STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2009011019 (Fines) 2009011021 (Cond.) SOUTH DAYTONA HEALTH CARE ASSOCIATES, LLC d/b/a OAKTREE HEALTHCARE, 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 South Daytona Health Care Associates, LLC, d/b/a Oaktree Healthcare (hereinafter “Respondent”), pursuant to §§120,569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 upon Respondent, pursuant to Sections 400.022(1)(1) and 400.23(8), Florida Statutes (2009). The imposition of this fine is based on two Class II deficiencies. The Agency also intends to impose a Conditional rating effective September 8, 2009 ending October 7, 2009, pursuant to section 400.23(7), Florida Statutes (2009). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. 1 Filed January 5, 2010 12:00 PM Division of Administrative Hearings. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of 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, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 65-bed nursing home, located at 650 Reed Canal Road, South Daytona, Florida 32119, and is licensed as a skilled nursing facility license number 1122096. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I RESPONDENT’S FACILITY FAILED TO PROTECT OTHER RESIDENTS FROM ONE RESIDENT WHO WAS IDENTIFIED AS BEING AT RISK OF INJURING OTHER RESIDENTS §§ 400.022(1)(1) and 400.102(1), Florida Statutes (2009) ISOLATED CLASS Wf DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to section 400.022(1)(1,) Florida Statutes, Florida law states: (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. 8. That pursuant to section 400,102(1), Florida Statutes, Florida law states: In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 9. That on September 8, 2009, the Agency conducted an unannounced complaint survey at the Respondent’s facility. The findings include: 10. An observation on 9/8/09 at 11:45 am revealed Resident #1 lying in a bed, completely covered by a blanket, in their room in the locked dementia unit of the facility. 11. A staff member was observed in the room with the resident. 12. It was observed Resident #1 shared a bedroom with another resident, Resident #3. 13. A review of Resident #1's clinical record revealed the resident had a Minimum Data Set (MDS) assessment dated 8/27/09. 14. The MDS coded the resident as having periods of restlessness, persistent anger with self or others and repetitive physical movements. 15. The MDS also coded Resident #1 as being verbally and physically abusive and the resident resisted care. 16. The resident was coded as being moderately impaired in decision making and as being able to independently move about the unit in which he/she lived. 17. Further review of the clinical record of Resident #1 revealed a care plan dated 12/4/07 for impaired cognition with long and short term memory problems and poor decision making. 18. Resident #1's 9/3/09 care plan addressed the need for total assist with activities of daily living with the staff to wear welder gloves when giving care if resident "is aggressive”. 19. The care plan of 9/3/09 further revealed the need for two Certified Nursing Assistants (CNA) at all times when providing care. 20. The resident was care planned for physical aggression (biting) as of 3/3/09. 21, Further review of the care plan revealed no revision of the care plan for physical aggression (biting) to protect other residents from being harmed, until 9/5/09 when one to one staffing for the resident was included. 22. Areview of the nurses notes in Resident #1's clinical record revealed a resident summary dated 3/22/09 stating under behavior problems "grabbing and biting." The summary also indicates violent/assaultive/physically abusive behavior. 23. A resident summary note dated 5/17/09 revealed "Pt agitated at times hits-spits at staff and residents." 24, A resident summary dated 7/18/09 stated "resident sometimes very agitated-grabs, hits and spits at other residents and staff. Has bitten other residents and staff". 25. Aresident summary dated 8/16/09 revealed "Bit another resident on thumb." 26. On 5/3/09 the nurses notes state "Awake entire night. Agitated, pounding on wall in room. Removed clothing and brief. Smeared feces on bed and floor, Antagonizing roommate, climbing on top of roommate and yelling at him/her." 27. On 5/4/09 Resident #1 “Attempted to sit on head of roommate. Removed wet brief and placed on roommate." 28, On 5/29/09 Resident #1 “climbed into the "B" bed naked, tugging on other resident. Unable to redirect." 29. On 6/1/09 Resident #1 "removed clothing and brief 3 x (times), climbed into bed naked grabbing out at resident and causing the resident in "B" bed to became very agitated. Removed from room each time, but (the resident) returns to room with same behaviors.” 30. On 6/14/09 Resident #1 was "Observed pulling on resident in "B" bed." “31. A review of nurses notes revealed on 7/29/09 Resident #1 "trying to crawl into bed with roommate (Resident #3), roommate yelling out, removed to his/her own bed." 32. A review of the facility provided incident log revealed Resident #1 had bitten other residents on 6/8/09, 7/11/09 and 8/1/09. 33, The incident log further stated that the incident on 8/1/09 resulted in wound to the resident who was bitten. 34, Further review of the facility incident log revealed an incident report dated 9/3/09 stating Resident #2 was observed sitting on Resident #1's bed. 35, Resident #2's finger on left hand was bleeding from a laceration at the finger tip and along the nail bed. Resident #1 was sleeping in his/her bed with blood on his/her mouth. 36. A review of the clinical record of Resident #2, revealed an MDS assessment dated 6/10/09. 37. | The MDS coded Resident #2 rarely/never understands others, was rarely/never understood, had repetitive physical movements and withdrawal from activities of interest. 38, Resident #2 was care planned for pacing the unit and mood and behavior as of 3/24/09. 39. Resident #2 was also coded as wandering daily and was care planned for severe cognitive loss as related to dementia as of 4/5/05. 40. Resident #2 was care planned for total assist with all activities of daily living and eating as of 4/10/07. 43. 41. An interview with a CNA in the locked unit at 12:11 pm on 9/8/09, revealed Resident #2 was not aggressive and was unable to defend him/herself. 42. A review of the clinical record noted that Resident #2 was bitten on 9/3/09 by Resident #1, 43. Further review of the clinical record of Resident #2 revealed a Resident Transfer Form dated 9/3/09 sending the resident to a local hospital. The reason for the transfer states "was bit by another Pt received injury to left hand." 44, A review of hospital documents revealed the resident had "human bite to left 3 finger and left hand and wrist." 45, An interview with Resident #3, Resident #1’s current roommate, at 2:41 PM on 9/8/09, revealed the resident was afraid of Resident #1. 46. An interview with the Administrator at 2:44 PM revealed Resident #1 was moved from room 27 to room 20 about 2 weeks ago. 47. An interview with the Administrator on 9/8/09 at 2:30 PM revealed Resident #3 could give limited information however Resident #3 would be moved to another room, leaving Resident #1 in a room by him/herself. 48. An interview with a CNA on 9/8/09 at 2:46 PM revealed that Resident #3, the former roommate of Resident #1, was not interviewable. 49. The Agency provided Respondent with the mandatory correction date for this deficient practice of October 8, 2009. 50. The above constitutes a violation of section 400.022(1)(), Florida Statutes, and constitutes an isolated class II deficiency pursuant to section 400.23(8)(b), Florida Statutes. $1. Based on the findings of a review of facility provided documents, a review of 2 residents clinical records, interview with one sampled resident and staff interviews, the facility failed to protect other residents from Resident #1, who was identified by the facility as being at risk of injuring other residents. 52. The facility did not ensure adequate supervision and a plan of care for Resident #1 to prevent this resident from inflicting physical harm and mental anguish to Residents #2 and #3. 53. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 400.102, Florida Statutes (2009), COUNT II 54, | The Agency re-alleges and incorporates paragraphs | and 2 of this Complaint as if fully set forth herein. 86. The Agency re-alleges and incorporates Count I of this Complaint as if fully set forth herein, 87. Based upon Respondent’s cited State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part IT of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2009). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing September 8, 2009. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Counts I and I. (B) Recommend administrative fines against Respondent in the amount of $2,500; (C) Impose a conditional license commencing September 8, 2009. (D) Assess attorney’s fees and costs; and 7 (BE) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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 AGENCY. Respectfully submitted this te day of December, 2009 D. Catlton Enfinee, , fa Fla. Bar. No. 793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4697 to: Facility Administrator Gus Murphy, Oaktree Healthcare, 650 Reed Canal Road, Dayton Beach, Florida 32119 and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4703 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 on December G , 2009: dD. Carlton Enfinger, Ty ( ) Copy furnished to: '" Rob Dickson, FOM FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST THOMAS W. ARNOLD GOVERNOR . SECRETARY December 3, 2009 Oaktree Healthcare 650 Reed Canal Road South Daytona, FL 32119 Re: License Issued for a Status Change to Standard Dear Administrator: The attached license with Certificate #16089 is being issued for the operation of your facility, Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Sincerely, Barbara Dombrowski Health Facilities Consultant Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need LORIDA F GOMPARE GARE Visit AHCA online at Health Care In the Sunshine http://ahca.myflorida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 ww.FloridaCompareCare.gov “ LICENSE #: SNF1122096 , Division of Health Quality Assurance tion, authorized in Chapter 400, Part I, Florida Statutes, and as 65 BEDS : -- TOTAL 650 REED CANAL ROAD OAKTREE HEALTHCARE SOUTH DAYTONA, FL 32119 Ss RY Sa Rn Py the licensee is authorized to operate the following: poets State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION ee DIVISION OF HEALTH QUALITY ASSURANCE fal © = 0 Z, — MN aa — Z. Sets See This is to confirm that SOUTH DAYTONA HEALTH CARE ASSOCIATES, LLC has complied with the mules and regulations adopted by the State of Florida, Agency For Health Care Ad: LICENSE EXPIRATION DATE: November 30, 2011 ACTION EFFECTIVE DATE: October 08, 2009 CERTIFICATE #: 16089 STATUS CHANGE FLORIDA AGENCY FOR HEAUTH CARE ADMINISTRATION CHARLIE CRIST : THOMAS W. ARNOLD GOVERNOR SECRETARY December 3, 2009 Oaktree Healthcare 650 Reed Canal Road South Daytona, FL 32119 Re: License Issued for a Status Change to Conditional Dear Administrator: The attached license with Certificate #16088 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Sincerely, [oarbare Qonbeerert Barbara Dombrowski Health Facilities Consultant Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need FLORIDA COMPARE CARE Visit AHCA online at Health Care in the Sunshine http://ahca.myfiorida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 ww.FloridaGompareCare.gov TLOC/OE/IT -ALVG NOILVaIEdXd ASNAOIT 6007/80/60 “ALVC FAILOSdIa NOLLOV FONVHDO SOLVLS $ddd $9 “IVLOL 6lIZ€ Td VNOLAVG HLNOS dvVOd TVNV)D Gaeta 069 FTaVOHLTVSH FAaLAVO :BuLmo]{oj ouR ayelodo 0} pozuoyNeE si sasusoy oy se pue ‘soimerg poly Ty Wed “OOp JodeyD ut pezuoymne ‘uonenstuupy ereD weay Joq Aowesy “epuopy jo aye1g ou Aq perdope suolyemnsal pur soynd ayy WIM poljdatoo sey DTT ‘SALVIOOSSV FAVO HLTVAH WNOLAVG HLNOS 28H wATMOD 0} st sty TVNOLLIGNOO HINOH ONISUON FONVANSSV ALITVNO HLTWAH AO NOISIAIG NOILVULSININGV Fav HLTVAH YO AONADV BPLIOL] JO 9327S S60CCITANS *# ASNAOIT 88091 :# ALVOIILYAO STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: South Daytona Health Care Associates, LLC d/b/a Oaktree Healthcare, CASE NO = 2009011019 2009011021 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to‘reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. J understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) | I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)__—s—s. dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), kuorida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed. action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC q7 Return Recalpt Feo (Endorgement Required) Restrloted Dalivery Fee (Endorsement Required) ‘Total Postage & Fees 7004 2890 DOOD S52b 4b ZN Aa.. Goade MA 44 § 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 mallplece, or on the front if space permits, 1. Article Addressed to: 7004 e650 0000 S5eb 4b47 3. Postmark. rCantoa rtifled Mail O Registered C1 Insured Mail PS Form 3811, February 2004 Domestic Return Receipt ress different from item 1? O] Yes It YES, enter delivery address below: No O Agent Z O Express Mail C] Retum Receipt for Merchandise O cop, 1540 | u703 | Cortified Fee Return Receipt Foo Postmark (Endorsement Toquirod) Here Restricted Dativery Fa (Endorgoment Floqulrad) ‘Total Postage & Feos 7004 2890 oo00 S525 SS oe 3Y ‘ 1 SENDER: COMPLETE: THIS SECTION ™ Complete Items 1, 2, and 3. Also complete Ay Signature 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 mallplece, or on the front if space permits, x 1 Agent O Addresses D. Is delivery address different from Item 1? [1] Yes If YES, enter delivery address below: O No + ail Adresse to Feayigendd, Aga SARE RAL RR Seri Kona ea Benen Vabichadas. RLBRA, 3. eye Type Certifled Mall © Express Mall 4 D Registered (© Return Recelpt for Merchandise |. C Insured Mat = 6,0.D, 4. Restricted Delivery? (Extra Fea) 552b 4703 7004 2890 Oooo February 2004 Domestic Return Recelpt PS Form 381

Docket for Case No: 10-000020