STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2019003347 CCRC OPCO-BRADENTON, LLC d/b/a THE NURSING CENTER AT FREEDOM VILLAGE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, CCRC OPCO-Bradenton, LLC d/b/a The Nursing Center At Freedom Village (“the Respondent”), and alleges: NATURE OF THE ACTION This is an action against a nursing home to impose an administrative fine of $4,000.00 and assign conditional licensure status effective April 26, 2018, and ending May 14, 2018, based on four uncorrected isolated class III deficiencies. PARTIES Is The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable state statutes and rules governing skilled nursing facilities pursuant to Chapters 400, Part II, and 408, Part II, Florida Statutes. (2016), and Chapter 59A-4, Florida Administrative Code. 2s The Respondent was issued a license by the Agency to operate a nursing home (“the Facility”) and was at all times material required to comply with the applicable statutes and rules governing nursing homes. COUNT I Fire Alarm System-Maintenance and Testing 3. Under Florida law, a fire alarm system must be tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing must be readily available. See NFPA 101 Life Safety Code (2015) 9.6.5, 9.6.7, 9.6.8. 4, Under Florida law, (1) Every licensed facility shall comply with all applicable standards and rules of the agency and shall: (h) Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner § 400.141(1)(h), Fla. Stat. (2018). 5. Under Florida law, (1) The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. (2) The licensee must provide: (a) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; (b) Clean bed and bath linens that are in good condition; (c) Furniture, such as a bed-side cabinet, drawer space; (d) Adequate and comfortable lighting levels in all areas; (e) Comfortable and safe room temperature levels in accordance with 42 CFR, Section 483.15(h)(6), which is effective October 1, 2014, and is incorporated by reference and available at http:/www.gpo.gov/fdsys/pkg/CFR-2014-title42- vol5/xml/CFR-2014-title42-vol5-sec483-15.xml and http://www. flrules.org/Gateway/reference.asp? No=Ref-06376; and, (f) The maintenance of comfortable sound levels. Individual radios, TVs and other such transmitters belonging to the residentwill be tuned to stations of the resident’s choice. (3) Each nursing home licensee must establish written policies designed to maintain the physical plant and overall nursing home environment to assure the safety and well-being of residents. (4) The building and mechanical maintenance programs must be supervised by a person who is knowledgeable in the areas of building and mechanical maintenance as determined by the facility. (5) All mechanical and electrical equipment must be maintained in working order and must be accessible for cleaning and inspection. (6) All heating, ventilation and air conditioning (HVAC) systems must be maintained in accordance with the manufacturer’s recommendation to ensure they are operating within specified parameters to meet manufacturers’ specifications. Operation manuals and as-built drawings must be maintained for equipment installed after June 1, 2015. Fla. Admin. Code R. 59A-4.122. 6. On or about March 13, 2018, the Agency conducted a survey of the Facility. 7. Based on record review and interview, the Facility failed to properly maintain its Fire Alarm System. Properly maintaining the Fire Alarm System ensures its proper operation and lessens the chance of a delayed alarm activation in the event of an emergency/hazardous condition. 8. On 3/13/18, at 9:15 AM, a record review was conducted, with the Facility’s Maintenance Director, on the Facility’s records. 9. Documentation, dated 3/10/16, was found for the Facility’s annual Fire Alarm System inspection. 10. The documentation found consists of a single page. 11. The documentation found fails to meet the NFPA 72 record requirements, as required. 12. No documentation was found showing that the Facility has had its Fire Alarm System inspected on a quarterly basis. 13, Documentation was found showing that the Facility’s last semi-annual Fire Alarm System inspection was completed on 4/28/17. 14. By having its last documented semi-annual Fire Alarm System inspection on 4/28/17, the Facility has failed to meet the inspection frequency requirements listed in NFPA 72 as required. 15. The documentation regarding the Facility’s inspection completed on 4/28/17 indicates that a sensitivity test was conducted. 16. However, that documentation does not indicate that a Duct Detector Differential Pressure test was conducted as required. 17. On 3/13/18, an interview was conducted with the Maintenance Director. 18. | The Maintenance Director confirmed the above findings. 19. The Facility failed to properly maintain its Fire Alarm System in accordance with § 400.141(1)(h), Fla. Stat. (2018), NFPA 25, and NFPA 101 Life Safety Code (2015) 19.3.4.1, 9.6. 20. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 21. The Agency cited the Respondent for an isolated class III deficiency and provided it a mandatory correction date. 22. On or about April 26, 2018, subsequent to the mandatory correction date, the Agency conducted a follow-up survey of the Facility. 23. Based on record review and interview, the Facility failed to properly maintain its Fire Alarm System. Properly maintaining the Fire Alarm System ensures its proper operation and lessens the chance of a delayed alarm activation in the event of an emergency/hazardous condition. 24, On 4/26/18, at 9:30 AM, a record review was conducted, with the Facility’s Maintenance Director, on the Facility’s records. 25. Documentation, dated 3/10/17, was found for the Facility’s annual Fire Alarm System inspection. 26. The documentation found consists of a single page. 27. The documentation found fails to meet the NFPA 72 record requirements, as required. 28. No documentation was found showing that the Facility has had an annual Fire Alarm System inspection conducted within the current year. 29. | Documentation was found showing that the Facility’s last semi-annual Fire Alarm System inspection was completed on 4/28/17. 30. By having its last documented semi-annual Fire Alarm System inspection on 4/28/17, the Facility has failed to meet the inspection frequency requirements listed in NFPA 72 as required. 31. The documentation regarding the Facility’s inspection completed on 4/28/17 indicates that a sensitivity test was conducted. 32. However, that documentation does not indicate that a Duct Detector Differential Pressure test was conducted as required. 33. On 4/26/18, an interview was conducted with the Maintenance Director. 34. | The Maintenance Director confirmed the above findings. 35. The Facility failed to properly maintain its Fire Alarm System in accordance with § 400.141(1)(h), Fla. Stat. (2018), NFPA 25, and NFPA 101 Life Safety Code (2015) 19.3.4.1, 9.6. 36. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 37. | The Agency cited the Respondent for an uncorrected isolated class III deficiency. Sanction 38. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2018). 39. Under Florida law: A class III deficiency is 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. Ifa class Ill deficiency is corrected within the time specified, a civil penalty may not be imposed. § 400.23(8)(c), Fla. Stat. (2018). 40. Under Florida law, a conditional licensure status means that a facility, due to the presence of one or more class I or class I deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. § 400.23(7)(b), Fla. Stat. (2018). 41. Due to the presence of an uncorrected class III deficiency at the time of the survey, the Agency assigned the Respondent conditional licensure status with a beginning date and ending date as set forth above. WHEREFORE, the Agency seeks to impose an administrative fine of $1,000.00 and the assignment of conditional licensure status against the Respondent based upon one uncorrected isolated class III deficiency. COUNT II Sprinkler System-Maintenance and Testing 42. Under Florida law, all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 (2011 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). See NFPA 101 Life Safety Code (2015) 18.3.5, 19.3.5, and 9.7.5. 43. Under Florida law, Sprinkler System - Maintenance and Testing- Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source See NFPA 101 Life Safety Code (2015) 9.7.5, 9.7.7, and 9.7.8. 44, Under Florida law, (1) Every licensed facility shall comply with all applicable standards and rules of the agency and shall: (h) Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner § 400.141(1)(h), Fla. Stat. (2018). 45. Under Florida law, (1) The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. (2) The licensee must provide: (a) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; (b) Clean bed and bath linens that are in good condition; (c) Furniture, such as a bed-side cabinet, drawer space; (d) Adequate and comfortable lighting levels in all areas; (e) Comfortable and safe room temperature levels in accordance with 42 CFR, Section 483.15(h)(6), which is effective October 1, 2014, and is incorporated by reference and available at http://www.gpo.gov/fdsys/pkg/CFR-2014-title42- vol5/xml/CFR-2014-title42-vol5-sec483-15.xml and http://www. flrules.org/Gateway/reference.asp?No=Ref-06376; and, (f) The maintenance of comfortable sound levels. Individual radios, TVs and other such transmitters belonging to the residentwill be tuned to stations of the resident’s choice. (3) Each nursing home licensee must establish written policies designed to maintain the physical plant and overall nursing home environment to assure the safety and well-being of residents. (4) The building and mechanical maintenance programs must be supervised by a person who is knowledgeable in the areas of building and mechanical maintenance as determined by the facility. (5) All mechanical and electrical equipment must be maintained in working order and must be accessible for cleaning and inspection. (6) All heating, ventilation and air conditioning (HVAC) systems must be maintained in accordance with the manufacturer’s recommendation to ensure they are operating within specified parameters to meet manufacturers’ specifications. Operation manuals and as-built drawings must be maintained for equipment installed after June 1, 2015. Fla. Admin. Code R. 59A-4,122. 46. | Onor about March 13, 2018, the Agency conducted a survey of the Facility. 47. Based on observation, record review, and interview, the Facility failed to properly maintain its Automatic Fire Sprinkler System (AFSS). Failing to properly maintain the AFSS could result in a delayed or premature response from the AFSS. During an emergency situation, this could potentially affect all occupants in the Facility. 48. On 3/13/18, at 9:15 AM, a tour of the Facility was conducted with the Facility’s Maintenance Director. 49. Four corroded sprinklers were observed in dish washing area of the Facility’s dietary kitchen. 50. A record review was conducted on the Facility’s records. 51. No documentation was found showing that the Facility had a sprinkler inspection conducted during the third quarter of 2017, as required. 52. On 3/13/18, an interview was conducted with the Maintenance Director. 53. | The Maintenance Director confirmed the above findings. 54. The Facility failed to properly maintain its AFSS in accordance with § 400.141(1)(h), Fla. Stat. (2018), NFPA 25, and NFPA 101 Life Safety Code (2012) 18.3.5, 19.3.5, 9.7.5, 9.7.7, and 9.7.8. 55. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 56. The Agency cited the Respondent for an isolated class III deficiency and provided it a mandatory correction date. 57. On or about April 26, 2018, subsequent to the mandatory correction date, the Agency conducted a follow-up survey of the Facility. 58. Based on observation and interview, the Facility failed to properly maintain its Automatic Fire Sprinkler System (AFSS). Failing to properly maintain the AFSS could result in a delayed or premature response from the AFSS. During an emergency situation, this could potentially affect all occupants in the Facility. 59. On 4/26/18, at 9:50 AM, a tour was conducted of the Facility with the Facility’s Maintenance Supervisor. 60. Four corroded sprinklers were observed in dish washing area of the Facility’s dietary kitchen. 61. On 4/26/18, an interview was conducted with the Maintenance Director. 62. | The Maintenance Director confirmed the above findings. 63. The Facility failed to properly maintain its AFSS in accordance with § 400.141(1)(h), Fla. Stat. (2018), NFPA 25, and NFPA 101 Life Safety Code (2012) 18.3.5, 19.3.5, 9.7.5, 9.7.7, and 9.7.8. 64. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 65. The Agency cited the Respondent for an uncorrected isolated class III deficiency. Sanction 66. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2018). 67. Under Florida law: A class III deficiency is 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class Ill deficiency is corrected within the time specified, a civil penalty may not be imposed. § 400.23(8)(c), Fla. Stat. (2018). 68. Under Florida law, a conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class II deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. § 400.23(7)(b), Fla. Stat. (2018). 69. Due to the presence of an uncorrected class III deficiency at the time of the survey, the Agency assigned the Respondent conditional licensure status with a beginning date and ending date as set forth above. WHEREFORE, the Agency seeks to impose an administrative fine of $1,000.00 and the assignment of conditional licensure status against the Respondent based upon one uncorrected isolated class [II deficiency. 11 COUNT IL Subdivision Of Building Spaces-Smoke Barriers 70. Under Florida law, Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly. NFPA 101 Life Safety Code (2012) 8.3.5.1. 71. Under Florida law, EXISTING SMOKE BARRIERS- Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. NFPA 101 Life Safety Code (2015) 19.3.7.3 and 8.6.7.1(1). 72. Under Florida law, NEW SMOKE BARRIERS- Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations of fully ducted HVAC systems. NFPA 101 Life Safety Code (2015) 18.3.7.3, 18.3.7.4, 18.3.7.5, and 8.3. 73. Under Florida law, (1) Every licensed facility shall comply with all applicable standards and rules of the agency and shall: (h) Maintain the facility premises and equipment and conduct its operations in a 12 safe and sanitary manner § 400.141(1)(h), Fla. Stat. (2018). 74. Under Florida law, (1) The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. (2) The licensee must provide: (a) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; (b) Clean bed and bath linens that are in good condition; (c) Furniture, such as a bed-side cabinet, drawer space; (d) Adequate and comfortable lighting levels in all areas; (e) Comfortable and safe room temperature levels in accordance with 42 CFR, Section 483.15(h)(6), which is effective October 1, 2014, and is incorporated by reference and available at http://Awww.gpo.gov/fdsys/pkg/CFR-2014-title42- vol5/xml/CFR-2014-title42-vol5-sec483-15.xml * and http://www. flrules.org/Gateway/reference.asp?No=Ref-06376; and, (f) The maintenance of comfortable sound levels. Individual radios, TVs and other such transmitters belonging to the residentwill be tuned to stations of the resident’s choice. (3) Each nursing home licensee must establish written policies designed to maintain the physical plant and overall nursing home environment to assure the safety and well-being of residents. (4) The building and mechanical maintenance programs must be supervised by a person who is knowledgeable in the areas of building and mechanical maintenance as determined by the facility. (5) All mechanical and electrical equipment must be maintained in working order and must be accessible for cleaning and inspection. (6) All heating, ventilation and air conditioning (HVAC) systems must be maintained in accordance with the manufacturer’s recommendation to ensure they are operating within specified parameters to meet manufacturers’ specifications. Operation manuals and as-built drawings must be maintained for equipment installed after June 1, 2015. Fla. Admin. Code R. 59A-4,122. 75. On or about March 13, 2018, the Agency conducted a survey of the Facility. 76. Based on record review and interview, the Facility failed to properly maintain its fire/smoke dampers within its heating, ventilation, and air conditioning (HVAC) system. The Facility also failed to properly maintain relevant documentation regarding its fire/smoke dampers. 77. Fire/smoke dampers help prevent the spread of fire and smoke between rooms, during an emergency situation, by sealing the HVAC ducts. Fire/smoke dampers must be serviced to maintain proper operation. 78. On 3/13/18, at 9:15 AM, a record review was conducted, with the Facility’s Maintenance Director, on the Facility’s records. 79. Documentation was found showing that the Facility had a fire/smoke damper inspection conducted in August of 2015. 80. That documentation indicates that several failures were identified during that inspection. 81. Documentation was found showing that, as of 3/27/17, corrections had been completed on all but one of the fire/smoke dampers. 82. That documentation indicates that a fire/smoke damper, identified as 1-FD-074, has not been corrected. 83. Documentation was found indicating that the other fire/smoke dampers that failed the August 2015 inspection were then either sealed off or removed. 84. No documentation was found showing that the Facility had received a cursory review from the Agency’s Office of Plans and Construction prior to sealing off and removing fire/smoke dampers. 85. On 3/13/18, an interview was conducted with the Maintenance Director. 86. The Maintenance Director confirmed the above findings. 87. The Facility failed to ensure that all fire/smoke dampers are properly maintained in accordance with NFPA 101 Life Safety Code (2015) 8.3.5.1, 8.4.6.2, 8.5.5.2, 8.6.7.1(1), 18.3.7.3, 18.3.7.4, 18.3.7.5, and 19.3.7.3. 88. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 89. The Agency cited the Respondent for an isolated class III deficiency and provided it a mandatory correction date. 90. On or about April 26, 2018, subsequent to the mandatory correction date, the Agency conducted a follow-up survey of the Facility. 91. Based on record review and interview, the Facility failed to properly maintain its fire/smoke dampers within its heating, ventilation, and air conditioning (HVAC) system. The Facility also failed to properly maintain relevant documentation regarding its fire/smoke dampers. 92. Fire/smoke dampers help prevent the spread of fire and smoke between rooms, during an emergency situation, by sealing the HVAC ducts. Fire/smoke dampers must be serviced to maintain proper operation. 93. On 4/26/18, at 9:30 AM, a record review was conducted, with the Facility’s Maintenance Director, on the Facility’s records. 94. Documentation was found showing that the Facility had a fire/smoke damper inspection conducted in August of 2015. 95. That documentation indicates that several failures were identified during that inspection. 15 96. Documentation was found indicating that the fire/smoke dampers that failed the August 2015 inspection were then either sealed off or removed. 97. No documentation was found showing that the Facility had received a cursory review from the Agency’s Office of Plans and Construction prior to sealing off and removing fire/smoke dampers. 98. On 4/26/18, an interview was conducted with the Maintenance Director. 99. The Maintenance Director confirmed the above findings. 100. The Facility failed to ensure that all fire/smoke dampers are properly maintained in accordance with NFPA 101 Life Safety Code (2015) 8.3.5.1, 8.4.6.2, 8.5.5.2, 8.6.7.1(1), 18.3.7.3, 18.3.7.4, 18.3.7.5, and 19.3.7.3. 101. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 102. The Agency cited the Respondent for an uncorrected isolated class III deficiency. Sanction 103. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2018). 104. Under Florida law: A class III deficiency is 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class II] deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, a civil penalty may not be imposed. § 400.23(8)(c), Fla. Stat. (2018). 105. Under Florida law, a conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. § 400.23(7)(b), Fla. Stat. (2018). 106. Due to the presence of an uncorrected class III deficiency at the time of the survey, the Agency assigned the Respondent conditional licensure status with a beginning date and ending date as set forth above. WHEREFORE, the Agency seeks to impose an administrative fine of $1,000.00 and the assignment of conditional licensure status against the Respondent based upon one uncorrected isolated class III deficiency. COUNT IV Gas Equipment-Cylinder and Container Storage 107. Under Florida law, Gas Equipment-Cylinder and Container Storage: Greater than or equal to 3,000 cubic feet- storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet- storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet- in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. See NFPA 99 (2012) 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.4.3.1.1, 11.6.5. 108. Under Florida law, (1) Every licensed facility shall comply with all applicable standards and rules of the agency and shall: (h) Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner § 400.141(1)(h), Fla. Stat. (2018). 109. On or about March 13, 2018, the Agency conducted a survey of the Facility. 110. Based on observation and interview, the Facility failed to properly store and handle oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of all staff, residents, and visitors in the Facility. 111. On 3/13/18, between 10:30 AM and 3 PM, a tour of the Facility was conducted with the Facility’s Maintenance Director. 112. Inside the C-wing medical gas storage room, 15 E-size oxygen cylinders with combustibles were observed stored within five feet of oxidizing gas(es). 113. Inside resident room #115, one E-size oxygen cylinder was observed unsecured on a single use cart. 114. No stay/set-screw was observed securing the oxygen cylinder to the cart. 115. On 3/13/18, an interview was conducted with the Maintenance Director. 116. The Maintenance Director confirmed the above findings. 117. The Facility failed to properly store and handle oxygen cylinders, in accordance with NFPA 99 (2012) 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.4.3.1.1, 11.6.5. 118. This failure 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 and thus this deficient practice constitutes an isolated Class II] deficiency. 119. The Agency cited the Respondent for an isolated class III deficiency and provided it a mandatory correction date. 120. On or about April 26, 2018, subsequent to the mandatory correction date, the Agency conducted a follow-up survey of the Facility. 121. Based on observation and interview, the Facility failed to properly store and handle oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of all staff, residents, and visitors in the Facility. 122. On 4/26/18, at 9:50 AM, a tour of the Facility was conducted with the Facility’s 19 Maintenance Director. 123. Inside the A-wing medical gas storage room, 14 E-size oxygen cylinders and two J-size oxygen cylinders (exceeding 300 cubic feet) with combustibles were observed stored within five feet of oxidizing gas(es). 124. Inside the C-wing medical gas storage room, 14 E-size oxygen cylinders (exceeding 300 cubic feet) with combustibles were observed stored within five feet of oxidizing gas(es). 125. On 4/26/18, an interview was conducted with the Maintenance Director. 126. The Maintenance Director confirmed the above findings. 127. The Facility failed to properly store and handle oxygen cylinders, in accordance with NFPA 99 (2012) 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.4.3.1.1, 11.6.5. 128. This failure 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 and thus this deficient practice constitutes an isolated Class III deficiency. 129. The Agency cited the Respondent for an uncorrected isolated class III deficiency. Sanction 130. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2018). 131. Under Florida law: A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or 20 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. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, a civil penalty may not be imposed. § 400.23(8)(c), Fla. Stat. (2018). 132. Under Florida law, a conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the Agency. § 400.23(7)(b), Fla. Stat. (2018). 133. Due to the presence of an uncorrected class III deficiency at the time of the survey, the Agency assigned the Respondent conditional licensure status with a beginning date and ending date as set forth above. WHEREFORE, the Agency seeks to impose an administrative fine of $1,000.00 and the assignment of conditional licensure status against the Respondent based upon one uncorrected isolated class III deficiency. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks an order that: 1. Makes findings of fact and conclusions of law in favor of the Agency. 21 2. Imposes the remedies against the Respondent as set forth above. Respectfully Submitted, Maire ee Maurice T. Boetger, Assistant General Counsel Florida Bar No. 0125192 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3536 Facsimile (850) 922-9634 Email: maurice.boetger@ahca.myflorida.com 22° NOTICE Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28-106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. 23 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the individuals named below by the method designated on this ‘4 © day of April, 2019. Wrawce Maurice T. Boetger, Assistant General Counsel Florida Bar No. 0125192 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 7 Tallahassee, Florida 32308 Telephone (850) 412-3536 Facsimile (850) 922-9634 Email: maurice.boetger@ahca.myflorida.com Administrator | Administrator The Nursing Center At Freedom Village The Nursing Center At Freedom Village 6410 21st Ave. W. 111 Westwood Place Bradenton, Florida 34209 Suite 400 (Certified Mail) Brentwood, Tennessee 37027 (Certified Mail) 9489 O90 OO2¢? BO4b 400b 14 3489 OO90 0027 &O04b 4o0b o2 24 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: CCRC OPCO-Bradenton, LLC d/b/a The Nursing Center At Freedom Village AHCA No. 2019003347 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but_must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. 25 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), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 26 USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 9489009000276046400602 Your item was delivered to the front desk, reception area, or mail room at 1:22 pm on May 13, 2019 in BRENTWOOD, TN 37027. Status Delivered May 13, 2019 at 1:22 pm Delivered, Front Desk/Reception/Mail Room BRENTWOOD, TN 37027 Get Updates Delivered USPS Tracking: Tracking FAQs_ Track Another Package + Remove Tracking Number: 9489009000276046400619 Your item was delivered to the front desk, reception area, or mail room at 11:21 am on May 2, 2019 in BRADENTON, FL 34209. Status Delivered May 2, 2019 at 11:21 am Delivered, Front Desk/Reception/Mail Room BRADENTON, FL 34209 Get Updates Delivered

Docket for Case No: 20-000559

Orders for Case No: 20-000559