Certified Mail Receipt > (7004 1160 0003 3739 8835) STATE OF FLORIDA a AGENCY FOR HEALTH CARE ADMINISTRATION S Cg STATE OF FLORIDA & AGENCY FOR HEALTH CARE ADMINISTRATION, Ol “O71 G a Petitioner, AHCA.NO: 2005010739 «& VS. SENIOR LIFESTYLES, LLC, d/b/a Eye KIPLING MANOR RETIREMENT CENTER, “es ON Respondent. % eS COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Senior Lifestyles, LL.C., d/b/a Kipling Manor Reticeracnt Center, (hereinafter, “Kipling Manor Retirement Center”) pursuant to Section 120.569, and 120.57, Fla. Stat. (2005), alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Kipling Manor - Retirement Center, pursuant to Sections 400.419(2c)}, Fla. Stat. (2005), and Sections 58A- 5.023(13b), Fla. Admin. Code (2005). JURISDICTION AND VENUE 1. This Agency has jurisdiction pursuant to 400, Part IH and Section Sections 120.569 and 120.57, Fla. Stat. (2005). aes LaTRCven- ‘A Z. Venue lies in Escambia County, Pensacola, Flotida, pursuant to Section 120.57 Fla, Stat. (2005); Rule 58A-5, Florida Administrative Code (2005), and Section 28,106,207, Fla, Stat. (2005), ) PARTIES 3. AHCA, is the regulatory authority responsible for Jicensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part ITI, Fla. Stat. and Rules 584-5, Florida Administrative Code (2005). 4. Kipling Manor Retirement Center is a for-profir corporation, whose 65-bed assisted living facility is located at 7901 Kipling Street, Pensacola, FL. Kipling Manor Retirement Center is licensed as an assisted living facility license # ALT285; certificate number #19076, effective August 27, 2005 through August 26, 2007. Kipling Manor Retirement Center was at all times material hereto, licensed faciliry under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNTI KIPLING MANOR RETIREMENT CENTER FAILED TO ENSURE THAT THE FACILITY’S INTERIOR SYRUCTURE, TO INCLUDE THE CEILING AND EXIT POORS, WAS NOT STRUCTURALLY SOUND AND IN GOOD REPAIR. STATE TAG A1002-PHYSICAL PLANT STANDARDS Section 400.419(2)(c), Fla. Stat. (2005) VIOLATIONS, IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 58A-5.023(1)(b), Fla. Stat..(2005) PHYSICAL PLANT STANDARDS 5. AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 6. On or about October 24, 2005, AHCA conducted a follow-up survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: 24% nina Oe AO a) On or about July 26, 2005, Kipling Manor Retirement Center failed to ensure that the facility's interior structure, to include the ceiling, was nor strucrurally sound and in good repair. b) During a follow-up survey on or about October 24, 2005, Kipling Manor Retirement Center failed to ensure that the facility's interior structure, to include the ceiling and exit doors, was not structurally sound and in good repair. The findings include: During the initial tour of the facility at approximately 10:35 AM on 10/24/05, the ceiling in the hallway in the vicinity of room 15 was found to be bulging with large dark water steins noted. The area was also nated to have dark discoloration indicative of mold and mildew. The exit door, between rooms 14 & 15, to the south screened area had a broken door opening bar, The retaining bracket at the door hinge edge of the door was missing. Throughout the faciliry the walls were noted to be chipped and scuffed, particularly on the closed unit, The chipping away of the sheet rock was most severe at the procuding wall corners in rooms 9B and 10B. At 12:15 PM, the administrator acknowledged the findings and smred, "We're working on this stuff. We just haven't gotten to these areas yet. Repair parts have been ordered, but have not arrived.” The administrator was unable to shaw documentation of orders of repair/replacement items. 7. The regulatory provisions of the Florida Statutes that are pextinent to this alleged violation read as follows: 400.419 Violations; imposition of adnainistrative fines; grounds. - (Z){c) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility ot to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class 1 or class II violations. The agency shall impose an administrative fine for a cited class If violation in an amount not less than $500 and not exceeding $1,000 for each violation. A citation for a class JE} violation roust specify the ime within which the violation is required red Loy Se eT POC ee 10: 9346932 P.5 to be corrected, Ef a class Il violation is corrected within the time specified, no fine may be imposed, unless it is a repeated offense. Rule 584-5.023 Physical Planc Standards. - (1)(b) The facility's physical structure, including the interior and exterior walls, floors, roof, and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or teplaced. Windows, doors, plumbing, and applications shall, be functional and in goad working order, All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled for safety reasons provided they are functionally available when needed, o 8 et 8. The violation alleged herein constitutes a class III deficiency, and warrants a fine of $500. WHEREFORE, AHCA demands the following relief. 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Tmpose a fine in the amount of $500. ye Respectfully submisted this 7 day of January 2006. Michael ©. Mathis Fla. Bar, No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922.5873 (office) * (850) 921.0158 (fax) JAN-S-2O@6 15:55 FROM:KM KIPLING MANOR 8584782864 TO: 9246932 ‘Respondent is notified that it has a right to tequest an administrative hearing pursuant to Section 120.569, Fla. Stat. (2004). Specific options for adroinistrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page), All requests for hearing shall be rade to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael ©. Mathis, Senior Attorney, Telephone (950) 922-5873. RESPONDENT 1S FURTHER ‘NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE . THEREBY CERTIF Het a tuc and correct copy of the foregoing has been sexved by certified mail on Y day of Jan. 2006 to Shannon Woody, Administrator, Kipling Manor Retirement Center, 790 Kipling Street, Pensacola, Florida 32514. Michael O. Mathis, Esquire STATE OF FLORIDA bing AGENCY FOR HEALTH CARE ADMINISTRATION [6 Ng R- 3 wi fe AGENCY FOR HEALTH CARE Adin, ‘p ADMINISTRATION, MEAG ING Petitioner, vs. AHCA Case No. 2005010739 SENIOR LIFESTYLES, L.L.C d/b/a KIPLING MANOR RETIREMENT CENTER, Respondent. PETITION FOR FORMAL ADMINISTRATIVE PROCEEDINGS Respondent, SENIOR LIFESTYLES, L.L.C d/b/a KIPLING MANOR RETIREMENT CENTER (“Kipling Manor”), by and through the undersigned counsel and pursuant to Sections 120.569 and 120.57(1), Florida Statutes, and Rule 28-106.201, Florida Administrative Code, petitions the State of Florida, Agency for Health Care Administration (“AHCA” or “Agency”) for a formal administrative hearing challenging the administrative complaint filed by the Agency of January 4, 2006. Kipling Manor states: 1. The Agency affected by this proceeding is the State of Florida, Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308. The Agency may be contacted through its counsel, Michael O. Mathis, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308, telephone number (850) 922-5873. The Agency file number assigned to this matter is Case No. 2005010739. 2. Kipling Manor’s address and telephone number are 7901 Kipling Street, Pensacola, Florida 32514, telephone number (850) 478-9051. Kipling Manor’s representatives in this matter and who shall be the contact persons and address for purposes of service during the course for this proceeding is its legal counsel, John F. Gilroy, I, P.A., 1725 Mahan Drive, Suite 210, Tallahassee, Florida 32308, telephone number (850) 671-2644. 3. On or about January 4, 2006, the Agency filed an administrative complaint against Kipling Manor seeking to impose an administrative penalty against Kipling Manor pursuant to Section 400,419(2)(c), Florida Statutes (2005). Kipling Manor received the administrative complaint through service by certified mail on or about January 9, 2006. In its complaint, AHCA alleges one uncorrected Class ITI violation and seeks a fine in the amount of $500.00. A copy of the administrative complaint is attached as Exhibit “A.” This petition is timely filed. 4. Kipling Manor’s substantial interests will be affected by the Agency determination in that the Agency intends to impose an administrative fine. 5. Disputed issues of material fact include the following: a. Whether, on or about July 25 and 26, 2005, Kipling Manor was out of compliance with applicable regulations regarding the facility’s physical structure, including that interior/exterior walls, floors, roof and ceilings and exit doors were not b. Whether, on or about October 24, 2005, Kipling Manor failed to ensure that the facility’s interior structure, to include ceiling, was not structurally sound and in good repair, as set out in the administrative complaint. 6. Kipling Manor’s ultimate position is that the administrative complaint has no basis in law or in fact. Kipling Manor disputes the allegations found in the administrative complaint and maintains that no action or inaction on its part constitutes a violation of law which supports the penalty sought. More specifically, Kipling Manor was not out of compliance. The facility was damaged by Hurricane Dennis on July 10, 2005. Kipling Manor had repaired and completely weathered-in the facility so as to be safe for the residents to live in and was proceeding expeditiously with all remaining repairs, consisting of cosmetic and non-critical items, parts for which were on order at the time of the survey. Kipling Manor had acted with all deliberate speed, taken all reasonably prudent actions and exercised all reasonably available means under the circumstances to ensure continuing compliance. Accordingly, for reasons including, but not limited to, the responses set forth herein, the rules and_ statutes cited within the administrative complaint, as well as Chapters 120 and 400, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, require reversal or modification of the Agency’s proposed action. WHEREFORE, Respondent, Kipling Manor respectfully requests: a. That this matter be referred to the Division of Administrative Hearings for the assignment of an Administrative Law Judge to conduct formal administrative proceedings; b. That a Recommended Order and Final Order be entered denying the Agency’s proposed action against Kipling Manor; and c. Other such relief as may be appropriate. Sa iaieh , my emer Os PF ROAE RT RSPLING MANOR 2564 Pae864 10: 9346932 P.5 » to be corrected. Lf a class HI violation is corrected within the rime specified, no fine may be imposed, unless it is a repeated offense. eee Rule 584-5.023 Physical Plane Standards. - (1)(b) The facility's physical structure, including che interior and exterior walls, floors, roof, and ceilings shall be structurally sound and in good repair. Peeling paint or wallpaper, missing ceiling or floor tiles, or torn carpeting shall be repaired or teplaced. Windows, doors, plumbing, and applications shall, be functional and in goad working order, All furniture and furnishings shall be clean, functional, free-of-odors, and in good repair. Appliances may be disabled, for safety reasons provided they are functionally available when needed. a eo oe 8. The violation alleged herein constitutes a class MI deficiency, and warrants a fine of $500. WHEREFORS, AHCA demands the following relief 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Tmpose a fine in rhe amount of $500. yee Respectfully subminted this? day of January 2006. Michael ©. Mathis Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) * (850) 921-0158 (fax) JON-9-20@6 15:55 FROM:KM KIPLING MANOR 8554782864 TO: 93465932 ‘Respondent is notified chat it has a vight to request an administrative hearing pursuant to Section 120.569, Fla, Stat. (2004). Specific options for adrainistrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to che Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney, Telephone (850) 922-5873. : RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY oem pet a truc and correct copy of the foregoing has been served by certified mail on day of lar. 2006 to Shannon Woody, Administrator, Kipling Manor Retirement Center, 7907 Kipling Street, Pensacola, Florida 32514. Michael O. Mathis, Esquire 5 CY FILED this 27th day of January, 2006 with the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308. JOHN F. GILROY, I, P. A. John F. Gilroy, Til Fla. Bar No. 0454729 1725 Mahan Drive, Suite 201 ; Post Office Box 15828 Tallahassee, Florida 32317-5828 (850) 671-2644 Counsel for Respondent Senior Lifestyles, L.L.C. d/b/a Kipling Manor Retirement Center EEN IN A ee LBS PETS, Coe FOC8E4A TQ: 9346932 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Case Name SENIOR LIFESTYLES, LUC, Wbh/a KIPLING RETIREMENT CENTER CASE NO; 2005010739 ELECTION OF RIGHTS FOR PROPOSED AGENCY ACTION' PLEASE SELECT ONLY 1 OF THE 3 OPTIONS OPTION ONE (1)__—s ©: I do not dispute the allegations of fact contained in the proposed agency sction and waive my right to object or to be heard. 1 understand that by waiving my rights, a final order will be issued that adopts the proposed agency action and imposes the sanctions sought. OPTION TWO (2) J do oot dispute and admit the allegations of fact ‘contained in the proposed agency action, but ¥ do wish to be afforded an informal proceeding, mmsuant to Section 120.57(2), Florida Statutes, at which time J will be permitted to submit oral and/or written evidence to the Agency: in mitigation of the penalty ynposed, OPTION THREE (3) x I do dispute the allegations of fact contained in the proposed agency action 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, ee. Parmeceren) Sere. PLEASE NOTE: Choosing OPTION THREE. (3), by itself, is NOT suffictent to obtain a formal hearing. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes, you must ALSO file a request for a formal hearing that conforms to the requirements of Rule 28- 106.201, Florida Administrative Code. The hearing request MUST contain: + The name and address of each agency affected and each agency's file or identification number; - Your nante, address, and telephone number, and the name, address, and telephone number of your representative, if any, in this proceeding; - An explanation of how your substantixl interests will be affected by the Agency’s proposed action; ~ A statement of when and how you received notice of the Agemcy’s proposed action; - A statement of all disputed issues of material fact; ~ A concise statement of the ultimate facts alleged, including the specific facts you contend warrant reversal or modification of the Agency’s proposed action; ' Proposed agancy action cofers to either the Notice of Intent or Adininistrative Complaint that you received from the Agency along with this Election of Rights. PL? 768 CISC tO PROPS KIPLING MANOR SSe47ee064 : TO: 93496932 x - A statement of the specific rules or statutes you contend require reversal or modification of the Agency’s proposed action; and ~ A statement of the relief you are seeking, stating exactly what action you wish the Agency to take with respect to its proposed action. In order to preserve your right to a hearing, the Election of Rights form (AND the . Yequest for a formal hearing if you have chosen OPTION THREE Q)) in this matter ust be received by AHCA within twenty-one (21) days from the date you received the proposed agency action. If the election of rights form with your selected option is not received by AHCA within twenty-one (21) days from the date of your receipt of the proposed agency action, you will bave waived your right to contest the Agency’s proposed action and a final order will be issued finding. the deficiencies and/or violations charged and imposing the penalty sought. Ifyou have elected either OPTION TWO (2) or THREE (3) above and are interested in disenssing » settlement of this matter with the Agency, please also mark and check this block, dl ‘ . Mediation under Section 120,573, Florida Statutes, is available in this matter if the Agency agrees. 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. SEMOR. FES LES, ULE Licensee: 60 Varta ie Mgyued, Berries geno Cv Te Licensee’s Representative (if any): 2¢duve hj aris , VERAGIMG RENEE. Address: Ol Kt S F tA, Fe BAS fey License No. and facility ype:_ “7985 ___ ASS/S7ea9_ Livin Agi Telephone No.: C SSO } 934 -/06/ PLEASE RETURN YOUR COMPLETED FORM TO: Agency for Health Care Administration, Attcation; Agency Clerk, 2727 Maban Drive, Mail Stop #3, Tallahassee, Florida 32308, ie os EEE ES — SEE Ms ao tessc P.2 Certified Mail Receipt S, (7004 1160 0003 3739 8835) - STATE OF FLORIDA a2 AGENCY FOR HEALTH CARE ADMINISTRATION S Cg STATE OF FLORIDA & AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA.NO: 2005010739 Vb. SENIOR LIFESTYLES, LLC, d/b/a KIPLING MANOR RETIREMENT CENTER, Respondent. —— ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint againat Senior Lifestyles, LL.C., d/b/a Kipling Manor Reticement Center, (hereinafter “Kipling Manor Retirement Center”) pursuant to Section 120.569, and 120,57, Fla. Stat. (2005), alleges: NATURE OF THE ACTION 1 This is an action to impose an administrative fine against Kipling Manor - Retirement Center, pursuant to Sections 400.419(2Xc), Fla. Stat. (2005), and Sections 58A- 5.023(1)(b), Fla. Admin, Code (2005). JURISDICTION AND VENUE is This Agency has jurisdiction pursuant to 400, Part IIL and Section Sections 120.569 and 120.57, Fla. Stat. (2005). ags herrrcrienente A JEN-9~-2806 15154 FROM:KM KIPLING MANOR aous7sess4 TO: 9346932 P.3 2. --Venue.lies in Escambia County, Pensacola, Florida, pursuant to Section 120.57 Fla. Stat. (2005); Rule 58A-5, Florida Adminiserative Code (2005), and Section 28,106.207, Fla. Stat. (2005), PARTIES 3 AHCA, is the regulatory authority responsible for licensure and enforcement of all applicable statutes and xules governing assisted living facilities pursuant to Chaprer 400, Part HI, Fla, Stat. and Rules 584-5, Florida Administrative Code (2005). 4. Kipling Manor Retirement Center Is a for-profic corporation, whose 65-bed assisted living facility is located at 7901 Kipling Street, Pensacola, FL. Kipling Manor Retirement Center is licensed as an assisted living facility license # AL7285; certificate number #19076, effective August 27, 2005 through August 26, 2007. Kipling Manor Retirement Center was at all times marerlal hereto, licensed faciliry under the licensing auchority of AHCA, and required to comply with all applicable rules, and statutes. COUNT] KAPLING MANOR RETIREMENT CENTER FAILED TO ENSURE THAT THE FACILITY’S INTERIOR STRUCTURE, TO INCLUDE THE CEILING AND EXIT POORS, WAS NOT STRUCTURALLY SOUND AND IN GOOD REPAIR. STATE TAG A1002-PHYSICAL PLANT STANDARDS Section 400.41.9(2)(c), Fla. Stat. (2005) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 584-5.023(1)(b), Fla. Seat. (2005) PHYSICAL PLANT STANDARDS 5. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 6. On or about October 24, 2005, ANCA conducted a follow-up survey at the Respondent's facility. AHCA cited :the Respondent based on the findings below, to wit: 24% UII ORAS 10 G FROMIKM KIPLING MANOR BS84 782864 TO: 5346932 =) On, or about July 26, 2005, Kipling Manor Retirement Center failed to ensure that the facility's interior structure, to include the ceiling, was not structurally sound and in good repair. b) During a follow-up survey on or about October 24, 2005, Kipling Manor Retirement Center failed to ensure that the facility's interior structure, ro include the ceiling and exit doors, was not structurally sound and in good repair, The findings include: During the initial tour of the facility at approximately 10:35 AM on 10/24/05, the ceiling in the hallway in the vicinity of room 15 was found to be bulging with Jarge datk woter steins nated. The area was also nated to have dark discoloration indicative of mold and mildew. The exit door, between rooms 14 & L5, to the south screened area had a broken door opening bar. The retaining bracket at the door hinge edge of the door was missing. Throughout the facility the walls were noted to be chipped and scuffed, particularly on the closed unit, The chipping away of the sheet rock was most severe at the procuding wall comers in rogms 9B and 10B. Ac 12:15 PM, the administrator acknowledged the findings and stated, "We're working on this stuff. We just haven't gotten to these areas yet. Repair parts have been ordered, but have not arrived." The administrator was unable to shaw documentation of orders of repait/replacement items, 7. The regulatory provisions of the Florida Starutes that are pextinent to this alleged violation read as follows: 400.419 Violations; imposition of administrative fines; grounds. - (2(c) ‘Clase “II” violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class 1 or class II violations. The agency shall impose an administrative fine for 9 cited class UI violation in an a . amount not less than $500 and not exceeding $1,000 far each violation. A citation for a class IIT violation roust specify the time within which the violation is required La¥

Docket for Case No: 06-000792