STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2013005226 SWOF LLC d/b/a GULF WINDS, 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, SWOF LLC d/b/a GULF WINDS (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and states: NATURE OF THE ACTION This is an action to impose an administrative fine against an assisted living facility in the sum of ONE THOUSAND DOLLARS ($1,000.00) based upon one (1) Class II. violation pursuant to Section 429.19(2)(b), Florida Statutes (2012), JURISDICTION AND VENUE 1, The Court has jurisdiction over the subject matter pursuant to Sections 120,569 and 120.57, Florida Statutes (2012). ‘2, The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part IL, and 429, Part I, Florida Statutes (2012). 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 state regulations, statutes and rules governing such facilities. Chapters 408, Part II, and 429, Part J, Florida Statutes (2012); 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 in the manner provided in Chapter 120, Florida Statutes (2012). Sections 408.815 and 429.14, Florida Statutes (2012). 5. The Respondent was issued a license by the Agency (License Number 7804) to “operate a 50-bed assisted living facility located at 2745 Venice Avenue East, Venice, Florida 34292; and -was at all times material required to comply with the applicable state regulations, statutes and rules governing assisted living facilities. COUNTI The Respondent Failed To Ensure Adequate equate Supervision Of Residents In Violation Of Rule 58A-5.0182(1), Florida Administrative Code . 6. . The Agency ye-alleges and incorporates by reference paragraphs one (1) through five (5). ) . 7. Pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, Florida Administrative Code. (b) Daily observation by designated staff of the activities of the resident while on - the ‘premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel 2 independently. in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the residen:t exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. ) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), Florida Administrative Code, any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. - Rule 58A-5.0182(1), Florida Administrative Code. 8. On or about January 31, 2013, the Agency. conducted a: Change of Ownership j sss Survey of the Respondent’s facility, 9. Based on a teview of resident records and interviews with staff, the facility failed to ensure one (1) of two (2) residents, specifically Resident number one (1), had supervision and intervention related to weight loss, and there were no written record related to falls, skin tears, and physician and family contact related to resident status. 10. Resident number one (1) was admitted to the facility on October 10, 2011, At the current time, Resident number one (1) is a Hospice patient and has been since September 21, 2011. . 11, A review of the Hospice team care plan dated January 18, 2013 was performed. The care plan included clinical updates/progress notes from Hospice nurses about Resident mumber one (1) going back to July 10, 2012, In the progress note dated July 10, 2012, there were statements indicating Resident number one’s (1) weight at admission was 160 pounds. The progress note of July 10, 2012 continued noting Resident number one’s (1) weight using a knee height caliper equation was 128.18 pounds. This was a change of 32 pounds since admission. 3 Also, Resident number one (1) is now requiring assistance with meals. 12. The July 18, 2012 Hospice progress note indicated the outcomes they axe. focusing on are "assisting the patient with meals with the initiation of a Hospice volunteer at lunch time." 13. An observation of Resident number one (1) on January 31, 2013 during lunch revealed the resident had no assistance with eating from either a Hospice volunteer or from facility staff. Resident number one (1) was observed using a spoon to eat potato soup; however, the resident was spilling a lange percentage of the soup down the clothing protector the resident was wearing. | 14, The September 6, 2012 Hospice progress notes stated Resident nuniber one (1) was "consistently losing weight." Resident number one’s @ current weight is 125. 46 pounds . using the knee height caliper equation. Resident number one (1) had a 2,5 pound weight loss during this recertification period and'a total loss of nearly 35 pounds since admission, The ae eer hee October 10, 2012 progress note indicated, "The outcomes we are focusing on continue to be nutrition due to Resident number one’s (1) fair to poor appetite. Resident number one (1) continues to feed him/herself, but needs more prompting by the staff to eat." On November 7, 2012, the progress note indicated Resident number one (1) weighed 122 pounds. On December 31, 2012, the Hospice nurse noted the "patient no longer leaves the room for meals and fatigues easily; attempt to feed him/herself. Resident number one (1) was unable to complete this task and the staff completed his/her feeding." The nurse noted Resident number one’s (1) weight was now 118 pounds. 15. While reviewing Resident number one’s (1) record, it was noted there was no facility weight record for Resident number one (1). When questioned on January 31, 2013 at 1:30 p.m, the assistant administrator stated the facility had never kept a weight record for Resident number one (1), The facility assumed since Hospice was doing it they did not have to. The assistant administrator was aware Resident number one (1) had lost some weight but was 4 ’ unaware of the total amount the resident had lost. The assistant administrator was unaware Resident number one (1) continued to lose weight and she could not describe any interventions the facility had tried to maintain the resident's weight. 16. A further review of the record for Resident number one (1) revealed no written documentation of any issués or changes in the resident's condition. During continued interview with the assistant administrator, she stated the facility had never kept notes of any type in the record, The facility keeps ai ongoing log where the staff communicates to each other and also documents resident occurrences. These notes ate multi-resident and do not ‘demonstrate communication between the staff and the resident's family or physician. For example, Resident number one (1) went to the hospital on January 23, 2013 after a fall with abrasions. Resident | ‘ ‘number one (1) returned home after the examination, but there was no documentation about the — | __srident in the resident reeord, There-was-no-documentation indicaing the family or paysicn ! , had been notified. | . 17. There was also a note in the communication book indicating on January 29, 2013 | that Resident number one (1) was placed on the toilet and scratched “so hard” that the resident's leg had to be cleansed and dressed. Again; there was no documentation in Resident number one’s . (1) record about this happening. 4 18. The Respondent’s deficient practice constituted a Class II violation in that it related to the operation and maintenance of a provider or to the care of clients which the Agency determined directly threatened the physical or emotional health, safety, or security of the clients, other than a Class I violation. Section 429.19(2)(b), Florida Statutes (2012). 19. 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 as set forth in Section 429. 19(2}(), Florida Statutes (2012). A fine shall be levied notwithstanding the correction of the violation. i 5 WHEREFORE, the Petitioner, State of F lorida, Agency for Health Care Adm inistration, intends to. impose an administrative fine against the Respondent in the amount of ONE | THOUSAND DOLLARS ($1,000.00) pursuant to Section 429.19(2)(b), Florida Statutes (2012). _ CLAYM 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 appropriate. » 2013. Respectfully submitted on this ol Gy of Dib Orbea éborah E. Leoci, Assistan# General Counsel Florida Bar No. 0814423 Agency for Healih Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C ‘ Fort Myers, Florida 33901 | . Telephone: (239) 335-1253 aon NOTICE RESPONDENT IS NOTIFIED THAT IT/AHE/SHE HAS A RIGHT TO REQUES'T AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.37, FLORIDA STATUTES, THE RESPONDENT IS FURTHER NOTIFIED THAT - TT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATEVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ~ ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA . 32308; TELEPHONE (850) 412-3630. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING 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 BY ‘THE AGENCY. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and nsdn pene nee eereee i Or neers Trey BEN Election of Rights form has been served to: Maria C., Williams, ‘Administrator, ‘a Gulf Winds, 2 2745 Venice Avenue East, Venice, Florida 34292, by US, Certified Mail, Return Receipt No. 7011 1570 0002 1695 8924 and to Jmworld Services, Inc., Registered Agent, SWOF LLC d/b/a Gulf Winds, 424 East Central Boulevard #106, Orlando, Florida or, U. S. Certified Mail, eiurn Receipt No. 7011 1570 0002 1695 8917 on this ya y: day of 2013. ‘ah E. Leoci, Assistant General Counsel Florida Bar No, 0814423 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 335-1253 Copy furnished to: Maria C. Williams, Administrator SWOF LLC d/b/a Gulf Winds 9731 Commerce Center Court Venice, Florida 34292 (U.S. Certified Mail) Deborah E. Leoci, Assistant General Counsel Office of the General Counsel =~ : Agency for Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Imworld Services, Inc., Registered Agent SWOF LLC d/b/a Gulf Winds 424 East Central boulevard #106 Orlando, Florida 32801 (US. Certified Mail) Harold Williams Field Office Manager ; Agency for Health Care Administration 2295 Victoria Avenue, Room 340A - Fort Myers, Florida 33901 : (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Gulf Winds | ACHA No. 20130-05226 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. Kt may be returned by mail or facsimile transmission, but_must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint, If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form to this address: . Agency for Health Care Administration Attention: Agency Clerk 1 3 : j antl tee 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing, | understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint, OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative . Complaint 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. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings. under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk. at the address above within 21 days of your receipt of this proposed agency. action. The request for formal hearing. must conform to the requizements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1, The name, address, telephone number, and facsimile number (if any).of the Resporadent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom’service of pleadings and other papers shall be made. . : ; 3. A statement requesting an administrative hearing identifying those material facts that are in dispute,. If there are none, the petition must so indicate. : 4. A statement of when the respondent received notice of the administrative complairat, 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter ifthe Agency . agrees, : ., ‘ Licensee Name: Contact Person: Title: — ; Address: . _ Number and Street City Zip Code 4 : | Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: a a ie [on een ere se ete hanced

Docket for Case No: 13-003280

Orders for Case No: 13-003280