PILED STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 96 SEP 19 PH 4:99 STATE OF FLORIDA, DIVISION OF AGENCY FOR HEALTH CARE ADPIBISTRATIVE ADMINISTRATION, HEARINGS Petitioner, vs. Case No. 2006006224 MANADEL, LLC, d/b/a HERITAGE VIEW ALF OF PLANT CITY, | Ole . av i 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 MANADEL, LLC, d/b/a HERITAGE VIEW ALF OF PLANT CITY, (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57, Fla. Stat. (2005), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $1,000.00, based upon Respondent being cited for one State Class II deficiency pursuant to § 400.419(2)(b), Fla. Stat. (2005). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. (2005). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part IIL, Fla. Stat., and Chapter 58A-5 Fla. Admin. Code, respectively. 4. Respondent operates a 9-bed assisted living facility located at 104 N. Gordon Street, Plant City, Florida 33563-5838, and is licensed as an assisted living facility, under license number 9180. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to Fla. Admin. Code R. 58A-5.0181(1)()(1-3), 58A-5.181(4)(b)(1-3), and 58A- 5.0181(5), a resident shall neither be admitted with, nor have any stage 3 or 4 pressure sores for continued residency. A resident requiring care of a stage 2 pressure sore may be admitted provided that: the facility has a LNS license and services are provided pursuant to a plan of care issued by a physician, or the resident contracts directly with a licensed home health agency ora nurse to provide care; the condition is documented in the resident’s record; and if the resident’s condition fails to improve within 30 days, as documented by a licensed nurse or physician, the resident shall be discharged from the facility. 8. On or about 06/01/06, the Agency conducted a change of ownership (CHOW) survey at Respondent's facility. 9. Based on observation, interview and record review the facility failed to transfer one of three residents reviewed with a stage 3 or 4 pressure sore to the appropriate setting as required. ww 10. Record review on 6/01/06, revealed that Resident # 9 was admitted to the facility on 07/12/04 with diagnosis of dementia, gastritis, and anemia, per a resident health assessment, DOEA/AIf Form 1823, dated 01/16/06. 11. The ADL assessment of the resident on 01/16/06 indicated the resident was total care with ambulation, bathing, dressing, and grooming, The resident required assistance with eating and transferring. 12. The resident was observed eating lunch on 06/01/06, at 12:30 p.m., and was fragile in appearance, seated in a wheelchair, eating. S/he did not acknowledge when addressed and did not respond verbally to anything during the hour of observation. 13. Record review revealed that Resident # 9 had been admitted to a home health care agency on 04/28/06, with a pressure sore measurement of 2 centimeter (cm) by 2.2 cm by 2 cm with 3 cm undermining at 3 o'clock and 1.8 cm Tunneling at 2 o'clock. 14. This pressure sore by definition was a stage 3 or 4 ulcer. 15. | New measurements on 05/28/06 in the home health agency nurse's notes revealed minimal improvement. The sore then measured 2 cm x 2 cm x 2 cm with 1.3 cm undermining, per the nurses documentation. 16. Interview with the home health nurse on 06/01/06, revealed the agency had obtained a low air loss mattress for the resident. 17, The nurse advised initially the wound had been unstageable due to the presence of eschar. The nurse stated she believed the wound had been at a stage 4. She stated there had been "a little improvement". 18. Interview with the assisted living caregiver on 06/01/06, revealed the staff got the resident out of bed for meals only. 19. The home health agency had recommended the patient not be out of bed more than two hours, three times per day and documented it on the home health resident folder. 20. At the date of the survey, Resident # 9 had not been discharged from the Respondent's facility to amore suitable facility able to care for the pressure sore. 21. The Agency determined that this deficient practice was related to the personal care of the resident, which the Agency determined directly threatened the physical or emotional health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 22. The Agency provided Respondent with a mandatory correction date of 07/01/06. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b) Fla. Stat., (2005). Respectfully submitted this ay of August 2006. rald L. Pickett, Esquire Fla, Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K St. Petersburg, Florida 33701 (727) 552-1526 (office) (727) 552-1440 (fax) 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. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida 32308. Telephone: (850) 922-5873 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. CERTIFICATE OF SERVICE THEREBY CERTIFY, that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8719 on August It. 2006 to: Jeffrey A. Dowd, P.A., Registered Agent, Manadel, LLC, d/b/a Heritage View ALF of Plant City, 609 W. Lumsden Road, Brandon, Florida 33511 and by U.S. Mail to: Lyzette Martinez, Administrator, Heritage View ALF of Plant City, 104 N. Gordon Street-Ptant City, Florida 33563-5838. her) uire ickett, Copies furnished to: Jeffrey A. Dowd, P.A. Lyzette Martinez Gerald L. Pickett, Esquire Registered Agent Administrator Agency for Health Care Manadel, LLC d/ba Heritage View ALF of Plant Administration Heritage View ALF of Plant City 525 Mirror Lake Drive, City 104 'N. Gordon Street 330K 609 W. Lumsden Road Plant City, Florida 33563-5838 | St. Petersburg, Florida Brandon, Florida 33511 (U.S. Mail) 33701 (U.S. Certified Mail) (Interoffice Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: MANADEL, LLC, d/b/a HERITAGE VIEW CASE NO: 2006006224 ALF OF PLANT CITY ELECTION OF RIGHTS FOR PROPOSED AGENCY ACTION! PLEASE SELECT ONLY 1 OF THE 3 OPTIONS OPTION ONE (1) I do not dispute the allegations of fact contained in the proposed agency action and waive my right to object or to be heard. I 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) | I do not dispute and admit the allegations of fact contained in the proposed agency action, but I do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time I will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3)_____—‘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. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient 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 name, address, and telephone number, and the name, address, and telephone number of your representative, if any, in this proceeding; - An explanation of how your substantial interests will be affected by the Agency’s proposed action; - A statement of when and how you received notice of the Agency’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 agency action refers to either the Notice of Intent or Administrative Complaint that you teceived from the Agency along with this Election of Rights. - 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 request for a formal hearing if you have chosen OPTION THREE (3)) in this matter must 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 have 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. If you have elected either OPTION TWO (2) or THREE (3) above and are interested in discussing a settlement of this matter with the Agency, please also check this block. 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. Licensee: Licensee’s Representative (if any): Address: License Number and Facility Type: Telephone Number: PLEASE RETURN YOUR COMPLETED FORM TO: Agency for Health Care Administration, Attention: Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. ® Complete items 1h_.-and 3. Also complete ' item 4 if Restricted Delivery ts 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: Sie Win eto |b 3, Wertage \eus GLE O Insured Malt Brondlon 3 e onl. S381 | 4, Restricted Delivery? (Extra Fee) CO) Yes is Ss 2. Article Number 7005 1160 QO0e 2e5y 14 (Transfer from ODA coe : PS Form 3811, February 2004 Domestic Return Recelpt . 102585-02-M-1549 Cy, SA UEN D. Is delivery address different from item*¢7 If YES, enter delivery address balow: q Mall legistered Retum Recelpt for Merchandise / ,

Docket for Case No: 06-003538