STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

Petitioner,

V.

CASE NOS. 2013013450

2014002084

DOAH NO. 14-3132

GRACE MANOR AT LAKE MORTON, LLC,

Respondent.

                                                                                 I

RENDITION NO.: AHCA· i S - Q / 'g J. -S-OLC

FINAL ORDER

Having reviewed the Administrative Complaint and Amended Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows:

1. The Agency has jurisdiction over the above-named Respondent pursuant to Chapter 408, Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions.

   
   

2. The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The Election of Rights forms advised of the right to an administrative hearing.

   
   

3. The parties entered into the attached Settlement Agreement. (Ex. 2) Based upon the foregoing, it is ORDERED:

1. The Settlement Agreement is adopted and incorporated by reference into this Final Order. The parties shall comply with the terms of the Settlement Agreement.

   
   

2. The Respondent shall pay the Agency $3,000.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. Any check made payable to the "Agency for Health Care Administration" and containing the AHCA ten-digit case number should be sent to:

Office of Finance and Accounting Revenue Management Unit

Agency for Health Care Administration 2727 Mahan Drive, MS 14

Tallahassee, FL 32308

Filed March 26, 2015 11:09 AM Division of Administrative Hearings

ORDERED at Tallahassee, Florida, on this_?!{ day of_, ' •-t4-.. ,2015.

Secretary

Care Administration

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed.

CERTIFICATE OF SERVICE

I CERTIFY that a true and corre is Final or45 as served on the below-named persons by the method designated on this (::,ctay of ,;1,lfl2-rC. h_ , 2015.

Richard Shoop, Agency Cler

Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3

Tallahassee, FL 32308-5403

Telephone: (850) 412-3630

I

STATE OF FLORIDA. !

AGENCY FOR HEALTH CARE ADMINISTRATION l

HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR I

Petitioner,

V.

CASE NO. 2013013450

'

2014002084

GRACE MANOR AT LAKE MORTON, LLC,

RespQndent.

---------------'/

ADMINISTRATIVE COMPLAINT

COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration .. ("the Agency"), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Grace Manor at Lake·Morton, LLC ("Respondent''), pursuant to Sections

120.569 and 120.57, Fla. Stat. (2013), and alleges:

This is an action against an assisted living facility ("ALP') to impose a$2,000 fine for one State Class II violation (Count I) and a $1,000 fine for an uncorrected State Class III violation (Count II).

JURISDlCTION AND VENUE

1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Fla. Stat. (2013).

2. Venue lies pursuant to Florida Administrative Code ("F.A.C.") Rule 2.8-106.207.

   
   

   1 EXHIBIT

   1

   
   

   PARTIES

3. The Agency is the regulatory authority responsible for licensure of ALFs and enforcement of an· applfoable State statutes and rules governing ALFs pursuant to Chapters 408,Part II, and 429, Part I, Fla. Stat., and Chapter 58A S, F.A.C., respectively.

4.. Respondent operates a 50 bed ALF at 610 East Lime St, Lakeland, FL 33801, Standard license

#5217.

1. Respondent. was at all times material hereto a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes.

   
   

   COUNT I $2,000 CLASS II FINE

   (Case No. 2013013450; State Tag A0030: Resident Care Rights & Facility Procedures)

2. The Agency re"alleges and incorporates paragraphs 1 - 5 as if fully set forth herein.

3. The Agency's surveyor conducted an unannounced complaintinvestigation (CCR2013008974) on 8

   October, 2013.

4. The surveyor learned this information during the survey:

   ..... -······----··---a.-Based-on-int@r:V-iews--and--a-reoord-re:views,-the-.faeility-failed-to-ensur-e--that-R-esident-#-1-,-an--85---------·· year old mari, with received appropriate medical care in a timely manner which led to delayed

   medical care and extreme continual pain.

   1. Phone interview with Staff 'A', a former med tech/caregiver, on 10/9/13at about 4:40 pm. She stated that the last night that Resident #1 was sent to the hospital, Staff'B' (another caregiver) and she were working. They did their final rounds. Resident #1 came out about 10:30 - 11:30 pm and complained about a burning, like a hot rod was in his eye. She called the resident care coordinator (RCC) and told her what was going on. She asked the RCC if she could give him a brand name medication for Acetaminophen that he had scheduled fqr later in the morning. The RCC

      
      

      said Staff 'A' wasn't supposed to but she could just this one time. Staff 'A' stated Resident #1 was hurting. She could tell he was in pain by his demeanor. About 11:30 to 12:30 am he started vomiting when he was in the recliner: He was in the recliner so they could keep an eye on h4ll. She called ih:e

      RCC again and she said just keep an eye on him and she would deal with him in the morning. The RCC told Staff 'A' that she knew the family would be upset if they sent him out because he had done this thing before. At 12:30 to 1:30 am it got worse and his breathing got worse. He was breathing funny. His vitals were going crazy. His blood pressure was 200 and something over 100 and something. His pulse was fast and oxygen saturation was low. His breathing was irregular..She called the RCC again and she said to call the home health company. The guy she spoke to at home health asked why did he need to come and she explained the situation and the vitals. He stated based on: Resident #1's vitals he should be sent out to the hospital. She called the RCC again and told her

      what home health said and the RCC said II no 11 , to not send him out and she would deal withhim in

      the morning. At 1:30 t9 2:30 am he was panic screaming (like yelling). He said now I know what it

      . .

      feels like to die alone. He already had problems with his left eye and it was white and he could not

      
      

      see out of it but he.could see out of his right eye. However, then he complained that he could not see

      
      

      would deal with him in the morning. At 3:30 am he was puking but she could hear it gurgling back in his lungs. He was as-pirating. She called the RCC and told her that she was sending this man out even if she had to be written up. He was throwing up and now he is aspirating. She stated OK do

      whatever you have to.do. EMTs (emergency medical technicians) got there about 3:45 am. They

      . --··-

      
      

      started to move him onto the stretcher. He couldn1t stand. He had a stroke. Emergency medical services (EMS) and the emergency room doctor asked her why the resident was not sent to _the hospital earlier. A friend who worked at the facility told her the next day that Resident #1 died at 6:45 am.

      
      

   2. PbQne interview with Staff 'B', a med tech/caregiver, on 10/9/13 at approximately 5:40 am. She reported that on. the night of the incident at 11:00 pm, Resident #1 complained that his eye hurt and he had a bad headache. Staff'A' called the RCC and she said to go ahead and give the brand name medication for Acetaminophen he had scheduled at some point during the next morning. In an hour he stated it was getting worse. Staff'A' called the RCC and she stated he did this before and to keep an eye on him. They sat with Resident #1 throughout the night in the living room in

      front. Resident #1 would freak out if he could not see them. He stated he could not see them and they were right in front of his face. He said to please not leave him because he did not want to die alone. Staff'A' called again and finally got pennission to call 911 from the RCC about 2:00 to 3:00 am.

      Paramedics asked if leaning to the side was nonnal for him and they told them it was not normal. They asked if his face-drooping was normal and they said, 11 no. 11 They did a stress.test and he was weaker cm one side. He fell to the side when they stood him up and stated they thought he had a stroke when they took him out on a stretcher. Staff 'B' stated she felt like Resident #1 should have went out to the hospital the first time Staff 'A' called the RCC. Resident #1 stated he felt like a hot rod was stabbing through his eye. It was not nonnal for him to come out of his room and complain

   3. Interview with the RCC about Resident #1 on 10/8/13 at about 2il5 pm. She stated that Staff'A' called.her once for Resident #l1s headache and she asked Staff' A' if he had anything she could give him for pain and Staff 'A' said a brand name medication for Acetaminophen. The RCC said, "well give him that. 11 Staff 'A' called back later and stated he was throwing up and she told Staff'A' to send him to the hospital. It started about 1:00 am and she did not know how long in between before Staff'A' called the second time. She stated she did not remember exact times

      · because it happened almost a year ago.

      
      

   4. Review of the EMS report dated 4/30/13. It indicated that the stroke alert was called at 3:28

      am and Resident #1 arrived at the hospital at 3:43 am.

      ' .

   5. Review of the hospital Emergency Department Note - Physician final report dated

      4/30/13. It noted that the physician spoke directly to the staff at the facility and was told that at 11:00 pm or so Resident #1 had severepain behind his right eye. He walked out to the nursing

      station to request help. Resident #1 sat down in a chair near the nursing station and stayed there for

      the next few hours. Somewhere between 3:00 and 3:1S am Resident #1 became less responsive and vomited and developed slurred speech. Facility staff did not notice left sided weakness. At the hospital Resident #1 was diagnosed with intracerebral hemorrhage (a type of stroke where an artery bursts in the brain and causes bleeding in the brain).

   6. Death. The hospital death record indicated that the resident died at 7:25 am on 4/30/13.

   7. Interview with the RCC on 10/8/13 at about :40 pm. Staff let them know if residents are sick and then they contact the nurse (a home health nurse because the facility has no nurses) and she

      comes to evaluate. If the nurse states they need to go out to hospital then they send them. If it's night time staff call her (the RCC) and then the nurse is called and the nurse still comes to assess. They

      
      

      
      

      
      

      and the nurse might say to go ahead and send out.

      i. Interview with the executive director (ED). The ED revealed that Resident #l ' s family was adamant about not sending him out to the hospital (not specifically talking about this event, but

      previous ones).

      t Review of the hospital Emergency Department Note - Nursing f'mal report dated 4/30/13.

      It revealed that EMS reported that the family was not thrilled with the idea of the resident being transported to the hospital.

      
      

      k. Review of the facility's medical emergencies policy. It was located on page 93 and 94 of its Assisted Living Policy and Procedure Manual. ·section 1 indicated that the administrator should be­ contacted immediately and section 2 indicated that the administrator makes the detennination of the severity of the situation. Section 3 indicated that the community summons emergency medical services by calling 911 when the resident exhibits signs and symptoms of distress and /or emergency condition. One example included was sudden onset of severe pain. Resident #1 had indicated to staff that he felt like a hot rod was stabbing through his eye but medical care was still delayed for hours.

5. Florida's law regarding residents having the right to a safe and decent living environment free from abuse and neglect is stated as follows:

   429.28 Resident bill of rights.-

   1. No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, ot the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to:

      1. Live in a safe and decent living environment, free from abuse and neglect. Section 429.28, Fla. Stat. (2013)

6. In sum, the facility failed to ensure that Resident #1 was free from neglect, to wit, he did not receive timely and appropriate medical care which led to extreme continual pain because he first alerted staff between the 10:30 to 11:30 pm time frame on 4/29/13 that he was in extreme pain but, despite his, e. g., repeated complaints of extreme pain, panic yelling, expressing his fear of dying alone, vomiting, lack of vision, crazy vitals, aspirating, leaning to the side and drooping face, 911 was notnotified until about 3:30 am the next morning, an inappropriate delay of several hours.

7. Respondent was cited for a Class II violation, defined as follows:

   
   

   408.813 Administrative fines; violations.-As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine.

   
   

   1. Violations of this part, authorizing statutes, or applicable rules shall be

   . classified according to the nature of the violation and the gravity of its probable effect on clients.

   . . Violations shall be classified on the written notice as follows:

   
   

   (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency detennines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class II violation. A fine shall be levied notwithstanding the correction of the violation.

   
   

   Section 408.813, Fla. Stat. (2013)

   
   

8. Florida law states as follows as regards the fine for an ALF for a Class II violation:

   
   

   429.19 Violations; imposition of administrative fines; grounds.-

   1. In addition to the requirements ofpartll of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted Jiving facility, for the actions of any person subject to level 2 background screening under s. 408.809, for the actions of any facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility.

   2. Each violation of this part and adopted rules shall be classified according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows:

      
      

      (b) Class "II'1 violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,0UO for each viotatfon. ·· · · · · ·· ··

      
      

   3. For purposes of this section, in determining if a penalty is to b.e imposed and in fixing the amount of the fine, the agency shall consider the following factors:

      1. The gravity of the violation including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential hann, and the extent to which the provisions of the applicable laws or rules were violated.

      2. Actions taken by the owner or administrator to correct violations.

      3. Any previous violations.

         d) · The financial benefit to the facility of committing or continuing the violation.

         (e) The licensed capacity of the facility.

         
         

         Section429.19, Fla. Stat. (2013)

         
         

         WHEREFORE, the Agency intends to impose a $2,000 fine against Respondent pursuant to Sections 408.813 and 429.19, Fla. Stat. (2013).

         
         

         CQUNT II • $1,000 UNCORRECIBD CLASS III FINE

         
         

         (Case No. 2014002084; State Tag AO010 - Admissions - Continued Residency)

         
         

9. The Agency re-alleges and incorporates paragraphs l - 5 as if fully set forth herein.

   
   

   1$' survev-11121113 (l!_aras14-19)

   
   

10. A complaint investigation (CCR.#2013012071) was conducted on 21 November, 2013.

    
    

11. Based upon record review the facility failed to ensure that an interdisciplinary care plan was developed and implemented for Resident #1, an 89 year old female receiving hospice care and services.

    A 11/21/13 review of her records showed that although she was retained at the facility on hospice care it failed to develop and implement an interdisciplinary care plan developed by hospice in coordination with her and/or another responsible party in order to meet her ne.eds.

12. Florida law provides as follows as regards an ALF resident receiving hospice services:

    ~""••-n-,---•-n~••'""-""" W ---- ---- ,-,~••- -•-,,,--•-• •-••--"•••-., ••••• m,_ ---•••-,-.. •-•--- •••••-,.•--"•u -•• "'-•

    SSA-S.0181 Admission Procedures, Appropriateness of Placement and

    .C..ontinued Residency Criteria.

    1. CONTINUED RESIDENCY. Except as follows in paragraphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a licensed health care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in. Rule SSA-5.0131,

    F.A.C. The results of the examination must_ be recorded on A.HCAForm 1823, which

    is incorporate<! by reference in paragraph (2)(b) of this rule. The form must be completed in accordance with that paragraph. After the effective date of this ru]e, providers shall have up to 12 months to comply with this requirement.

    (c) A terminally ill resident who no longer meets the criteria for continued residency

    may continue to reside in the facility if the following conditions are met:

    1. The resident qualifies for, is admitted to, and consents to the services of a licensed

       
       

       hospice which coordinates and ensures the provision of any additional care and services that may be needed;

    2. Continued residency is agreeable to the resident and the facility;

    3. An interdisciplinary care plan is developed and implemented by a licensed hospic.e in consultation with the facility. Facility staff may provide any nursing service permitted under the facility's license and total help with the activities of daily living; \ and

    4. Documentation of the requirements of this paragraph is maintained in the resident's file.

    
    

    Rule 58A-5.0181, F.A.C.

    
    

13. Insum, the facility failed to develop and implement Resident #1's interdisciplinary plan for hospice care and services.

14. Petitioner cited Respondent for a Class III violation, defined as follows:.

    408.813 Administrative fines; violations.-As a penalty for any violation of this part, authorizing statutes, or applicable rules, the ag ncy may impose an administrative fine.

    
    

    (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients.

    . .. Violations shall be classified on the written notice as follows:

    
    

    (c)· Class "Ill" violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which

    ..............·-·-······.........    

    ..._.!!i - ncy detennines inclirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in

    this section for a cited class III violation. A citation for a class Ill violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed.

    
    

    Section 408.813J Fla. Stat. (2013)

    t

    ,-, ~~••-,•m,_,_µo,•-!•

    
    

15. By letter dated 9 December, 2013, Respondent was notified of a mandatory cc>rrection date of 30 days from the letter's 9 December date, to wit, on or about9 January, 2014.

    
    

    2nd Survey - 1131/14 (oaras 20- 25)

16. A revisit survey was conducted on 31 January, 2014, to check on the deficiencies cited during

    
    

    the first survey on 21 November, 2013.

17. a. Based upon record review the facility failed to ensure that an interdisciplinary care plan was developed and implemented for resident #I, an 89 year old female receiving hospice care and

    services.

    
    

    1. An 11/21/13 review of Resident #1's records showed that although she was retained at the facility on hospice care it failed to develop and implement an interdisciplinary care plan with hospice in coordination with her and/or another responsible party to meet her needs.

    2. During the revisit survey an interdisciplinary care plan was still not available for her. The facility had a hospice 'Interdisciplinary Care Plans' form which was a blank form with the words 11Interdiciplinary Care Plans" hand written at the top of the page labeled as a 11HHA Plan of Care and Note". The rest of the page consisted of a check list to indicate the information for all areas pertaining to pain level, mental status, bathing, grooming, dressing, nutrition, activity tolerance and transfer . In sum, the form was empty in content and did not meet the intent of the requirement.

    3. During a staff interview the surveyor determined that they did not have a good understanding of the requirement_to dev l!?P" Q..il!lP l!! n.!fu.i:!!Y,P _2f.2! .'.Ih Y..i!1:dicated after discussion that they were going to develop their own form for this purpose.

18. In sum, the facility failed to correct the prior deficiency by still not having developed and implemented the required interdisciplinary care plan for Resident #1 who was still receiving hospice care and services.

19. Florida law regarding an ALF resident receiving hospice services is cited in paragraph 16.

    
    

20. Petitioner cited Respondent for a Class III violation, defined in paragraph 18.

    
    

    
    

21. The·same constitutes an uncorrected Class III violation with the fine detennined as follows:

429.19 · Violations; imposition of administrative fines; grounds.-

1. In addition to the requirements of part II of chapter 408, the agency

   ·shall impose an administrative fme in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility ...

2. Each violation of this part and adopted rules shall be classified . according to the nature of the violation and the gravity of its probable effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows:

(c) Class "III" violations are defined ins. 408.813. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation.

Section 429.19, Fla. Stat. (2012)

WHEREFORE, the Agency intends to impose a $1,000 fine against Respondent, an ALF in the State ofFlorida, pursuant to§ 429.19 (2) (c), Fla. Stat. (2013).

·r"t.

Submitted this!!._ day of April, 2014.

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

525 Mirror Lake Dr. N., Ste 330

.........................................................................................

.... .. . ... --·-· .... . -- . _ ..... St...J>..eiers.b.ur-&-ELJ.3.1. 01     -----··............      ---·­

Ph: (727) 55-2-1942

Fax: -1440

A--

david.selby@ahca.myflorida.com

By: L19

Edwin D. Selby

Assistant General Counsel Fla. Bar No. 262587

NOTICE OF RIGHTS

The Respondent is notified that.it/he/she has the right to request an administrative hearing pllrsQ.ant to·Sectim1s 120.569 and 120.57, Florida Statutes. {f 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.

T_be 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 rmal order will be entered.

The Electi.on 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) 412-3630.

CERTIFICATE OF SERVICE

I CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No.7012 1640 0000 0115 1193 on ?-· April, 2014, to Administrator Susan Martin, Grace Manor ai Lake Morton, LLC, 601 East Lime St, Lakeland, FL 33801, and by regular U.

Edwin D. Selby

S. mail to Registered Agent Christopher Desrochers, 2504 Ave G NW, Winter Haven, FL 33880.

Cc: Patricia Caufi:nan, ARCA Area 6 Field Office Manager

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE. GRACE MANOR AT LAKE MORTON, LLC. Case No. 2013013450

2014002084

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (ARCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. ·

Your Election of Rights must be returned by mail or by fax within 21 days of the day you. receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

If your Election of Rights with your selected option is not received by AHCA within twenty­ one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency's proposed action and a final order will be issued.

(Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes and Rule 28, Florida Administrative Code.)

PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS:

Agency for Health Care Administration Attention: Agency Clerk

2727 Mahan Drive, Mail Stop #3

Tallahassee, Florida 32308

Phone: (850) 412-3630 Fax: (850) 921-0158

PLEASESELECT ONLYT OF THESR3.OPTIONS

OPTION ONE (1)   I admit to the allegations of facts and law contained in the

Notice oflntent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action.

OPTION TWO (2) I admit to the allegations of facts contained in the Notice of

Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative

Complaint, but I 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 administrative action is too severe or that the fine should be reduced.

OPTION THREE (3) I dispute the allegations of fact contained in the Notice of

Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 administrative action. The request for formal hearing .must confo to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain:

1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any;

. 2. The file number of the proposed action;

1. A statement of when you received notice of the Agency's proposed action; and

2. A statement of all disputed issues of material fact. If there are none, you must state that there are none.

   
   

   Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.

   
   

   License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number:                        

   Contact person:----------- -------------

   Name Title

   Address:                                                                             Street and number City Zip Code

   Telephone No. · Fax No.

                          Einail(optional)                   _

   
   

   I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above.

   Signed:                                               =D=at=e:!..:                    _

   
   

   Print Name:                                              Title:                                       

   STATE OF FLORIDA

   AGENCY FOR HEALTH CARE ADMINISTRATION

   
   

   STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

   
   

   Petitioner,

   
   

   V. AHCA NO. 2013013450

   2014002084

   DOAH NO. 14-3132

   
   

   GRACE MANOR AT LAKE MORTON, LLC,

   
   

   Respondent.

                                                                            /

   
   

   SETTLEMENT AGREEMENT

   
   

   Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the "Agency"), and Respondent, Grace Manor at Lake Morton, LLC (hereinafter "Respondent"), through their respective undersigned representatives, pursuant to Section 120.57(4), Florida Statutes, each individually, a "party," collectively as "parties," hereby enter into this Settlement Agreement ("Agreement") and agree as follows:

   WHEREAS, Respondent is an Assisted Living Facility ("ALF") licensed pursuant to pursuant to Chapters 408, Part II and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code; and

   WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing

   
   

   authority over Respondent, pursuant to Chapters 408, Part II and 429, Part I, Florida Statutes; and

   WHEREAS, the Agency served Respondent with an administrative complaint on 8

   
   

   April, 2014, notifying Respondent of its intent to impose a $2,000 administrative fine for one Class II violation and a $1,000 fine for one uncorrected Class III violation; and

   EXHIBIT 2

   
   

   WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and

   NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows:

   1. All recitals herein are true and correct and are expressly incorporated herein.

      
      

   2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties.

   3. Upon full execution of this Agreement, Respondent agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal

      .. proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions oflaw) to which it may be entitled, provided, however, that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement.

   4. Upon full execution of this Agreement, Respondent agrees to pay the total sum of

      
      

      $3,000.00 within 30 days from the date of the Final Order.

      
      

   5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida.

   6. By executing this Agreement, Respondent denies the allegations set forth in the administrative complaint, and the Agency asserts the validity of the allegations raised in the administrative complaint referenced herein. No agreement made herein shall preclude the Agency from imposing a penalty against Respondent for any deficiency/violation of statute or rule

      
      

      identified in a future survey of Respondent, which constitutes a "repeat" or "uncorrected" deficiency from surveys identified in the administrative complaint.

   7. No agreement made herein shall preclude the Agency from using the deficiencies from the surveys identified in the administrative complaint in any decision regarding licensure of Respondent, including, but not limited to, licensure for limited mental health, limited nursing services, extended congregate care, or a demonstrated pattern of deficient performance. The Agency is not precluded from using the subject events for any purpose within the jurisdiction of the Agency. However, if the Agency seeks to use the facts recited in the administrative complaint herein for any future administrative action, Respondent retains the right to contest those facts in any such administrative action which is based solely, or in part, on the subject events in the underlying administrative complaint. Further, Respondent acknowledges and agrees that this Agreement shall not preclude or estop any other federal, state, or local agency or office from pursuing any cause of action or taking any action, even if based on or arising from, in whole or in part, the facts raised in the administrative complaint. This Agreement does not prohibit the Agency from taking action regarding Respondent's Medicaid provider status, conditions, requirements or contract.

   8. Upon full execution of this Agreement, the Agency shall enter a Final Order

      
      

      adopting and incorporating the terms of this Agreement and closing the above-styled case.

      
      

   9. Each party shall bear its own costs and legal fees, if any.

      
      

   10. This Agreement shall become effective on the date upon which it is fully executed by all the parties.

   11. Respondent for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys

       
       

       
       

       of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent or related facilities.

   12. This Agreement is binding upon all parties herein and those identified in paragraph 11.

   13. In the event that Respondent was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G-9.070, Florida Administrative Code.

   14. Respondent agrees that if any funds to be paid under this agreement to the Agency are not paid within 30 days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Respondent in the Final Order, or any portion thereof, owed by Respondent to the Agency from any present or future funds owed to Respondent by the Agency, and that the Agency shall hold a lien against present and future funds owed to Respondent by the Agency for said amounts until paid.

   15. The undersigned have read and understand this Agreement and have the authority to bind their respective principals to it. Respondent has the capacity to execute this Agreement.

   16. This Agreement contains and incorporates the entire understandings and agreements of the parties.

   17. This Agreement supersedes any prior oral or written agreements between the

       
       

       parties.

       
       

       
       

       
       

       e that faxed and scanned signatures suffice for original signatures.

   18. This greement may not be amended except in writing. Any attempted

Florida Bar No. 262587

Agency for Health Care Administration 525 Mirror Lake Dr N, Suite 330

-                       

St. Petersburg, F 3 701 DATED: f & 2Pl.J,--

Stuart F. Williams, General Counsel Florida Bar No. 670731

Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3

Tallahassee, FL 2308 DATED: -=---J-----Jf--------'-----1'--"----"---

Grace Manor at Lake Morton, LLC c/o Mainstay Financial Services 5578 Commercial Blvd NW

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Winter Haven, FL 33880

DATED:                             

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J. ¥

Florida Bar No. 714313

Peterson & Myers, P.A. 225 East Lemon St.

Lakeland, FL 33802-4628 DATED: "J-l"J-/1

D

Agency for Health Care Administration 2727 Mahan Dr

Tallahassee, FL 32308

DATED: 3{2-'f /f,

Docket for Case No: 14-003132

Orders for Case No: 14-003132