section 400.23(7)(b), Florida Statutes (2007). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2007). 3. ° Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the regulatory authority responsible for the licensure of skilled nursing facilities and the enforcement of all applicable federal and state statutes, regulations and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes (2007) and Chapter 59A-4, Florida Administrative Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121 and 400.23, Florida Statutes (2007); assign a conditional license pursuant to Section 400.23(7), Florida Statutes (2007), and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2007). 5. Respondent operates a 120-bed nursing home, located at 2900 12™ Street North, Naples, Florida 34103, and is licensed as a skilled nursing facility, license number 12840962. Respondent was at all times material hereto, a licensed skilled nursing facility under the licensing authority of the Agency, and was required to comply with all applicable state rules, regulations and statutes. COUNT I The Respondent Failed To Periodically Review And Revise The Comprehensive Care Plan For Changes In Care And Treatment According To The Needs Of The Resident And To Assure The Continued Accuracy Of The Assessment As The Needs For The Residents Changed in Violation Of Rule 59A-4.109(1), Florida Administrative Code 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: a.) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. b.) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. c.) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within fourteen (14) days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be reviewed no less than once every three (3) months; reviewed promptly after a significant change in the resident’s physical or mental condition, and revised as appropriate to assure the continued accuracy of the assessment. Rule 59A-4.109(1), Florida Administrative Code. 8. On or about March 11, 2008 through March 12, 2008 the Agency conducted a Complaint Investigation (CCR# 2008003055) of the Respondent’s facility. 9. Based on observation, record review and interview the facility failed to periodically review and revise the comprehensive care plan for changes in care and treatment according to the needs of the resident and to the extent practicable to assure the continued accuracy of the assessment as the needs changed for two (2) of five (5) sampled residents, Resident number two (2) and Resident number five (5). Resident number five’s (5) care plan documented he/she was to be showered twice a week and had not been updated to reflect he/she could not tolerate a shower and had been receiving bed baths. This led to a Certified Nursing Assistant taking Resident number five (5) to the shower where Resident number five (5) died. The facility also failed to update the care plan for Resident number two (2) when Oxygen orders were changed. 10. | On March 11, 2008 a review of records for Resident number five (5) revealed he/she was admitted to the facility on January 30, 2008 with a diagnosis including, but not limited to, pulmonary fibrosis, congestive heart failure, shortness of breath, non-insulin dependent diabetes, debility, respiratory failure, respiratory insufficiency, coronary artery disease, and renal insufficiency. 11. The records indicate that Resident number five (5) expired at the facility on Wednesday March 5, 2008 in the shower without the use of ordered oxygen. 12. A review of Resident number five’s (5) care plan revealed he/she was to receive showers on Wednesday and Saturday of each week. The care plan indicated that Resident number five (5) ambulated with a walker and ‘in his/her wheelchair, he/she had an air mattress on his/her bed for prevention of skin breakdown and required the use of continuous oxygen at four (4) liters per minute per nasal cannula. 13. On March 12, 2008 an interview with six (6) of the certified nursing assistants that had cared for Resident number five (5) during his/her stay at the facility revealed that five (5) of the six (6) staff members interviewed reported that Resident number five (5) was receiving bed baths and not showers as listed on his/her care plan. One staff member could not recall Resident number five (5). The certified nursing assistants stated that they were providing bed baths related to the fact that Resident number five (5) was often short of breath and that he/she was unable to tolerate the exertion required to take a shower. They all stated that to the best of their knowledge, Resident number five (5) did not receive any showers during his/her stay at the facility. 14. Records revealed that Resident number five (5) received physical therapy and occupational therapy up to five (5) times a week as tolerated. 15. During an interview with the physical therapist on March 12, 2008. she reported that frequently during therapy Resident number five (5) had to have frequent rest periods because he/she would become very short of breath. She stated that Resident number five’s (5) oxygen saturation would often drop to the 70's percentage and he/she would be unable to continue with therapy. She stated that because of Resident number five’s (5) shortness of breath he/she was unable to ambulate. When Resident number five (5) attempted to ambulate a few steps to the restroom he/she would become extremely short of breath again with oxygen saturation in the 70's. The normal oxygen saturation at rest with no activity for Resident number five (5) was primarily in the low 90's. A normal healthy individual would have normal oxygen saturation between 97-100%. 16. A review of nurses notes in the record of Resident number five (5) revealed that on multiple occasions with slight exertion his/her oxygen saturation would often drop in the 60's and 70's. The notes revealed that Resident number five (5) was often unable to get out of bed due to this fact. 17. A review of facility records dated Wednesday March 5, 2008 revealed that on this date the certified nursing assistant providing care to Resident number five (5) assisted him/her out of bed and to the shower room for the shower as listed on Resident number five’s (5) care plan for Wednesday. Resident number five (5) did not have his/her oxygen on as ordered by the physician when he/she went to the shower room. Resident number five (5) was in the shower when the certified nursing assistant called for assistance from the nurse. The nurse responded as well as the physician who was in the facility at the time. Upon arrival, the physician found Resident number five (5) to be without vital signs. Resident number five (5) had a Do Not Resuscitate status in his/her records signed by the physician. The physician present pronounced Resident number five (5) as deceased. 18. A review of the document (activities of daily living care plan) that instructs staff on the care for Resident number five (5) indicated that he/she was scheduled for showers twice weekly on Wednesday and Saturday. This care plan sheet did not accurately reflect the severity of the respiratory status of Resident number five (5) and the fact that he/she was unable to tolerate showers due to Resident number five’s (5) shortness of breath and needed bed baths. 19. | On March 12, 2008 during an interview with Staff number one (1), who was providing the shower to Resident number five (5), she reported that she had worked at the facility for six (6) years. She stated that she was unaware of any activities of daily living care plan sheets that would instruct her in the care for Resident number five (5). She stated that the charge nurse for that shift had instructed her to give Resident number five (5) a shower and she was doing as she was instructed by her supervisor. She stated this was the first time she had worked with Resident number five (5) on his/her scheduled shower day. She stated that she was unaware that Resident number five (5) had been receiving bed baths. 20. During an interview with the spouse of Resident number five (5) on March 12, 2008 at 3:30 p.m., who was present during the preparation for the shower and also present in the facility when Resident number five (5) expired, revealed that to the best of the spouse’s knowledge Resident number five (5) had never received a shower during his/her stay at the facility. Resident number five’s (5) spouse stated that he/she visited Resident number five (5) on a daily basis and that when he/she was present Resident number five (5) always received bed baths instead of showers on his/her scheduled days because Resident number five (5) was unable to tolerate being out of bed for extended periods of time and often became short of breath with any exertion or when he/she was up in the chair. 21. | The comprehensive care plan and the activities of daily living care plan did not accurately reflect the care to be provided to meet the needs of Resident number five (5) in regards to his/her intolerance of shower activity related to Resident number five’s (5) compromised respiratory status. 22. A review of records for Resident number two (2) revealed that he/she was admitted to the facility on January 24, 2008 with a diagnosis including, but not limited to pneumonia, anxiety, chronic obstructive pulmonary disease and high blood pressure. 23. A review of records for Resident number two (2) revealed that on January 26, 2008 Resident number two (2) had an order for oxygen at two (2) liters per minute via nasal cannula as needed. A further review of physician's orders revealed an updated order beginning February 1, 2008 for the oxygen to be at two (2) liters per minute via nasal cannula. The "as needed" status had been eliminated and Resident number two (2) was receiving oxygen on a continuous basis. 24. A review of the activities of daily living care plan for Resident number two (2) revealed that the instruction listed for guidance by care providers was inaccurately stated as oxygen via nasal cannula at two (2) liters as needed. 25. On March 12, 2008 at 8:20 am. during an interview with Resident number two (2), he/she reported that he/she wears oxygen on a continuous basis. Resident number two (2) reports that when he/she attends activities or goes to the dining room or showers that he/she uses a portable oxygen tank. 26. An observation of Resident number two (2) on six (6) occasions (March 11, 2008 at 9:30 a.m. and 2:00 p.m., and March 12, 2008 at 6:20 a.m., 7:30 a.m., 8:20 a.m., and 9:30 a.m.) during the survey revealed that Resident number two (2) always had oxygen on and in place. 27. The current care plan had not been updated to accurately reflect the status of oxygen usage for Resident number two (2) as ordered for February 1, 2008 by the physician. 28. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility. The Agency cited Respondent for an isolated Class I deficiency as set forth in Section 400.23(8)(a), Florida Statutes (2007). 29. The Agency provided Respondent with a mandatory correction date of April 12, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of TEN THOUSAND DOLLARS ($10,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT I | The Respondent Failed To Provide Continuous Oxygen To A Resident As Ordered By A Physician In Violation Of Section 400.102(1), Florida Statutes (2007) : 30. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 31. Pursuant to Florida law, in addition to the grounds listed in Part II of Chapter 408, Florida Statutes (2007), the following condition shall be grounds for action by the agency against a licensee: An intentional or negligent act materially affecting the health or safety of residents of the facility. Section 400.102(1), Florida Statutes (2007). 32. Onor about March 11, 2008 through March 12, 2008 the Agency conducted a Complaint Investigation (CCR# 2008003055) of the Respondent’s facility. 33. Based on observation, record review, facility record review, and interviews with facility staff, residents, and family members, the facility neglected to provide one (1) of five (5) sampled residents, Resident number five (5), with continuous oxygen as ordered by the resident’s physician and required, as evidenced throughout the resident’s stay that the resident’s oxygen saturation (percentage of oxygen in the blood) was low upon exertion, getting out of bed or with no exertion at all, even with the continuous use of oxygen. 34, Facility staff removed Resident number five’s (5) oxygen and transported him/her into the shower room for a shower and Resident number five (5) died. After the incident the facility implemented an action plan but observation on March 11, 2008 during the initial tour of the facility revealed a resident was being taken out of his/her room without oxygen by a Certified Nursing Assistant who had not been instructed in the action plan. The failure of the facility to ensure the action plan was fully implemented jeopardized the health and safety of all residents. 35. During an interview by phone on March 10, 2008 at 9:13 p.m., the daughter of Resident number five (5) stated her parent, Resident number five’s (5) spouse, told her that Staff number one (1) came into Resident number five’s (5) room on March 5, 2008, and said it was Resident number five’s (5) shower day and removed his/her oxygen. The daughter of Resident number five (5) said that Resident number five’s (5) spouse told Staff number one (1) that Resident number five (5) is supposed to be on oxygen and needs to keep it on. Staff number one (1) told Resident number five’s spouse that Resident number five (5) would be fine without his/her oxygen. Staff number one (1) wheeled Resident number five (5) out of his/her room without Resident number five’s (5) oxygen and within a few minutes Resident number five’s (5) spouse saw staff running into the shower room with oxygen tanks. The doctor was in the facility at this time. The doctor took Resident number five’s (5) spouse into the shower room and he/she saw Resident number five 6) slumped in his/her shower chair and was told by the doctor that Resident number five (5) had passed away. Resident number five’s (5) daughter stated the cause of Resident number five’s (5) death was contributed to by the fact Resident number five (5) did not have his/her oxygen on while taking a shower even when Staff number one (1) was reminded Resident number five (5) needed it. 36. A review of Resident number five’s (5) medical record revealed he/she was admitted into the facility on January 30, 2008 with diagnosis of pulmonary fibrosis, congestive heart failure, shortness of breath, major cardiovascular surgery and debility. Resident number five (5) was admitted into the facility from the hospital for congestive heart failure and pulmonary fibrosis. Resident number five (5) was discharged from the hospital with other diagnoses of respiratory failure, secondary interstitial lung disease and respiratory insufficiency. Upon admission to the facility, Resident number five (5) had a doctor's order for oxygen via concentrator at four (4) liters per minute every shift. A further review of Resident number five’s (5) medical record revealed the doctor's order did not change throughout Resident number five’s (5) stay at the facility. The order for the oxygen was an as needed order. 37. A review of the nurse's notes for Resident number five (5) revealed documentation throughout his/her stay that Resident number five (5) used oxygen continuously and Resident number five’s (5) oxygen saturation (percentage of oxygen in the blood) was low upon exertion, when getting out of bed or with no exertion at all. The following are nurse's notes documenting Resident number five’s (5) oxygen levels: February 9, 2008: "CNA (certified nursing assistant) took resident to the bathroom...res. (resident) was SOB (shortness of breath)." "02 (oxygen) sat (saturation) was 89-90%." Normal range of oxygen saturation for Resident number five (5) is the low 90%. "Res. put back in bed keep HOB (head of bed) up. o sat up to 96-97%. February 10, 2008 "02 sat 94 on oxygen. Spouse requesting staff get Resident number five (5) up. Reminded spouse O2 sat drops to 80's." February 10,2008: "O2 sat 94 on oxygen. Spouse requesting staff get resident up. Reminded spouse 02 sat drops to 80"s." February 12, 2008: "SOB on exertion, lung sounds diminished bilaterally... Therapy today c/o (complaint of) being tired and week (weak)." "Resident with O2 sats dropping into upper 60's on exertion needs frequent rest periods between activities." February 12,2008: "...lung sounds diminished bilaterally, O2 sat while on O2 and resting in upper 80's, with transfers and any exertion drops into upper 60's to 70's.” February 15, 2008: O2 sat at 90 -92% while resting in chair, SOB on exertion O2 sats drop to upper 60's to 70's,...” February 19, 2008: "States got headache due to work out with PT (physical therapy)." February 23, 2008: "SOB on exertion, 02 sat 90%..." February 25, 2008: “O2 sat at 89-90% while on 02, on any type of exertion O2 sats drop into upper 60's to upper 70's.” February 27, 2008: "O2 sat at 80-82% on 02, SOB on exertion noted,..." February 28, 2008: "SOB on exertion, O2 sats in mid to upper 80's, they drop with any exercise." March 3, 2008: "O2 sat at 89-90% on O2 drops on exertion,..." March 4, 2008: "...lungs sounds with crackles noted throughout, SOB on exertion O2 sat at 88-90% with O2, sats drop during any exertion ...” 38. An interview was conducted with the Director of Nursing on March 12, 2008 at 9:15 am. and she stated the oxygen orders for Resident number five (5) are on the Activities of Daily Living care plan sheet for all Certified Nursing Assistants to read. A review of the Activities of Daily Living sheet revealed Resident number five’s (5) oxygen order read "02 4L (liter) N/C (nasal/cannula) per shift." A review of Resident number five’s (5) Minimum Data Sheet Assessment revealed Resident number five (5) required extensive assistance from staff for showers/baths. 39. Another interview with the Director of Nursing was conducted at 11:00 a.m. on March 12, 2008. She stated she started an investigation on Resident number five’s (5) death on March 5, 2008. A written statement from the Certified Nursing Assistant, Staff number one (1), was given’ to the Director of Nursing during this investigation. The Director of Nursing stated Staff number one (1) gave Resident number five (5) a shower. Resident number five (5) washed his/her hair and face and after the shower as Resident number five (5) was drying he/she started shaking and not looking good. The Certified Nursing Assistant called for a Registered Nurse for help. Another Certified Nursing Assistant came in the shower room and a rehabilitation staff called out to Resident number five (5) but Resident number five (5) did not respond. A Registered Nurse came in with an oxygen tank which was empty and a second oxygen tank was brought in but was empty as well. A third oxygen tank was brought in and that one had oxygen in it. The nurse put the oxygen on Resident number five (5), but it was too late. This was the end of Staff number one’s (1) statement. The Director of Nursing stated she put Staff number one (1) on suspension while she continued her investigation. 40. An interview was conducted with Staff number one (1) by telephone on March 12, 2008 at 2:30 p.m. Staff number one (1) requested a translator during this interview which was provided by the facility. Staff number one (1) stated she was told by a nurse to give Resident number five (5) a shower. When Staff number one (1) got off of break at approximately 10:00 am, Staff number one (1) went into Resident number five’s (5) bedroom and Resident number five’s (5) spouse was there. Staff number one (1) told Resident number five’s (5) spouse she was going to take Resident number five (5) to the shower. Resident number five’s (5) spouse told Staff number one (1) that Resident number five (5) is on oxygen and that Resident number five’s (5) spouse would tell Resident number five (5) to have a shower. Resident number five’s (5) spouse told Staff number one (1) that Resident number five’s (5) spouse was surprised Resident number five (5) was going to take a shower because Resident number five’s (5) spouse never thinks Resident number five (5) wants the shower. Both Resident number five (5) and Resident number five’s (5) spouse agreed to the shower. Resident number five’s (5) spouse wanted to help assist the staff to get Resident number five (5) to sit up in bed. Staff number one (1) put Resident number five (5) in his/her chair. Staff number one (1) said she does not know who took the oxygen off of Resident number five (5). Staff number one (1) stated she did not know what the oxygen order was for Resident number five (5). Staff number one (1) said the nurse is supposed to give this information to her. Staff number one (1) said she does not know anything about the oxygen. The oxygen information is not on the Activities of Daily Living sheet and Resident number five’s (5) spouse did not tell Staff number one (1) anything about the oxygen. Staff number one (1) also said this was the first time she had worked with Resident number five (5). 41. Aninterview was conducted with the Director of Nursing when the telephone interview with Staff number one (1) was completed. The Director of Nursing stated Staff number one (1) had worked with Resident number five (5) before but not on his/her shower day. The Director of Nursing gave six (6) Certified Nursing Assistant names who have worked with Resident number five (5) during the days Resident number five (5) is scheduled to take showers. The shower days are Wednesday and Saturday. The six (6) Certified Nursing Assistants were interviewed on March 12, 2008. Five (5) of the six (6) Certified Nursing Assistants stated they gave Resident number five (5) bed baths. One Certified Nursing Assistant stated Resident number five (5) couldn't tolerate sitting in his/her wheelchair for too long. One Certified Nursing Assistant stated she could not remember if she gave Resident number five (5) bed baths or showers. 42. At3:30 p.m. on March 12, 2008 an interview was held with Resident number five’s (5) spouse by telephone. Resident number five’s (5) spouse stated he/she was in the room with Resident number five (5) on March 5, 2008 in the morning when Staff number one (1) walked into the room and told both Resident number five’s (5) spouse and Resident number five (5) that Staff number one (1) was giving Resident number five (5) a shower. Resident number five’s (5) spouse told Staff number one (1) it was news to Resident number five’s (5) spouse because Resident number five (5) has been getting sponge baths from the other staff since Resident number five (5) has been at the facility. Resident number five’s (5) spouse stated that Resident number five’s (5) spouse and Resident number five (5) were not asked if Resident number five (5) wanted a shower but were told Resident number five (5) was getting a shower. Resident number five’s (5) spouse told Staff number one (1) Resident number five’s (5) spouse did not think it was possible for Resident number five (5) to have a shower with oxygen on. Staff number one (1) told Resident 13 number five’s (5) spouse, "he/she will be fine." Staff number one (1) then took the oxygen off Resident number five (5) and started to wheel Resident number five (5) out of the bedroom. Resident number five’s (5) spouse told Staff number one (1), "wait a minute", and told Staff number one (1) Resident number five (5) couldn't be without oxygen and said, "He/she needs his/her oxygen to breathe." Staff number one (1) told Resident number five’s (5) spouse Resident number five (5) "will be fine." Staff number one (1) took Resident number five (5) out of the room to go to the shower room. Resident number five’s (5) spouse stated Resident number five’s (5) spouse was following them out of the room when Resident number five’s (5) spouse went back into the room to get Resident number five’s (5) spouse’s purse/wallet. Resident number five’s (5) spouse’s phone was ringing and Resident number five’s (5) spouse answered it. When Resident number five’s (5) spouse finished the telephone conversation, Resident number five’s (5) spouse went out into the hallway to see where Staff number one (1) took Resident number five (5). Resident number five’s (5) spouse said within a few minutes Resident number five’s (5) spouse saw staff running to a room with oxygen tanks. After a few minutes, the doctor went to Resident number five’s (5) room and took Resident number five’s (5) spouse into the shower room to see that Resident number five (5) had passed away. 43. A review of records reveals the facility had the oxygen information for Resident number five (5) in Resident number five’s (5) medical records and on the Activities of Daily Living care plan for the Certified Nursing Assistants to review daily. The Director of Nursing stated these Activities of Daily Living care plans are updated with information as changes occur for each resident. The doctor's order for the oxygen for Resident number five (5) has not changed since Resident number five’s (5) admission to the facility and this information is readily available to the Certified Nursing Assistants. Also, Resident number five’s (5) spouse reminded Staff number one (1) twice of Resident number five’s (5) need for the oxygen prior to being wheeled out of Resident number five’s (5) room for a shower. Resident number five’s (5) spouse also told Staff number one (1) that Resident number five (5) had not had any showers since Resident number five (5) was admitted to the facility. Resident number five (5) has always received sponge baths from the other Certified Nursing Assistants. Staff number one (1) chose to ignore all of this information, removed Resident number five’s (5) oxygen and gave Resident number five (5) a shower instead of a bed bath and Resident number five (5) died. The facility also had to bring three portable oxygen containers to the shower room before finding one (1) that contained oxygen. This delay could have contributed to Resident number five’s (5) death. 44. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility. The Agency cited Respondent for an isolated Class I deficiency as set forth in Section 400.23(8)(a), Florida Statutes (2007). 45. The Agency provided Respondent with a mandatory correction date of April 12, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of TEN THOUSAND DOLLARS ($10,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT It Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2007) 46. The Agency re-alleges and incorporates by reference the allegations in Count I and Count II. 47. The Agency is authorized to assign a conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2007). 48. Due to the presence of two (2) Class I deficiencies, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2007), or the rules adopted by the Agency. 49. The Agency assigned the Respondent conditional licensure status with an action effective date of March 12, 2008. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 50. The Agency assigned the Respondent standard licensure status with an action effective date of April 21, 2008. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period beginning March 12, 2008 and ending on April 21, 2008 pursuant to Section 400.23(7)(b), Florida Statutes (2007). COUNT IV Assessment Of Survey Fee Pursuant To Section 400.19(3), Florida Statutes (2007) 51. The Agency re-alleges and incorporates by reference the allegations in Count I and Count Il. 52. The Respondent has been cited for two (2) Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two (2) years and a survey fee of SIX THOUSAND DOLLARS ($6,000.00) pursuant to Section 400.19(3), Florida Statutes (2007). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two (2) years and impose a survey fee in the amount of SEX THOUSAND DOLLARS ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency on Count I through Count IV. Impose an administrative fine against the Respondent in the amount of TWENTY THOUSAND DOLLARS ($20,000.00), and assess a survey fee in the amount of SIX THOUSAND DOLLARS ($6,000.00) for a total of TWENTY SIX THOUSAND DOLLARS ($26,000.00). Assign a conditional license to the Respondent for the period of March 12, 2008, to April 21, 2008. Assess costs related to the investigation and prosecution of this case. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this #A@ day of augeual , 2008. tov Daley infec Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to: Corporation Service Company, Registered Agent for 2900 Twelfth Street North, LLC d/b/a Lakeside Pavillion Rehabilitation and Nursing Center, 1201 Hays Street, Tallahassee, Florida 32301, by United States Certified Mail, Return Receipt No. 7006 2760 0003 1537 3396 and to Joyce A. Cuffe, Administrator, 2900 Twelfth Street North, LLC d/b/a Lakeside Pavillion Rehabilitation and Nursing Center, 2900 12" Street North, Naples, Florida 34103, by United States Certified Mail, Return Receipt No. 7006 2760 0003 1537 3389 on this Mlle _say of arsgeuat ——, 2008. hon Daley J he Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 18 Copies furnished to: Joyce A. Cuffe, Administrator 2900 Twelfth Street North, LLC d/b/a Lakeside Pavillion Rehabilitation and Nursing Center 2900 12 Street North Naples, Florida 34103 (U.S. Certified Mail) Mary Daley Jacobs, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) Corporation Service Company, Registered Agent for 2900 Twelfth Street North, LLC d/b/a Lakeside Pavillion Rehabilitation and Nursing Center 1201 Hays Street Tallahassee, Florida 32301 (U.S. Certified Mail) Harold D. Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) Exhibit A Original Certificate of Conditional License For 2900 Twelfth Street North, LLC d/b/a Lakeside Pavillion Rehabilitation and Nursing Center Certificate No. 15230 License No. SNF12840962

Docket for Case No: 08-004439