STATE OF FLORIDA 03 for 5 AGENCY FOR HEALTH CARE ADMINISTRATION SE AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003006103 Return Receipt Requested: v. 7002 2410 0001 4236 9120 7002 2410 0001 4236 9137 FIZA INVESTMENT, INC., d/b/a 7002 4210 0001 4236 9144 WINDSOR COURT, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Fiza Investment, Inc., d/b/a Windsor Court (hereinafter “Windsor Court” or the “facility”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2002), and alleges: NATURE OF THE ACTION 1. This is an action to impose and maintain the Agency’s administrative fine and survey fee totaling $10,500.00, pursuant to Sections 400.414, 400.419, Florida Exhibit "A" Statutes (2002), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Palm Beach County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities, pursuant to Chapter 400, Part III, Florida Statutes (2002), and Chapter 58A-5, Florida Administrative Code. 5. Windsor Court operates a 9i-bed assisted living facility located at 3700 N. Poinsettia Avenue, West Palm Beach, Florida 33407. Windsor Court is licensed as an assisted living facility under license number AL5943, with an expiration date of April 9, 2004. Windsor Court 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 T WINDSOR COURT FAILED TO PROVIDE CARE AND SERVCIES APPROPRIATE TO THE NEEDS OF EACH RESIDENT AND FAILED TO ENSURE THAT RESIDENTS WERE FREE FROM NEGLECT. 400.428(1), Fla. Stat. and/or 58A-5.0182 F.A.C., and/or 58A- 5.0182 (3) (a), F.A.C., and/or 58A-5.0181(2), F.A.c. (RESIDENT CARE STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. “As. a result of a complaint investigation survey conducted by the Agency on 8/15/2003 and based on record review and interview, the Agency found that: Windsor Court failed to provide care and services appropriate to the needs of each resident.and failed to ensure that residents were free from neglect. The Agency found that all residents were not receiving proper care and services nor free of neglect. Findings include the following, to wit: 8. Resident #1 was admitted to the facility on 6/03/2003, and was noted to be confused and using a walker to ambulate. The facility did not have the required medical “examination performed. This resident was admitted without full medical knowledge of the resident’s needs, any special requirements and any precautions. The resident fell on — 7/17/2003 and sustained a fracture of this/her left shoulder. 9. The resident returned to the facility on 7/18/2003. The facility still did not ensure that a required medical examination of the resident was performed. The hospital discharge notes and patient directions indicated that the resident was to see a Physician within 48 hours after discharge. The discharge directions specified the name of the physician that the resident was to see. The facility did not contact and arrange for this follow-up care nor assist the resident win making or keeping the appointment. By not ensuring» that a medical examination was performed, the resident’s needs, special requirements and any precautions needed were unknown, presenting an imminent: danger to the resident. 10. After ‘sustaining a fall. on 7/17/2003 at ll pm, Resident #1 was taken to the hospital emergency room where she/he was diagnosed with a fracture of her/his left shoulder and then returned to the facility at 2 am on 7/18/2003, ll. The hospital ‘discharge notes and patient directions indicated that the resident was to see a physician within 48 hours. The discharge directions also specified the name of the physician that the resident was to see. The facility did not contact and arrange for this follow-up care nor assist the resident in making or keeping the appointment. The facility did not accomplish this and-also did not properly monitor the resident’s condition during the following days. 12. Four days later, on 7/23/2003, the facility first noticed that! the resident’s hand was turning blue. At that time, a visiting agency nurse was asked to look at the resident’s arm and then, after calling a physician, the resident was returned to the hospital emergency room. As a result of the lack of follow-up care and monitoring, the resident was found to have a gangrenous arm, which, according to the treating physician, would need to be amputated to avoid sepsis and death of the resident. The facility’s failure to provide care and services appropriate to the needs of Resident #1 and failure to ensure that the resident’ was free from neglect presented an imminent danger to the resident or a substantial probability that death or serious harm would result therefrom. 13. Based on the foregoing, Windsor Court violated 400.428(1), Fla. Stat., -and/or S58A-5.0182, F.A.C., and/or 58A-5.0182(3) (a), F.A.C., and/or 58A-5.0181(2), F.A.C., a Class I violation, pursuant to Section 400.419(1) (a), Florida Statutes, which carries an assessed fine of $10,000.00. SURVEY FEE 14. Pursuant to Section 400.419(8), Florida statutes, AHCA may assess a survey fee of $500 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of: the Agency on Count I. B. Assess an administrative fine of $10,000 against Windsor Court on Count I for the Class I violation. Cc. Assess a survey fee of $500 against Windsor Court, pursuant to Section 400.419(9), Florida Statutes. D. Grant such other relief as this 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 (2002). 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, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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, Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar # 142832 8355 N.W. 53 Street Miami, Florida 33166 (305) 499-2165 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration : 1710 East Tiffany Drive, Suite 100 West Palm Beach, FL 33407 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, ,Florida 32308 (Inter-officé Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE SE VE SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Carmen Guzman, Administrator, Windsor Court, 3700 N. Poinsettia Avenue, Fiza Investment, Inc., 3700 N. Flagler Drive, West Palm Beach, Florida 33407 and to Arvind B. Ajinkya, Registered Agent, 4524 Gun Club Road #102, West Palm Beach, Florida 33415 on. LSA) , 2003. Kathfyn f. Fenske, Esq.

Docket for Case No: 03-003853