C5 JUH1T PH 42h Certified Mail Receipt (7001 0360 0005. 3804 6535) STATE OF FLORIDA HEARS AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY POR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NOS; 2005003587 vB. an SENIOR LIFESTYLES, LLC, d/b/a C SDS / KIPLING MANOR RETIREMENT CENTER, Respondent. ee 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 Section 120.569, and 120.57, Fla. Stat. (2004), 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{2\(c), Fla. Srac. (2004), and Sections 58A- 5.020(2)(g), Fla. Admin. Code (2004), TURISDICTION AND VENUE 2. This Agency hes Jurisdiction pursuant to 400, Part III and Section Sections 120.569 and 120.87, Fla. Star. (2004), EXHIBIT _A__ 3. Vemue lies in Escambia County, Pensacola, Florida, pursuant to Section 120.57 Fla. Stat. (2004); Rule 58A-5, Florida Adminiswative Code (2004), and Section 78,106,207, Fla, Stat. (2004). PARTIES 4. AHCA, is the regulatory authority responsible for licensure and enforcement of al! applicable statutes and rules governing assieted living facilities pursuant to Chapter 400, Pare IJ, Fla, Stat. and Rules 584-5, Florida Administrative Code (2004), 5. Kipling Manor Rerirement Center is a forprofit corporation, whose 6S-bed assisted living facility is located at 7901 Kipling Steet, Pensacola, FL. Kipling Manor Retirement Center is licensed as an assisted living facility ficense # AL7285; certificate number #15006, effective August. 27, 2003 through August 26, 2005, Kipling Manor Retirement Center was at all times material heteto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable tules, and statutes, GQUNTY KIPLING MANOR RETIREMENT CENTER FAILED TO DISTRIBUTE UTENSILS FOR 6 OR 6 SAMPLED RESIDENTS OF THE FACILITY. (RESIDENT #8, 1, 2, 3, 4, STATE TAG ASI@NUTRIIION & DIETARY STANDARDS Section 400.419(2)(c), Fla. Stat, (2004) VIOLATIONS; IMPOSITION OF ADMINISTRATIVE FINES; GROUNDS Seetiom 58A-5.020(2)g), Fla. Stat. (2004) DIETARY STANDARDS 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7 On or abour April 5, 2004, AHCA conducted a followup survey to an appraisal visit conducted at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: &) On or about February 10, 2005, Kipling Manor Retitement Center failed to b) On or shour April 5, 2004, Kipling Manor Retirement Center failed op indicated the resident was oriented to person only and history of falls, The Medication record indicated the reaideny did not have an order for pain medication and did nor Teceive anv_pain_ medication after the fall, Review of the record swelling to hip and elbow for 11 hours arid stal¥ did nor *Ppropriately follow up. facility failed to Provide care and services to meet needs of resident including Pain management, notifying family, physician, Management suff. The facility failed % provide an environment free from abuse/neglecr, resident #6 his supper. 8. The regulatory Provisions of the Florida Statutes that are pertinent to this alleged violation tead as follows, 400-419 Violations; imapostion of administrative fines; grounds, « Rule 584-5.020 Resident Care Standards, ~ (2X@) Bood shall be served atmactively ax safe and Palatable temperatures. All residents shall he encouraged to eat a¢ tables in the dining areas, A supply of earing ware sufficient for all residents, including adapsive equipment if needed by any resident, shall be on hand. » e & 8, The violation alleged hercin constitutes a class IM defictency, and warrant: a fine of $500, WHEREFORE, AHCA demands the following relief: 1 Enter factual and findings as act forth in the allegations of this administrative complaint, 2. Impose a fine in the amount of $500. Respectfully submited this MA, of May, 2005. Fla. Bar, No, 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC 43 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922.5873 (office) (850) 921.0158 (fax) Respondent is notified thar it has a tight to request an administrative hearing Pursuant to Nn 120,569, Fa, Star, (2004), Specific options for administrative action are ser out in the atrached Election of Rights (one Page) and explained in the attached Explanation of Righty (one page), All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Adminivtration, Building 3, MSC #3, 2727 n Delve, Tallahassee, Florida 32308; Michael 0. Mathis, Senior Attorney, Telephone (850) 922.5873, REASULT IN AW ADMISSION OF TRE FACTS ALLEGED IN THE COMPLAINT SND THEENTRY OF A FINAL ORDER By as eED CERIFICATE OF seRvicp L HEREBY CERTIFY, shat 8 tre and correct copy of the foregoing has been served by certified mail on 4g day of Pay » 2005 to Deborah A, Grant, inistrator, Kipling Manor Retirement Center, 790} Kipling Street, Pensacola, Florida 32504, hes Michael O. Mathis, Esquire

Docket for Case No: 05-002187