STATE OF FLORIDA Division of Administrative Hears. AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA F | [ F AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No: 2001067601 vs. Return Receipt Requested #7000 1670 0011 4848 0128 ANDIE’S, INC., d/b/a WILLOW MANOR RETIREMENT HOME, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Andie’s, Inc., d/b/a Willow Manor Retirement Home (hereinafter “Willow Manor”) pursuant to 28-106.111 Florida Administrative Code (2000) (F.A.C.) and Chapter 120, Florida Statutes ("Fla. Stat."), hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of five thousand five hundred ($5,500) dollars pursuant to Section 400.419(1) (a), Fla. Stat. cS J JS | SS Sa sR: JURISDICTION AND VENUE 2. This court has jurisdiction Pursuant to Sections 120.569 and 120.57, Fla. Stat. and Chapter 28-106.207 F.A.C. 3. Venue lies in Broward County, Florida pursuant to 120.57, Fla. Stat. and Chapter 28-106.207, F.A.C. PARTIES 4. AHCA is the enforcing authority with regard to assisted living facility licensure law, pursuant to Chapter 400, Part III, Fla. Stat., and Chapter S8A-5, F.A.C. 5. Willow Manor is an assisted living facility located at 150 Stirling Road, Dania, Florida 33004 and is licensed under Chapter 400, Part III, Fla. stat. and Chapter 58A-5, F.A.C. COUNT I WILLOW FAILED TO NOTIFY THE PHYSICIAN AND THE FAMILY OR FURTHER ADDRESS THE RESIDENTS SIGNIFICANT CHANGE (WEIGHT LOSS) 58A-5.0182(1) (d), F.A.c. (RESIDENT CARE STANDARDS) CLASS II 6. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 10/22/01 and based on record review and interview there were three residents (#1,#4 and #5) who had exhibited a significant change and there was no documentation that the facility had notified the physician and the family. 8. During record review of Resident #1 it was noted that upon admission to the facility on 08/07/01 the resident weighed 113 pounds. On 09/28/01 the resident's weight was recorded as 105 pounds, an 8 pound weight loss. On 09/28/01 the facility documented that the resident was lethargic, with a poor appetite. Facility notes written by the staff and the physicians document a decline in the resident's condition (the Health Assessment completed on 07/30/01 documents that the resident required supervision for all ADL's. By 10/10 the facility documented that the resident had to be fed.) The resident was ordered to have Ensure supplement three times a day. The entries were initialed on the MOR as given, however, the pharmacy only billed the resident for 48 cans in September when if the resident had been receiving all the ordered amount the pharmacy should have billed for 90 cans. 9. There was no documentation that the facility addressed the weight loss. There was no documentation that the facility notified the physician specifically about the resident's weight loss. The Resident Care coordinator was interviewed and unable to explain why the facility did not address the weight loss. 10. The same resident was noted to have a nasal discharge on 10/04/01. The physician was called. The next three days there are notes in the record that the resident continued to have a nasal discharge and the Physician still had not called back until 10/08 at which time an antibiotic was ordered. The Resident Care coordinator was unable to explain why it took 4 days to get a response from the physician and what other efforts the facility might have made to contact another Physician or the family in order to obtain treatment for the resident. 11. Resident #4's weight in 08/01 was 83 pounds and in 09/01 the weight was recorded as 79 and a half, almost a 4 pound weight loss in one month. Further record review revealed no documentation that the facility addressed the weight loss, including notifying the Physician and family. The Resident Care coordinator was interviewed and was unable to provide an explanation. 12. Resident #5's weight in 08/01 was 138 pounds and in 09/01 was 130 pounds, an 8-pound loss. Further record review revealed no documentation that the facility addressed the weight loss, including notifying the physician and family. The Resident Care coordinator was interviewed and was unable to provide an explanation. 13. Based on the foregoing, Willow Manor, violated 58A-5.0182(1) (d), F.A.C., a class II violation which carries, in this case, an assessed fine of $5,000. COUNT II ASSISTED LIVING FACILITY SURVEY FEE (400.419(9), Fla. Stat.) 14. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 15. In addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of the facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was subject of the complaint or monitoring visits conducted under §400.428(3) Fla. Stat. to verify the correction of the violations. 16. Based on the foregoing, the Agency is imposing a $500 fine. CLAIM FOR RELIEF WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: A. Make a factual and legal finding in favor of the Agency on Counts I and II. B. Assess against Willow Manor an administrative fine of $5,5000 for a Class II violation in Count I in accordance with Section 400.419(1) (b), and 400.419(9) Fla. Stat. : Cc. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 NW 53°" Street, Miami, Florida 33166; Nelson Rodney. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT oF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. rr cemmmcenenccen muoe nese | aeeuetneteue cunnounsestenmaseenees eutsten msnhieentaesere: Issued this 2 y day of , 2002. Assistant General c unsel Agency for Health Cadre Administration 8355 NW 53°49 Street Miami, Florida 33166 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing complaint and election of rights was sent by U.S. Certified Mail, Return Receipt Requested to Mary Ann Signore, Administrator, Willow Manor Retirement Home, 150 Stirling Road, Dania, Florida 33004 on ekson Rddney Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive West Palm Beach, Florida 33407 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 ALF Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 cS SS sete cbesnenesnsmanesnsenee ee SV: [SSS eeesesaeeeasesesetssiese see STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: CASE NAME: Willow Manor CASE No. 2001067601 ELECTION OF RIGHTS PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 6 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 6 =f do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal Proceeding, pursuant to Section 120. 57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penaity imposed. OPTION THREE (3) 8 Ido dispute the allegations of fact contained 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. If you choose OPTION THREE (3), in order to obtain a formal Proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations Charged and imposing the penalty sought in the Complaint. If you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. () Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT Now — REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES, (Please sign and fill in your current address.) Respondent (Licensee) Address: —_— —_—_—__-._-+—T License. No. and facility type: Phone No. _ ee PLEASE RETURN YOUR COMPLETED FORM TO: Agency for Health Care Administration, Nelson Rodney, Assistant General Counsel, 8355 NW 53” Street, Miami Florida 33166 Telephone Number: (305) 499-2165_; FAX (305) 499-2195 + TDD 1-800-955-8771, reer —A a | Sa ener enna ates STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (To be used in conjunction with Election of Rights form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency’), you must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. If you do not dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you Quilty of the violations charged and imposing the penalty sought in the Complaint. You will be Provided a Copy of the final order, OPTION? if you do not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you May request an informal hearing pursuant to Section 120.57(2), Florida Statutes (1999) before the Agency. At the informal hearing, you will be given an pportunity to present both written and oral evidence to reduce the Penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you May request a formal hearing pursuant to Section 120.57(1), Florida Statutes (1999). To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal Proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the Material facts you dispute, sought in the Complaint.

Docket for Case No: 02-001293