0A-/3B0/ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION oy AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No: 06-01-0243-NH FRAES No: 2001049331 < SENIOR HEALTH PROPERTIES-SOUTH INC a ~ D/B/A/ WINTER HAVEN HEALTH «& REHABILITATION CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against SENIOR HEALTH PROPERTIES~SOUTH INC D/B/A/ WINTER HAVEN HEALTH AND REHABILITATION CENTER, (hereinafter “WINTER HAVEN”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine on WINTER HAVEN in the amount of $2500.00, pursuant to Section 400.121(3), Florida Statutes (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction Pursuant to Chapter 400, Part II, Florida Statutes (2001). 3. Venue lies in Polk County, Pursuant to Section 400.121(1) (e), Florida Statutes (2001). PARTIES rules governing skilled nursing facilities, Pursuant to Chapter 400, Part II, Florida Statutes (2001), and Chapter S9A~4 Fla, Admin. Code, 5. WINTER HAVEN Operates a 144-bed nursing home located at 202 Avenue “ov N.E., Winter Haven, Florida 33881. WINTER HAVEN is licensed as a skilled nursing facility, license number SNF1185096; certificate number 8017, effective 12/31/01 THROUGH 12/31/02. WINTER HAVEN was at all times Material hereto a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable rules, and Statutes. COUNT I WINTER HAVEN FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN AND MAINTAIN THE HIGHEST PRACTICABLE WELL-BEING OF THE RESIDENTS IN ACCORDANCE WITH ASSESSMENT AND PLAN OF CARE §400.022(1) (1) Fla. Stat. (2001); Fla. Admin. Code R. 59A- 4.1288 incorporating by reference 42 C.F.R. 483.25 CLASS II DEFICIENCY 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about September 7, 2001 a complaint investigation was conducted at WINTER HAVEN. Based upon a record review and staff interview it was determined that WINTER HAVEN neglected one of four sampled residents (#1), by failing to accurately assess and inform the physician of a decline in condition of Resident #1 resulting in avoidable harm of hospitalization The above constitutes a violation of § 400.23 (8) (b) Fla. Stat. (2001), and requires imposition of a fine. Claim for Relief WHEREFORE, the Agency requests the following relief: 1) Make factual and legal findings in favor of the Agency on Count 1; and 2) Recommend imposition of a fine in the amount of $2500 and; Se 3) Assess costs related to the investigation and prosecution of this case, pursuant to section 400.121(10), Fla. Stat. (2001). 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, 525 Mirror Lake Drive Suite 310J, St. Petersburg, Fl 33701 Eileen O'Hara Garcia ,Senior Attorney 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. a FRU: 0159100 per Eileen O'Hara Garcia Assistant General Counsel Florida Bar No. 504149 525 Mirror Lake Drive Suite 3107 St. Petersburg, Fl 33701 (727) -552-1439 (phone) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been sent by U.S. Certified Mail Return Receipt No #7001 2510 0004 3009 4093 to Larry Potter, Administrator, Winter Haven Health & Rehabilitation Center, 202 Avenue “0” Northeast, Winter Haven, Florida 33881 on this the [3TH day of February, 2002. fe Copies furnished to: jleen O'Hara GarcL Larry Potter, Administrator Winter Haven Health & Rehabilitation Center 202 Avenue “O” Northeast Winter Haven, Florida 33881 (U.S. Certified Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration (Inter-office mail) Eileen O'Hara Garcia Assistant General Counsel Agency for Health Care Administration (Inter-office mail)

Docket for Case No: 02-001301