Certified Mail Receipt (7003 0360 0003 3804 6548) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ao a STATE OF FLORIDA 7 a AGENCY FOR HEALTH CARE a i ADMINISTRATION, a S| Petitioner, a AHCA NO: 2008003583 Va. KIPLING MANOR RETIN CENTER Cs: | {% Respondent. ey ADMINISTRATIVE 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 Retirement Center (hereinafter “Kipling Manor Retirement Center"), pursuant to Sections 120.569, and 120.57, Fla. Star. (2004), and alleges: NATORE OF THE ACTION ‘This is an action to impose an administrative fine in the amount of $3,000.00 {includes a survey fee of $500.00) based upon three cited State Class IY deficiencies pursuunt to §400.419(2\b) and §400,428(1), Fla. Stat. (2004), and Rules 59A-5,0182 and 58A-5.0185(1Xd), Fla, Admin. Code or in the alternative, to revoke the Respondent’s license pureuant to the provisions of §400.414 Fla. Stat, (2004), EXHIBIT A TURISDICTION AND VENUE 1 AHCA has jurisdiction pursuant to Chapter 400, Part HL, Fla. Stat., and Sections 120.569 and 120.57, Fla, Stat. (2004), a Venue lies in Escambia County, Pensacola, Florida, pursuant to Section 120.57 Fla. Stat. (2004), Rule SB8A-5, Fla, Admin, Code (2004), and Section 28.106.207, Fla. Stat, (2004), PARTIES 3. AHCA is the regulatory authority tesponsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Fla, Star. and Ryle 58A-5, Florida Admintetrative Code (2004), 4, Kipling Manor Retirement Center ig a for-profit ‘corporation, whose 65-bed assisted living facility is located at 7901 Kipling Street, Pensacola, FL, Kipling Manor Retirement Center is licensed 48 an assisted living facility, license # AL7285 certificate number #15006, effective August 27, 2003 through August 26, 2005. Kipling Manor Retirement Cenver was, ut all tmes material hereto, a licensed facility under the licensing authority of AHCA, and waa required to comply with all applicable rule and statutes. COUNTY Section 400.419(4)(b), Fla. Stat, (2004) VIOLATIONS, IMPOSITION OF AD ‘TIVE FINES, GROUNDS Section 584-5.0182, Fla. Adinin. Code (2004) RESIDENT CARE STANDARDS 5, AHCA realleges and incorporates patagraphs (1) through (4) as if fully set forth herein. 6. Oni or about April 5, 2005, AHCA conducted a complainy Investigation survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit; . 8 On ot abour April 5, 2005, Kipling Manor Retirement Center failed to provide services (necessary monitoring of blood sugar) to meet the needs of t out of 6 sampled residents (#3). The findings are; monitoring to be done daily before meals, 2 hours after meals and at bedtime. Interview with the wellness director Girector of nursing) on 4/4/05, in an office ac (the resident was admitted 11/19/04), with no further evidence of monitoring documented in the record. Upon request for additional documentation, the wellness director supplied the surveyor documentation of monitoring reflecting emergency medical services, 7. ‘The regulatory provisions of the Florida Statutes thar are pertinent to this alleged violation read 9s follows; 400.415 Violations; iraposition of admintstrative fines; grounds, ~ T violations. The agency shel! tmpose an administrative fine for a cited clas If sake it an amount not kes than $1,000 and not exceeding $5,000 for each violatlan. A fine shall be levied notwithstanding the correction of the violation. then $5,000 and nor exnveding $40,000 for each violarion. A fine may be levied notwithscanding the earection of the violation es 8 Rule 564-5.0182 Resident Care Standards, - As setined Wing factiey shall provite cae and servicts appropiate to the needs of rexidenm accepted for admission to the facility, * *e & 8. The violation alleged herein constitutes a class II deficiency and warrants a fine of $1,000, WHEREFORE, AHCA demands the following relief. 1. Enter factual and findings ag set forth in the allegations of this administrative complaint. 2, Impose a fine in the amount of $1,000, COUNT TH KIPLING MANOR RETIREMENT CENTER FAILED TO NOTIFY/CONTACT THE HEALTH CARE PROVIDER AND OTHER APPROPRIATE PARTIES WHEN A RESIDENT EXHIBITED A SIGNIFICANT CHANGE FOR 2 OF 6 SAMPLED RESIDENTS. (#4 AND 5). REFER TO A718 FOR ADDITIONAL FINDINGS ON RESIDENTS ¢6, STATE TAG A706 RESIDENT CARH STANDARDS Section 400.4192)(b), Fa, Star. (2004) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 58A-5.0182(1Md), Hla, Admin. Code (2004) RESIDENT CARE STANDARDS 9. AHCA realleges and incbrporates paragraphs (1) through (4) as if fully set forth herein. 10. On or about April 5, 2005, AHCA conducted a complaint investigation survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a On or about April 5, 2005, Kipling Manor Retirement Center failed to notify/contact the health care provider and other appropriate Parties when a resident exhibited a significant change for 2 of 6 sampled residents, (#4 and 5), Refet to A718 for additional findings on resident #6, The findings are: Interview with the director of nursing on 4/4/05 at 1:00PM stared resident #4 wandered irito another resident's room. A resident pushed resident #4, resulting in 11. — The regulatory provisions of the lorida Statutes that are pertinent to this alleged violation read as follows: 400-419 Violations impesition of administrative finesy grounds. « ee oe Rule 564-5.0182(1Nd) Resident Care Standards. — Contacting the resident's health cate provider and other appropriate party such as the resident's family, guardian, healh care surrogate, or case manager if the resident exhibits significant change; consscring the residenr’s frmily, guardian, health care stirtogate, or casé mumager if the resident is discharged or moves our, s ¥ ® 12. The violation alleged herein constitutes a class YI deficiency and warrants a fine of $1,000. WHEREFORE, AHCA demands the following telief: 1. Enter factual and findings a8 set forth in the allegations of this administrative complaint. 2, impose « fine in the amount of $1,000. COUNT Mm KIPLING MANOR RETIREMENT CENTER BAILED TO PROVIDE AN ENVIRONMENT FREE FROM NEGLECT FOR 2 OF 6 SAMPLED RESIDENTS. (#'s 4 and 6), RESIDENT #6 LACKED APPROPRIATE PAIN MANAGEMENT, AND RESIDENT #4 WAS NOT TREATED WITH DIGNITY AND RESPECT. STATE TAG A718 MEDICAL STANDARDS Section 400.419(2)(b), Fla. Stat, (2004) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Section 400,428(1), Fla, Stat. (2004) RESIDENT CARE STANDARDS 13, AHCA realleges and incorporates paragraphs (1) through (4) as if fully set forth herein. 14. On or about April 5, 2005, AHCA tonducted a complaint investigation survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a On or about April 5, 2005, Kipling Manor Retirement Center failed to notify/contact the health care provider amd other appropriate parties when a resident exhibited a significant change for 2 of 6 sampled residents. (#4 and 5). Refer to A718 for additional findings on resident *6. The findings are: Interview with the director of nursing on 4/4/05 at 1:00PM revealed that resident #4 wandered into another resident's room. The resident pushed resident #4, cesulting in a foll. Staff witnessed the fall. The resident was confused and was screaming, it hucts, they are killing me, it hurts, The aides picked up the resident and placed her/him in a chair with the resident screaming the entire time. The aides put the resident to bed. The aides noted a rad area to the right hip, elbow and pain upon movement. The director of nursing stated the aldes did not call family, physician or management staff. At the change of the 3-11 shift the aides gave report to oncoming staff and stated the resident had fallen. The 11-7 staff went into the resident’s room around 2:00AM and found the resident in pain, right hip swollen and red. The staff tried calling management staff until 6:45 AM but realized they were calling the wrong person. They finally got the right humber and called management, who said ro send the resident to the hospital. The resident was sent to the hospital where a fracture of the right hip was found. The resident remains in the hospital receiving rehabilitation. Record review for resident #4 indicated an admission on 1/12/05 with a diagnosis of Alzheimer’s and Dementia. The record indicated the resident was oriented to person only and had a history of falls. ‘The medication record Indicated the resident did not have an order for pain medication and did nor receive any pain medication after the fall Review of the record indicted rhe facility did complete an adverse incident report. Review of the record and staff interview indicated the resident fell, scrcamed in pain, had redness and swelling to hip and elbow for 11 fioure, and steff did not appropriately follow up. The facility failed to provide care and services to meet needs of resident including pain management, notifying family, physician, management staff. The facility failed to provide an environment free from abuse/neglect. Interview with complainant on 4/4/05 at 9:30 AM indicated resident #6 was in the main dining room waiting for evening meal on an undetermined date, The meal. wes delayed for some time. The cook on duty became irritated with the resident, The resident left the dining room to go back to his/her room. After supper the staff remembered the resident did not receive supper. The staff went to the kitchen where the cook was and asked for a meal for the resident. The cook gave a hor dog to the steff to give to the resident. The resident received the hot dog and consumed iv. Further interview with the complainant at the same time indicated the cook harassed residents, belittled them and was rude. She stated in this case the cook refused to give the resident his/her meal in revaltation for being in the dining for so long waiting on the evening meal, Interview with the roommate of the resident on 4/4/05 at 10:00AM stated this did happen but was not sure why. Intexview with the resident on 4/4/05 at 10:00 AM stated he/she did receive only a hot dog for supper over the weekend bat was not sure why. Record review of the resident indicated an order for double portions of a regular diet. The facility failed to treat resident #6 with respect and with due recognition of personal dignity by not serving resident #6 his supper. . 18. The regulatory provisions of the Florida Stavuces that are pertinent to this alleged violation read as follows: 400.419 Violations; imposition ef administrative fines; grounds, ~ QXb) Class "I" violations are those conditions ot occurrences xelated wo the operation src mainvenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, sxfety, oF security of the facility residents, ether than class ew # Via. Star, 400.428(1) Revident Care Standards. « No vealdent of x facilty shall be deprived of any civil or legal rights, benefits, o privileges guasanteed by law, the Constinition of the Stare of Florida, or the Constitution of the United States as a resident of = facility. ves 16. ‘The violation alleged herein constitutes a clase I] deficiency and warrants a fine of $1,000, WHEREFORE, AHCA demands the following relief. 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000. COUNT IV 17, AHCA realleges and incorporates paragraphs (1) through (4) as if fully set forth heroin. 18 = Pursuant to Florida law, the Petitioner, Agency for Health Care Administration, may revoke the license of an Assisted Living Facility when the facility has been cited with three or more class II deficiencies. Section 400.414(1Xe)2, Fla. Star. (2004). 19. facility was cited with three (3) class II deficiencies on The Respondent April 5, 2005. 20. Pursuant to Section 400.414(D(@), Fla. Stat. (2004), AHCA may deny, revoke, or suspend any license issued under this parr, or Impose an adwinistrative fine in the manner provided in Chapter 120, for an intentional or negligent act seriously affecting, the health, safety, or welfare of a resident of the facility. 21. The Petitioner Agency intends to revoke the license of the Respondent as a result of the numerous cited deficiencies above. 9 noted in comolaing survey of _ April 5, 2005, In the event the Respondent should admit, default or fail to tespond to the allegations of chis administrative complaint, the same shall be deemed as consent for revocation, ‘WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Adnrinistration, intends to revoke the license of the Respondent Kipling Manor Retirement Center, an Assisted Living Facility in the State of Florida, pursuant to the provisions of Chapter 400, Fla, Seat, (2004), : coUNTV 22, The Agency realleges incorporates paragraphs (1) through (4) as if fully set _forth herein, 23. As a result of the Agency's complaint investigation ending April 5, 2005, the Respondent was cited for three class Il deficiencies, which were the subject of the complaint. 24. Pursuant to Section 400.419(10), Fla. Stat. (2004), AHCA is authorized addition to any adsainistrative fines to, assess a survey fee equal to the lesser of one-half of the facility's biennial license and bed fee, ot $500, to caver the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for Monitoring visits conducted under §400.428(3Xc), Fla. Stat. (2004), to verify the correction of the violations. In, this case, AHCA Is authorized to request a survey fee in the amount of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the Stare of Florida, pursuant to § 400.419(10), Fla, Star. (2004), COUNT VI . THE FACILITY Ig IN DEFAULT AS ‘TO FINES ASSESSED BY THE AGENCY, in violation of Section 408.831, Florida Stamtes (2004) 25. AHCA realleges and incorporates paragraphs (1) through (4) 26. In AHCA case number 2004001014, a final order was entered on July 16, 2004, giving Respondent 30 days to pay $1,500.00 in fines and survey fees. To date, payment has not been made, n. Tn AHCA case numbers 2004007258/2004007257, a final order was entered on September 13, 2004, giving Respondent 30 days to pay $2,000.00 in fines. To date, payment has not been made. “WB: Purmant to Section 408.831(1)), Florida Statutes (2004), AHCA may revoke Respondent’s license for failure to pay al} outstanding fines. WHEREFORE, Respondent's license should be revoked on the basis of non Payment of fines, Respecefully submited this 18%, of May, 2005. ‘a~ Michael O. Mathis Fila. 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) Respondent is notified thar it hae a tight to request an administrative hearing pursuant to Section 120.569, Fla. Star, (2004), Specific options for administearive 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 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 O, Mathis, Senior Attorney, Telephone (850) 922-5873, TE O) CE T HEREBY CERTIFY that a true and copy of the foregoing has been served by certifted mail on /3® day of fleas » 2005 to Deborah A, Grant, Administrator, Kipling Manot Retirement Cented, 7901 Kipling Streer, Pensacola, Florida 32504. ne Michael O. Mathis, Esq. u

Docket for Case No: 05-002186