STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No. 2008002358 vs. EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC d/b/a ENCORE SENIOR VILLAGE AT NAPLES, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative . Complaint against the Respondent, EXTENDED CARE PORTFOLIO FLORIDA TENANT, LLC d/b/a ENCORE SENIOR VILLAGE AT NAPLES (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and alleges as follows: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) based upon one (1) Class II violation. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42, 120.60 and Chapters 408, Part II, and 429, Part I, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules governing such facilities. Chapters 408, Part II, and 429, Part I, Florida Statutes (2007); Chapter 58A-5, Florida Administrative Code. The Agency may deny, revoke, or suspend any license issued to an assisted living facility or impose an administrative fine for violations. Sections 408.813, 408.815, and 429.14, Florida Statutes (2007). In addition to any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility to verify the correction of violations. Section 429.19(7), Florida Statutes (2007). 5. The Respondent was issued a license (License Number 9761), by the Agency to operate a 70-bed assisted living facility located at 1155 Encore Way, Naples, Florida 34110, and was at all material times required to comply with the applicable federal and state regulations, statutes and rule governing such facilities. COUNTI The Respondent Failed To Provide Care And Services Appropriate To The Needs Of Residents Accepted For Admission To The Facility In Violation Of Rule 58A-5.0182, Florida Administrative Code 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, assisted living facilities shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Rule 58A-5.0182, Florida Administrative Code. | 8. The Respondent failed to comply with the above referenced provisions of law. 9. On or about, February 4, 2008 through February 6, 2008 the Agency conducted a Change of Ownership Survey of the Respondent and its facility. 10. Based on observation, interview and record review, the facility failed to provide care and services to meet the needs of the residents for two (2) of six (6) sampled residents, Resident number one (1) and Resident number five (5), as evidenced by the development of pressure sores for these residents while residing in the facility. 11. A pressure sore is a wound that develops over a bony area such as the heel or tail bone area of the body. 12. | Arecord review of Resident number one’s (1) health record indicated the resident moved into the facility on January 16, 2004. Resident number one’s (1) "1823" Agency for Health Care Administration form indicated no pressure ulcers were present on admission. Resident number one (1) has a diagnosis of Dementia and has'been noted by the staff to be "Declining." Resident number one’s (1) most recent health assessment, dated November 12, 2007 indicates no evidence of a pressure ulcer or problems with skin integrity. » 13. A record review of Resident number one’s (1) nurses notes on February 5, 2008 revealed a one (1) cm. open area with a depth of 1/8 cm. on Resident number one’s (1) outer aspect of the right foot. By January 14, 2008, when the home health nurses were requested to evaluate Resident number one (1) and start wound care treatment, the lateral aspect of the ankle wound was measured at 0.4 cm x 0.4 cm x 0.4 cm. 14. An observation of Resident number one (1) in the dining room on February 4, 2008 revealed Resident number one (1) ate and drank. Resident number one’s (1) weight ranged from 115 Ibs. to 119 Ibs. For the year 2007, the weight was recorded as 115 Ibs. and in 2008 it was 119 Ibs. 15. On February 5, 2008 at 12:30 p.m. during a conversation with a nurse in Cottage number four (4), the nurse indicated, "The resident rolls over on the right side a lot." An observation of Resident number one (1) in bed on February 5, 2008, revealed there was a heel protector in place. 16. A review of the resident record for Resident number five (5) on February 5, 2008 revealed Resident number five (5) moved into the facility on November 4, 2003 with a diagnosis of, but not limited to, Alzheimer's Dementia. A further review of the record revealed Resident number five (5) had a hip fracture on October 19, 2007. Resident number five (5) had a hip repair and was returned to the facility on November 15, 2007. 17. A review of the facility "Skin Assessment/Status" form located in the resident record and dated November 15, 2007 revealed Resident number five (5) did not have any open areas on either heel when returned to the facility. 18. A review of a facility "Occurrence Note" dated December 19, 2007 revealed Resident number five (5) had developed a 3.5 cm (centimeter) by 3.5 cm open area on Resident number five’s (5) right heel. 19. A review of a Home Health Agency "Nursing Visit Record" dated December 2, 2007 confirmed Resident number five (5) had developed a 3 cm by 3.5 cm wound that was 0.2 om deep on the right heel. 20. The Respondent’s deficient practice was related to the operation and maintenance of the facility or to the personal care of residents which directly threatened the health, safety, or security of the resident and constitutes a Class II deficiency as defined in Section 429.19(2)(b), Florida Statutes (2007). 21. The Agency shall impose an administrative fine for a cited Class II violation in an amount not less than one thousand dollars ($1,000.00) and not exceeding five thousand dollars ($5,000.00) for each violation. A fine shall be levied notwithstanding the correction of the violation. Section 429.19(2)(b), Florida Statutes (2007). 22. The Respondent was given a mandatory correction date of March 6, 2008. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief: 1. Enter findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00). 3. Order any other relief that the Court deems just and ay 4. Respectfully submitted on this re of Aa y C1 , 2008. Andrea M. Lang, Quem tone 0 sec Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 NOTICE THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. IF THE RESPONDENT WANTS TO HIRE AN ATTORNEY, IT/HE/SHE HAS THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS FORM. THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DELIVERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BUILDING 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election or Rights form have been served to: Zachary Ward, Administrator, Extended Care Portfolio Florida Tenant, LLC d/b/a Encore Senior Village at Naples, 1155 Encore Way, Naples, Florida 34110, by U.S. Certified Mail, Return Receipt No. 7006 2760 0003 1537 2849, and to: Walter A. Frey III, Registered Agent for Extended Care Portfolio Florida Tenant, LLC d/b/a Encore Senior Village at Naples, 7575 Dr. Phillips Boulevard, Suite 235, Orlando, Florida 32819, by U. S. Certified Mail, Return Receipt No. 7006 2760 0003 1537 2856 on this UZ™ _ day of Reci\ , 2008. Qoabeaye /V\. LB mney Andrea M. Lang, Senior Atto: Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 Copies furnished to: Zachary Ward, Administrator Extended Care Portfolio Florida Tenant, LLC d/b/a Encore Senior Village at Naples 1155 Encore Way Naples, Florida 34110 (USS. Certified Mail) Walter A. Frey III, Registered Agent for Extended Care Portfolio Florida Tenant, LLC d/b/a Encore Senior Village at Naples 7575 Dr. Phillips Boulevard, Suite 235 Orlando, Florida 32819 (U.S. Certified Mail) Andrea M. Lang, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) Kriste J. Mennella - Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) a SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ™ Complete items 1, 2, and 3. Also compiete item 4 if Restricted Delivery is desired. _ lM Print your name and address on the reverse * _ so'that we can returfi the card to you. ® Attach this card to the back of the mailpiece, or on the front if space permits. |1. Article Addressed to:: 2008002353 | Zachary Ward, Adocinitra : Enore Senior Village af Nagle ISS Enc Way Naples, Florida 340 /D. 1s delivery address different from item 1? LI Yes IF YES, enter delivery address below: 0 No ‘3. Service Type O Certified Mail © Express Mail © Registered C Return Receipt for Merchandise O Insured Mat =O 6.0.0. 4. Restricted Delivery? (Extra Fee) 2. Article Number __Aranstertrom sevice boy 006 270 OO03 1537 2a49, _ PS Form 3811, February 2004 Domestic Return Receipt 102595-02--1840 ,

Docket for Case No: 08-002629