STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Case Nos. 2016004641 _ Petitioner, 2016012835 AM GRAND COURT LAKES LLC, Respondent. 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, AM Grand Court Lakes, LLC (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2016), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to revoke its licensure to operate an assisted living facility in the State of Florida and to impose an administrative fine in the amount of three thousand five hundred dollars ($3,500.00) and survey fees of one thousand dollars ($1,000.00), for a total sum of four thousand five hundred dollars ($4,500.00) based upon three (3) uncorrected Class III deficiencies, and four (4) unclassified deficient practices. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2016). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities. pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent operates a one hundred forty (140) bed assisted living facility located at 280 Sierra Drive, North Miami Beach, Florida 33179, and is licensed as an assisted living facility, license number 8390. 5. 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. COUNTI 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(1)(e) pursuant to Chapter 435 and Section 408.809. § 429.174, Fla. Stat. (2015). 8. Under Florida law, the eligibility results of employee screening and the signed Attestation referenced in subsection 59A-35.090(2), F.A.C., must be in the employee’s personnel file, maintained by the provider. Rule 58A-5.010(3)(c), Florida Administrative Code. 9. Based upon record review and interview, the Respondents failed to ensure that employee eligibility results and a signed attestation of Compliance with Background Screening (AHCA form 3100-0008) was maintained in the personnel records of seventy-seven (77) employee files, the same being contrary to the mandates of law. 10. That Petitioner’s representative reviewed Respondent’s staffing schedules and noted Respondent employed seventy-seven (77) persons within the facility. 11. That Petitioner’s representative reviewed Respondent’s personnel records and noted the personnel files of employees did not contain a signed attestation of Compliance with Background Screening (AHCA form 3100-0008) signed by the employee. 12.. That Petitioner’s representative interviewed Respondent’s employees “A” and “B” on May 13, 2016, at 1:23 PM who indicated that they were unaware that Respondent had to keep the attestation reference with the staffs’ background screening. 13. That Respondent’s administrator acknowledged to Petitioner’s representative that the facility employee personnel records did not contain the required attestation. 14. The Respondent’s actions or inactions constituted a violation of Rule 59A-35.090(3)(c), Florida Administrative Code. 15. Under Florida Jaw, in addition to the requirements of part IT of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2015). 16. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2015). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500.00 against the Respondent. COUNT II 17. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. Under Florida law, the Agency for Health Care Administration in consultation with the Department of Law Enforcement shall create a secure web-based system, which shall be known as the “Care Provider Background Screening Clearinghouse” or “clearinghouse,” and which shail be implemented to the full extent practicable no later than September 30, 2013, subject to the specified agencies being funded and equipped to participate in such program. The clearinghouse shall allow the results of criminal history checks provided to the specified agencies for screening of persons qualified as care providers under s. 943.0542 to be shared among the specified ~ agencies when a person has applied to volunteer, be employed, be licensed, or enter into a contract that requires a state and national fingerprint-based criminal history check. The Agency for Health Care Administration and the Department of Law Enforcement may adopt rules to create forms or implement procedures needed to carry out this section. 435.12(1) Fla. Stat. (2016). 19. Under Florida law, an employer of persons subject to screening by a specified agency must register with the clearinghouse and maintain the employment status of all employees within the clearinghouse. Initial employment status and any changes in status must be reported within 10 business days. § 435.12(2)(c), Fla. Stat. (2016). 20. That on June 2, 2016, the Agency completed a complaint survey of Respondent and its facility. 21. Based upon record review and interview, the Respondents failed to ensure that it maintained the employment status of all employees within the state clearing house in a timely manner, the same being contrary to the mandates of law. 22. That Petitioner’s representative reviewed Respondent’s staffing schedules and noted that seventy-seven (77) persons were employed by the Respondent facility. 23. That Petitioner’s representative reviewed Respondent’s employee roster for the facility on the Agency for Health Care Administration Care Provider Background Screening Clearinghouse website during the survey on May 10, 2016, and no staff members were listed for Respondent. 24. That Petitioner’s representative interviewed Respondent’s business manager, employee “B,” on May 10, 2016 at 11:00 AM, who indicated, "The facility did not have the staff registered on the clearinghouse website, but I will do it right now." 25. That Respondent failed to maintain employment records on the Care Provider Background Screening Clearinghouse as mandated by law. 26. The Respondent’s actions or inactions constituted a violation of Sections 435.12, Florida Statutes (2016). 27. Under Florida law, in addition to the requirements of part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter.429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2016). 28. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class IIL, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $500.00 against the Respondent. COUNT IT 29. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 30. That on June 2, 2016, the Agency completed a complaint survey of Respondent and its facility. 31. Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(1)(e) pursuant to Chapter 435 and Section 408.809. § 429.174, Fla. Stat. (2015). 32. Under Florida law, level 2 background screening pursuant to Chapter 435 must be conducted through the Agency on each of the following persons, who are considered employees for the purposes of conducting screening under Chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the Agency has reason to believe that such person has been convicted of any offense prohibited by Section 435.04. For each controlling interest who has been convicted of any such offense, the licensee shall submit to the Agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. § 408.809(1), Fla. Stat. (2015). 33. Under Florida law, in addition to the offenses listed in Section 435.04, all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the offenses or any similar offense of another jurisdiction listed in Section 408.809(4). § 408.809(4), Fla. Stat. (2015). 34. Under Florida law, if an employer or Agency has reasonable cause to believe that grounds exist for. the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. § 435.06(1), Fla. Stat. (2015). 35. Under Florida law, (a) an employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the Agency as provided under Section 435.07. (b) If an employer. becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to Section 435.07. (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. § 435.06(2)(a)-(d), Fla. Stat. (2015). 36. Under Florida law, any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. § 435.06(3), Fla. Stat. (2015). 37. Under Florida law, all staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S. ... Rule 58A-5.019(3)(a), Florida Administrative Code. 38. Under Florida law, “Staff” means any person employed by a facility; or contracting with a facility to provide direct or indirect services to residents; or employees of firms under contract to the facility to provide direct or indirect services to residents when present in the facility. The term includes volunteers performing any service which counts toward meeting any staffing requirement of this rule chapter. Rule 58A-5.0131(34), Florida Administrative Code. 39. Based upon record review and interview, the Respondents failed to ensure that the Facility staff had the required background screening or exemption for one (1) of twenty (20) sampled staff members, the same being contrary to law. 40. That Petitioner’s representative reviewed Respondent’s personnel records during the survey and noted the following for staff member “O”: a. The staff member was hired on May 6, 2016 and worked the 7:)00 AM to 3:00 PM shift. b. The personnel record of the staff member did not contain a copy of the employee’s Level II criminal history background screening. 42. _- That Petitioner’s representative interviewed Respondent’s staff members “A,” the administrator, and “B,” the business manger on May 19, 2016, who acknowledged that Respondent did not have an eligible criminal history background screening in the personnel record for staff member “O.” 43. That providers are required to obtain and maintain such records as criminal history background screening for Agency review in personnel records. See, Rule S8A-5.024(2)(a), Florida Administrative Code. 44, That Respondent allowed individuals, in an employment or volunteer role, access to residents, their records, and property, without having obtained a criminal history background check on the individual, the same being contrary to the mandates of law. 45. The Respondent’s actions or inactions constituted a violation of Sections 429.174 and 408.809, Florida Statutes (2015). 46. Under Florida law, in addition to the requirements of part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part 1, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2015). 47. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by 10 law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2015). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of one thousand five hundred dollars ($1,500.00) against the Respondent. COUNT IV 48. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 49. That on June 2, 2016, the Agency completed a complaint survey of Respondent and its facility. 41. Under Florida law, the Agency shall require level 2 background screening for personnel as required in Section 408.809(1)(e) pursuant to Chapter 435 and Section 408.809. § 429.174, Fla. Stat. (2015). 50. Under Florida law, level 2 background screening pursuant to Chapter 435 must be conducted through the Agency on each of the following persons, who are considered employees for the purposes of conducting screening under Chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the Agency has reason to believe that such person has been convicted of any offense prohibited by Section 435.04. For each controlling interest who has been convicted of any such offense, the licensee shall submit to the Agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. § 408.809(1), Fla. Stat. (2015). 51. | Under Florida law, every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward the person’s fingerprints.to the Federal Bureau of Investigation for a national criminal history record check unless the person’s fingerprints are enrolled in the Federal Bureau of Investigation’s national retained print arrest notification program. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h), the person must submit fingerprints electronically to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints shall be retained by the Department of Law Enforcement under s.943.05(2)(g) and (h) and enrolled in the national retained print arrest notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records - checks required by level 2 screening may be borne by the licensee or the person fingerprinted. 12 Until a specified agency is fully implemented in the clearinghouse created under s. 435.12, the agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Department of Elderly Affairs, the Agency for Persons with Disabilities, the Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that: (a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s. 435.04 and this section; (b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and (c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency. § 408.809(2), Fla. Stat. (2015). 52. Under Florida law, any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. § 435.06(3), Fla. Stat. (2015). 53. Under Florida law, “Staff” means any person employed by a facility; or contracting with a facility to provide direct or indirect services to residents; or employees of firms under contract to the facility to provide direct or indirect services to residents when present in the facility. The term includes volunteers performing any service which counts toward meeting any staffing requirement of this rule chapter. Rule 58A-5.0131(34), Florida Administrative Code. 13 54. Based upon record review and interview, the Respondents failed to ensure that the Facility to verify the Level II background screening for one (1) of twenty (20) sampled staff that no more than ninety (90) days had elapsed prior to the staff person beginning work for Respondent that the staff member had continuously been working in another facility without a break in service., the same being contrary to law. 55. That Petitioner’s representative reviewed Respondent’s personnel records during.the survey and noted the following; a. The personnel record for staff member “G” contained a Level II criminal background screening dates august 7, 2013. b. . The employment application for staff member “G”’ was dated January 28, 2015 c. The personnel records of staff members “G” and “N” did not contain a letter of recommendation or other documentation reflecting that they had been working in another facility requiring background screening without a break in service of more than ninety (90) days. d. The applications of staff memberes “G” and “N” had no dates reflected for prior employment. 56. That Petitioner’s representative interviewed Respondent’s staff members “A,” the administrator, and “B,” the business manger on May 13, 2016, who indicated they did not know that the background screening needed to be completed before the employee started working at the facility. 57. That Florida law requires that a new Level II criminal histroy background screening be obtained where there has been a break of employment in a position requiring screening for a period exceeding ninety (90) days. 14 58. That providers are required to obtain and maintain such records as criminal history background screening for Agency review in personnel records. See, Rule 58A-5.024(2)(a), Florida Administrative Code. 59. That Respondent allowed individuals, in an employment or volunteer role, access to residents, their records, and property, without having obtained a criminal history background check on the individual, the same being contrary to the mandates of law. 60. The Respondent’s actions or inactions constituted a violation of Sections 429.174 and 408.809, Florida Statutes (2015). 61. Under Florida law, in addition to the requirements of part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter .120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2015). 62. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2015). 15 WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of one thousand five hundred dollars ($1,500.00) against the Respondent. COUNT V 63. The Agency re-alleges and incorporates paragraphs (1) through (5) and Counts I through IV as if fully set forth herein. 64. That pursuant to Section 429.19(7), Florida Statutes (2015), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2015), to verify the correction of the violations. 65. That Respondent was subject to the citation of one or more Class II deficient practices or the citation of a violation that was subject of the complaint which requires the imposition of a survey pursuant to law. See, Section 429.28(3)(c), Florida Statues (2015). 66. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2015). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2015). COUNT VI 67. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 16 68. 69. and its facility. 70. That Florida law provides: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. 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, F.A.C. (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 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 resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(G3), F.A.C., 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. That on November 10, 2015, the Agency completed a complaint survey of Respondent That based upon the review of records, observation, and interview, Respondent failed to provide care and services, including personal supervision, appropriate to the needs of residents relating to, inter alia, the provision of care and services to address residents with known risk of falls, the same being contrary to the requirements of law. 71. That Petitioner’s representative observed resident number four (4) on November 3, 2015, at 9:15 AM in the resident’s room and noted the resident seated in a recliner sofa with foot cast boot on the right leg. 17 72. That Petitioner’s representative reviewed Respondent’s records related to resident number four (4) during the survey and noted as follows: a. The resident was admitted to the facility on April 8, 2013. b.. The resident’s most recent health assessment, dated November 14, 2014, provided as follows; i. Diagnoses: Vitamin D deficiency, High blood pressure, Lumbar Myelopathy, polymyalgia Rheumatic, Dermatopathia pigmentosa reticularis , Legally Blind, physical or sensory limitation ambulate with walker and nursing medication management. ii. Activities of daily living (ADLs): Independent with ambulation, dressing, eating, self-care, toileting, transferring, and need assistance with bathing. iii. Special diet instruction: regular/no added salt. iv. Need assistance with self-administration of medications. v. Hospital Bed with half side rails for safety. c. Emergency room records of October 13, 2015 reflects: i. Diagnosis: "Multiple closed fractures of metatarsal bone, right, initial encounter." ii. Problem list: T11 vertebral fracture, Myopathy, Rib fractures. d. On July 1, 2015, the resident was admitted to a medical center and was discharged on July 2, 2015, with a discharge diagnoses of Rib fractures." (see photo). €. On March 19, 2015, the resident was admitted to the hospital at 6:46 PM with diagnoses of Head Injury, Abrasions, PGH- Cold Therapy - "should follow up with physician in 1 day.” 18 f. On March 19, 2015, at 13:48:13, Fire Rescue dispatched and arrived at destination at 14:31 with HX present cause: Fall/ Slipped/ Tripped. Complaint: head pain. g. On February 8, 2015, the resident was transferred to the Hospital with diagnoses: head injury, Urinary tract infection female. You should follow up with the following physician in 2 days. 73. That Petitioner’s representative interviewed resident number four (4), an alert and aware individual, on November 3, 2015, at 9:20 AM, and the resident indicated as follows: a. The resident had lived at the facility for three (3) years. b. The resident had fallen a few times - "maybe five times." c. The resident fell in the bathroom and wanted the facility to repair the bathroom. d. The resident was scared about the bathtubs and takes showers on the toilet with clothes (towels). e. A certified nursing assistant (CNA) showed the resident how to do it. f. The resident now has a fracture in the right foot. g. “T was very independent person and now I need to learn how to slow down,” and added the resident’s spouse had fallen at the facility two times. 74. That Petitioner’s representative interviewed Respondent’s administrator related to resident number four (4) on November 3, 2015, who indicated that the resident had a history of falls and falls happened when changes occurred at facility with administration and construction. 75. That Petitioner’s representative reviewed a facility document entitled “Fall Risk Acknowledgement” which provided: a. "T, the undersigned, understand that the Resident is considered ‘at risk’ for falls based on a health assessment and prior medical history. ] also understand that a fall may have severe consequences and result in injuries including lacerations, broken bones and even death. b. “T acknowledge, assisted living facilities are specially designed to offer residents freedom, independence and autonomy, and that 24-hour one-on-one care is not provided. I further understand and acknowledge that AM Grand Court Lakes, LLC cannot make any assurance that a resident will not fall. I have been given the opportunity to have questions answered and discuss this fall risk with AM Grand Court Lakes, LLC employee's.” 76. That Petitioner’s representative noted in Respondent’s records related to resident number four (4) a document entitled, “Discharge Summary,” and dated September 24, 2015 which documented: a. The resident was admitted on June 16, 2015, and discharged on Sepiember 24, 2015. b. - The resident requires Level One which includes standard services as well as supervision with bathing grooming and dressing and scheduled transportation to MD office. 77. That Petitioner’s representative reviewed Respondent’s records related to resident number six (6) during the survey and noted as follows: a. A hospitalization of September 15, 2015, documented “Discharge diagnosis - Pt (Patient) was brought to ER (emergency room) from the ALF (Assisted Living Facility), Pt was noted by the ALF Staff to have facial swelling. _ Pt was admitted and evaluated, [] had a lump on the left side of forehead, C/Scan (Computed Tomography Scan) of the face showed that Pt had hematoma of the 20 left side of head and had AC. Fracture of the Roof of the Right Orbit. Patient has Dementia and [] is not able to give any information." b. The health assessment, form 1823, dated August 21, 2015, provided: i, Diagnosis reflected no known allergies, Diabetes Mellitus, Hypertension and Chronic Kidney Disease Stage II. Resident has memory problems, dementia, disoriented, unable to administer her own - medications + needs help with her daily living activities. Resident has dementia, sometimes gets confused, unable to live independently and has insomnia. ii. Resident needs administration of medications including insulin, checking blood sugar, 3x daily, preparation of diet, assistance with daily living activities. iii. Patient has dementia and has been used to getting out of the resident’s house. iv. Resident needs assistance for bathing, dressing and grooming. Vv. Resident needs supervision on ambulation and toileting. vi. Resident needs total assistance for transferring. vii. Resident is independent eater. viii. Resident special diet instruction reflects diabetic diet, no added salt, low fat/low cholesterol, low sodium and low cholesterol diet. ix. Resident has a diagnosis of communicable disease has Chronic Hepatitis C, and resident required 24-hour nursing or psychiatric care. 21 x. The resident had Dementia, Insulin dependent Diabetes Mellitus, however, the 1823 Form documented the Resident needs can be met in the facility. c. In comparison, the Form 1823 signed on April 24, 2015, reflected, "Resident's needs cannot be met by facility due to Patient should be in a facility where there is nursing care and supervision. Pt needs insulin to be administrated + blood sugar has to be check regularly.” d. A progress notes dated September 15, 2015, documents, "Resident observed by home health nurse and facility staff at dining table (while getting ready for lunch) with head down on the table very lethargic swelling observed to both eyes. Doctor immediately called orders received transfer to emergency room for evaluation. Son notified. .... resident transported to ER.” e. A note of September 18, 2015, documents a meeting with the resident’s relative and the executive director with the relative being quoted "[] has a fx in [the] face. Someone is going to pay," and further noting the executive director handled meeting and will have investigation done. f On September 21, 2015, a note documents a call from a social worker from the hospital which reads "[Resident number six] is being discharged today back to CCL. This write advised her to speak with family as they stated, ‘We are not happy with the services CCL is providing." g. An order dated September 18, 2015, provided "Place mattress on the floor for safety purpose." 22 78. h. An order for the use of half bed rails was signed on September 11, 2015, with noted diagnoses of Gait Difficulty, Weakness of legs, Dementia and Polyneuropathy. i. An evaluation order of August 21, 2015, provided "Vitamin D 50,000 IU Q week, D/C Namenda, Fall Precautions, encourage PO (by mouth) fluids and Ferrous Sulfate 525 mg.” That Petitioner’s representative interviewed Respondent’s administrator on November 4, 2015, regarding resident number six (6), and the administrator indicated as follows: a. 9:39 AM: i."[The resident] was not on fall precautions when [] arrived to the facility. [The resident] was able to walk and move around, however, [] became sick, [] stomach was distended, [] had diarrhea, and [] started to decline. Therefore, we had to provide a higher level of care for [] because [the resident] was not as [] used to be, and [] could not live in the ALF area anymore. [The resident] was moved to the memory care unit. However, [] was transferred to the Memory Unit because s[]was an elopement risks resident. ii. The administrator reported the resident was transferred to the Memory Care Unit because there are less residents and more certified nursing assistants. iii. During the daytime, the Memory Care unit has two certified nursing assistants, and at night time there are three certified nursing assistants. iv.The doctor recommended hospice for the resident, but the family declined. Db. 9:55 AM: 23 i. “[The resident] slept in the assisting living facility room B 501, but [] was transferred to the Memory care unit because the night shift staff reported the . resident was saying, ‘I am going home, I am not staying here.’” ii. The resident was transferred to A 505 the next day on June 17, 2015. iii. The family did not like the change because they could not understand that the resident was an elopement risk, and I did not want to have an incident of elopement in the facility. c. 9:58 AM - When asked regarding the discrepancy between the interviews at 9:39 AM and 9:55 AM, she stated, "I have so many things in my head, and J cannot remember exactly everything.” d. 10:00 AM: i, The Administrator stated that if a resident falls, the Resident calls to the front desk, and the CNA will go to assist the Resident. ii. If there is blood, they call for emergency, but if the resident states that he/she is okay, they will call the primary doctor for assessment and X-ray. iii. "To be honest, I cannot recall if [resident number six] fell here or at [the] family's house, because [the resident] kept coming back and forth. A CNA reported, that [the resident] had her face down on the table, and we sent [the resident] to the hospital.” 79. That Petitioner’s representative interviewed Respondent’s staff member “B” on November 4, 2015, regarding resident number six (6), and the staff member indicated as follows: 24 a. "J do not remember exactly that day, but I will use my notes. On 9/18/15 for safety precaution the Doctor wrote an order for the use of the mattress on the floor, but there was a verbal order on 9/1/15 per the Doctor." b. "[The resident] left with the [adult child] on 9/1/15 and came back to the facility on 9/2/15 with [adult children], [] blood sugar was 437, which was high, and we gave the insulin, and they took [the resident] back with them. c. “On 9/3/15 [the resident] was still out, and the family states that [] will be out for two more days, and we provided medications for two days. d. “On 9/4/15, [the resident] came back to CCL, [] was assessed and [] was okay. e. “On 9/5/15, [the resident] was okay in [] room, and 9/9/6 [] was okay. f. “On 9/11/15, [the resident] was seen by the doctor. g. “On 9/15/15, we were making rounds, and [the resident] was non-verbal and lethargic. W sent [] to ER, and notified the doctor.” 80. That Petitioner’s representative interviewed Respondent’s staff member “H,” a certified nursing assistant, on November 4, 2015, regarding resident number six (6), and the staff member indicated as follows: a. "I have been working in this facility since March of this year. I am happy to work here especially at the Memory Care Unit. They are like family and I know all of them well. I work from 7:00 am - 3:00 pm, I do not know the specific days because administration rotates my days, and I am full time. b. "The Memory Care Unit floor is on the fifth floor, and it is a closed unit. This unit is for residents that have Alzheimer’s and/or are elopement risk. 25 c. “T used to assist [the resident] when [the resident] was living in the Memory unit in room 505. d. “When [] arrived to the facility, [the resident] used to walk, and [] just needs assistance. e. “One day, I saw [the] stomach distended, and [the resident] did not want to eat. Therefore, I reported this to the office, and [the resident] went to the hospital. However, when [the resident] came back from the hospital, [the resident] was down. f. “[The resident] went two or three times to the hospital until []] had an operation, but [] came back worse. g. “One day, I found [the resident] sleeping with the mattress on the floor for fall precautions because [] moved a lot." h. "[The resident] stopped walking, became incontinent and needed to be fed. i. “I was feeding [the resident] the day [the resident’s] face fell down to the table, [] did not want to eat, I stood up and went to feed another resident, and I heard when [the resident’s] face fell down on the table. j. “T approached [the resident], and [] was unresponsive. I did not notice any bump or redness in [the] face. I called administration mostly because [the resident] was unresponsive. k. “The nurses came, and [the resident] went to the hospital on that day. 1. “I was working by myself and there were between 8-10 residents, but most of them feed themselves, it is an easy unit. 26 81. That the above reflects Respondent's failure to ensure it provided care and services appropriate to resident needs, including but not limited to 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, where Respondent failed to provide services or interventions to address known risk of falls by residents, the same being contrary to the requirements of law. 82. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 83. That the same constitutes a Class II] offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class III deficient practice. 84. That Florida law requires that cited deficient practice be corrected within thirty (30) days. 85. That on February 12, 2016, the Agency completed a re-visit to November 12, 2015, . complaint survey of Respondent’s facility. 86. That based upon the review of records, observation, and interview, Respondent failed to provide care and services, including but not limited to 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, where Respondent failed observe a resident’s well-being for an extended period of time after the resident had experienced a fall, the same being contrary to the requirements of law. 87. That Petitioner’s representative reviewed Respondent’s “Resident Handbook” during the survey which provides “Housekeeping is scheduled on a weekly basis and available as needed." 27 88. That Petitioner’s representative reviewed Respondent’s records related to resident number one (1) during the survey and noted as follows: a. A note read "Miami Dade Fire Rescue responded to call for Resident #1. A staff member called 911 on 11/10/2015 at 11:47 pm. When fire rescue arrived, the resident was unaware of how long he had been on the floor. The staff members reported to Fire Rescue they found the resident on the floor during routine cleaning, but did not know how long he had been on the floor. The resident's clothes were soiled with urine and feces. The staff reported to Fire Rescue the resident was independent and did not have any information on him. Captain also reports the resident's room was dirty and unkempt." b. The resident's health assessment, Form 1823, completed on January 21, 2015, indicated that the resident was diagnosed with Depression. c. Progress notes documented: i. On 11/10/2015 resident was found on the floor in his apartment (living room). [] did not say how [] fell when 911 was activated resident was transferred to the hospital. ii. On 11/11/2015 the resident will be relocated to another apartment so [] apartment can be thoroughly cleaned and renovated. 89. That hospital records regarding resident number one (1) reflect the resident was admitted on November 11, 2015; had suffered a mechanical fall due to loss of balance and fell on the ground.; had no energy to get up; and has been lying on the ground for four (4) days. 90. That Petitioner’s representative interviewed resident number one (1) on January 27, 2016, and the resident indicated as follows: 28 a. "T felt on the floor and I was unable to reach my phone. I stayed on the floor for 4 days. No staff came to check me because at that time I was an independent resident. b. “On the four day the staff and rescue came. I was transferred to the hospital. c. “T do not remember how long I stayed at the hospital. I was admitted in the ALF when I returned from the hospital." 91. That Petitioner’s representative interviewed Respondent’s staff member “A,” a licensed practical nurse, on January 27, 2016, regarding resident number one (1), and the nurse indicated "[The resident] is independent. We do not assist [] with anything. [The resident] has the rights to refuse to come in [the resident’s] room. [The resident] was not on the floor for four days. The progress notes did not document that.” 92. That Petitioner’s representative interviewed Respondent’s staff member “B,” the business manager, on January 27, 2016, regarding resident number one (1), and manager indicated "We closed the independent unit a year ago.” 93. That Petitioner’s representative interviewed a family member of resident number one (1) on January 27, 2016, who indicated "The facility contacted me. My [relative] told me that [the relative] was left on the floor for four days. I asked the facility staff why [the relative] was left on the floor for four days. No one called me back." 94. That Petitioner’s representative interviewed Respondent’s staff member “C,” Respondent’s housekeeping supervisor, on January 27, 2016, regarding resident number one (1), and the supervisor indicated "[The resident} refused that we clean [the] room. [The resident] let us enter [the] room sometimes, but [] looked at us all the time. [The resident] did not allow us to 29 change [] linens. | did not have too many furniture's. The room was dirty. I heard that {the resident] fell and [] did not have idea for how long [] was on the floor. We moved [the resident] to another room when [the resident] came from the hospital. [The resident] allows us to clean [] room daily and changes [] linens at present. [The resident] is doing much better." 95. That the above reflects Respondent’s failure to ensure it provided care and services appropriate to resident needs, including but not limited to 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, where a resident who suffered a fall was left without facility awareness of the fall or response thereto for an extended period of time. 96. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 97. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class III deficient practice. 98. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2016). COUNT VII 99. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 100. That Florida law provides: 30 The facility must maintain required records in a manner that makes such records readily available at the licensee’s physical address for review by a legally authorized entity. If records are maintained in an electronic format, facility staff must be readily available to access the data and produce the requested information. For purposes of this section, “readily available” means the ability to immediately produce documents, records, or other such data, either in electronic or paper format, upon request. (1) FACILITY RECORDS. Facility records must include: (b) An up-to-date admission and discharge log listing the names of all residents and each resident’s: 1. Date of admission, the facility or place from which the resident was admitted, and if applicable, a notation indicating that the resident was admitted with a stage 2 pressure sore; and 2. Date of discharge, reason for discharge, and identification of the facility or home address to which the resident was discharged. Readmission of a resident to the facility after discharge requires a new entry in the log. Discharge of a resident is not required if the facility is holding a bed for a resident who is out of the facility but intending to return pursuant to Rule 58A-5.025, F.A.C. If the resident dies while in the care of the facility, the log must indicate the date of death. Rule 58A~-5.024(1)(b), Florida Administrative Code. That on November 10, 2015, the Agency completed a complaint survey of Respondent and its facility. 102. That based upon the review of records, interview, and observation, Respondent failed to maintain an accurate admission and discharge log for resident, contrary to the requirements of 103. That Petitioner’s representative reviewed Respondent’s admission and discharge log with Respondent’s administrator on November 3, 2015, and noted as follows: a. Resident number six (6) was not listed in the admission and discharge log. b. Respondent’s administrator searched each page of the admission and discharge log, and the name of resident number six (6) was not written. 31 c. The facility’s census, listing resident names and room numbers, and dated July 23, 2015, listed resident number six (6) as residing in room A 505. d. The resident record for resident number six (6) contained a document entitled “Discharge Summary” and dated September 24, 2015, which reflected the resident was admitted on June 16, 2015, and discharged on September 24, 2015. 104. That Petitioner’s representative interviewed on November 3, 2015, Respondent’s shareholder who confirmed that the Admission/Discharge log did not have resident number six (6) correctly and accurately recorded. 105. That the above reflects Respondent’s failure to maintain an accurate admission and discharge log. 106. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 107. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class III deficient practice. 108. That Florida law requires that cited deficient practice be corrected within thirty (30) days. 109. That on February 12, 2016, the Agency completed a re-visit to November 12, 2015, complaint survey of Respondent’s facility. 110. That based upon the review of records, interview, and observation, Respondent failed to maintain an accurate admission and discharge log for resident, contrary to the requirements of law. 111. That Petitioner’s representative reviewed Respondent’s admission and discharge log with Respondent’s staff member on January 27, 2016, and noted as follows: 32 a. The log did not list resident number six (6). b. The staff member reviewed the log three (3) times and could not locate resident number six (6) as annotated therein. c. Resident number six (6) could not be located as listed in the log. 112. That Petitioner’s representative interviewed on January 27, 2016, Respondent’s staff member “A,” a licensed practical nurse, who acknowledged the log had not been corrected and did not have resident number six (6) listed as a resident. 113. That the above reflects Respondent’s failure to maintain an accurate admission and discharge log. 114. The Agency determined that this deficient practice was a condition or occurrence related. to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 115. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class III deficient practice. 116. That the same constitutes an uncorrected Class HI deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2016). COUNT VIII 117. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 118. That Florida law provides: (2) Every facility licensed under this part is required to maintain adverse incident reports. For purposes of this section, the term, “adverse incident” means: 33 (a) An event over which facility personnel could exercise contro! rather than as a result of the resident’s condition and results in: 1. Death; 2. Brain or spinal damage; 3. Permanent disfigurement; 4. Fracture or dislocation of bones or joints; 5. Any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives; 6. Any condition that requires the transfer of the resident from the facility to a unit providing more acute care due to the incident rather than the resident’s condition before the incident; or 7. An event that is reported to law enforcement or its personnel for investigation; or (b) Resident elopement, if the elopement places the resident at risk of harm or injury. (3) Licensed facilities shall provide within 1 business day after the occurrence of an adverse incident, by electronic mail, facsimile, or United States mail, a preliminary report to the agency on all adverse incidents specified under this section. The report must include information regarding the identity of the affected resident, the type of adverse incident, and the status of the facility’s investigation of the incident. (4) Licensed facilities shall provide within 15 days, by electronic mail, facsimile, or United States mail, a full report to the agency on all adverse incidents specified in this section. The report must include the results of the facility’s investigation into the adverse incident. (5) Each facility shall report monthly to the agency any liability claim filed against it. The report must include the name of the resident, the dates of the incident leading to the claim, if applicable, and the type of injury or violation of rights alleged to have occurred. This report is not discoverable in any civil or administrative action, except in such actions brought by the agency to enforce the provisions of this part. (6) Abuse, neglect, or exploitation must be reported to the Department of Children and Families as required under chapter 415. (7) The information reported to the agency pursuant to subsection (3) which relates to persons licensed under chapter 458, chapter 459, chapter 461, chapter 464, or chapter 465 shall be reviewed by the agency. The agency shall determine whether any of the incidents potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of s. 456.073 apply. The agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken in response to the incident. The agency shall review each incident and determine whether it potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of s. 456.073 apply. 34 (8) Ifthe agency, through its receipt of the adverse incident reports prescribed in this part or through any investigation, has reasonable belief that conduct by a staff member or employee of a licensed facility is grounds for disciplinary action by the appropriate board, the agency shall report this fact to such regulatory board. (9) The adverse incident reports and preliminary adverse incident reports required under this section are confidential as provided by law and are not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or appropriate regulatory board. (10) The Department of Elderly Affairs may adopt rules necessary to administer this section. § 429.23, Florida Statutes (2015). 119. That Florida law provides: (1) INITIAL ADVERSE INCIDENT REPORT. The preliminary adverse incident report required by Section 429.23(3), F.S., must be submitted within 1 business day after the incident pursuant to Rule 59A-35.110, F.A.C., which requires online reporting. (2) FULL ADVERSE INCIDENT REPORT. For each adverse incident reported in subsection (1) above, the facility must submit a full report within 15 days of the incident. The full report must be submitted pursuant to Rule 59A-35.110, F.A.C., which requires online reporting. Rule 58A-5.0241, Florida Administrative Code. 120. That on November 10, 2015, the Agency completed a complaint survey of Respondent and its facility. That based upon the review of records, interview, and observation, Respondent failed to timely complete state required adverse incident reports for two (2) of seven (7) residents reviewed, the same being contrary to the requirements of law. 122. That Petitioner’s representative interviewed Respondent’s administrator on November 3, 2015, who indicated as follows: a. She did not send the Agency for Health Care Administration (AHCA) any incident reports since she started working at the facility as the Administrator. 35 b. Not all incidents have to be sent to AHCA, such as fractures or dislocation due to falling. c. The facility has no policy and/or procedure regarding incident reports, however, presented the Initial Adverse Incident Report to submit within one (1) business day after the incident, and the full adverse incident report within fifteen (15) days of the incident. 123. That Petitioner’s representative observed resident number four (4) on November 3, 2015, at 9:15 AM in the resident’s room and noted the resident seated in a recliner sofa with foot cast boot on the right leg. 124. That Petitioner’s representative reviewed Respondent’s records related to resident number four (4) during the survey and noted as follows: a. The resident was admitted to the facility on April 8, 2013. b. The resident’s most recent health assessment, dated November 14, 2014, provided as follows; i. Diagnoses: Vitamin D deficiency, High blood pressure, Lumbar Myelopathy, polymyalgia Rheumatic, Dermatopathia pigmentosa reticularis , Legally Blind, physical or sensory limitation ambulate with walker and nursing medication management. ii. Activities of daily living (ADLs): Independent with ambulation, dressing, eating, self-care, toileting, transferring, and need assistance with bathing. iii. Special diet instruction: regular/no added salt. iv. Need assistance with self-administration of medications. c. Emergency room records of October 13, 2015 reflects: 36 i. Diagnosis: "Multiple closed fractures of metatarsal bone, right, initial encounter." ii. Problem list: T11 vertebral fracture, Myopathy, Rib fractures. d. A physician’s order of October 16, 2015 prescribed “SN (skilled nursing0 to eval and treat wound to right elbow cleanse wound NS (normal saline) applt TAO cover . adaptic gauze, secure, tegaderm 3X wkly PT/OT 9physical and occupational therapy) eval + treat. [Signature of nurse] Verbal orders read back. Hospital bed with half side rails for safety.” €. On February 8, 2015, the resident was transferred to the Hospital with diagnoses: head injury, Urinary tract infection female. You should follow up with the following physician in 2 days. 125. That Petitioner’s representative interviewed resident number four (4), an alert and aware individual, on November 3, 2015, at 9:20 AM, and the resident indicated as follows: a. The resident had lived at the facility for three (3) years. db. The resident had fallen a few times - "maybe five times.” c. The resident fell in the bathroom and wanted the facility to repair the bathroom. d. The resident was scared about the bathtubs and takes showers on the toilet with clothes (towels). e. A certified nursing assistant (CNA) showed the resident how to do it. f. The resident now has a fracture in the right foot. g. “T was very independent person and now I need to learn how to slow down,” and added the resident’s spouse had fallen at the facility two times. 37 126. That Petitioner’s representative reviewed a facility document entitled “Fall Risk Acknowledgement” which provided "I, the undersigned, understand that the Resident is considered ‘at risk’ for falls based on a health assessment and prior medical history. I also understand that a fall may have severe consequences and result in injuries including lacerations, broken bones and even death. 127. That Respondent’s records were reviewed and Respondent did not have any adverse incident reports reflecting transfer to a higher level of care for resident number four (4). 128. That Petitioner’s representative reviewed Respondent’s records related to resident number six (6) during the survey and noted as follows: a. The resident was hospitalized on September 15, 2015, with the following information documented — “Discharge diagnosis - Pt (Patient) was brought to ER (emergency room) from the ALF (Assisted Living Facility), Pt was noted by the ALF Staff to have facial swelling. Pt was admitted and evaluated, [] had a lump on the left side of forehead, C/Scan (Computed Tomography Scan) of the face showed that Pt had hematoma of the left side of head and had AC. Fracture of the Roof of the Right Orbit. Patient has Dementia and [] is not able to give any information. " i. The resident’s Health Assessment, Form 1823, dated August 12, 2015: 1. Resident medical diagnosis reflected no known allergies, Diabetes Mellitus, Hypertension and Chronic Kidney Disease Stage III. Resident has memory problems, dementia, disoriented, 38 unable to administer her own medications + needs help with daily living activities. 2. Resident has dementia, sometimes gets confused, unable to live independently and has insomnia. 3. Resident needs administration of medications including insulin, checking her blood sugar, 3x daily, preparation of diet, assistance with daily living activities. 4. Patient has dementia and has been used to getting out of - house. 5. Resident needs assistance for bathing, dressing and grooming. Resident needs supervision on ambulation and toileting. Resident needs total assistance for transferring. Resident is a independent eater. 6. Resident special diet instruction reflects diabetic diet, no added salt, low fat/low cholesterol, low sodium and low cholesterol diet. 7. Resident has a diagnosis of communicable disease has Chronic Hepatitis C, and it stated that Resident required 24-hour nursing or psychiatric care. 8. The resident had Dementia, Insulin dependent Diabetes Mellitus. 9. Needs can be met in the facility. In comparison. 39 ii. The resident’s Health Assessment, Form 1823, dated April 24, 2015, the Form 1823 signed on 4/24/15 documented "Resident's needs cannot be met by facility due to Patient should be in a facility where there is nursing care and supervision. Pt needs insulin to be administrated + blood sugar has to be check regularly.” Progress notes: i. September 15, 2015 - "Resident observed by Home Health Nurse and facility staff at dining table (while getting ready for lunch) with head down on the table very lethargic swelling observed to both eyes. Doctor immediately called orders received transfer to emergency room for evaluation. [Adult child] notified. .... resident transported to ER.” ii. September 18, 2015 — “Meeting with [family member] and Exec Dir [ ]. [Family member] stated, ‘[Resident] has a fx in [] face. Someone is going to pay.’ Exec Dir handled meeting will have investigation done. On 9/21/15, received call from social worker of Hospital states, ‘[Resident] is being discharged today back to CCL’ This write advise her to speak with family as they stated, ‘We are not happy with the services CCL is providing.’" 129, That on November 3, 2015, Respondent’s records were reviewed and Respondent did not have any adverse incident reports reflecting transfer to a higher level of care for resident number 130. That the above reflects Respondent’s failure to timely file with the Agency adverse incident reports as required by law. 40 131. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 132. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class JI deficient practice. 133. That Florida law requires that cited deficient practice be corrected within thirty (30) days. 134. That on February 12, 2016, the Agency completed a re-visit to November 12, 2015, complaint survey of Respondent’s facility. 135. That based upon the review of records, interview, and observation, Respondent failed to timely complete state required adverse incident reports for one (1) of three (3) residents reviewed, the same being contrary to the requirements of law _ 136. That Petitioner’s representative reviewed Respondent’s records related to resident number one (1) during the survey and noted a note reading "Miami Dade Fire Rescue responded to cail for Resident #1. A staff member called 911 on 11/10/2015 at 11:47 pm. When fire rescue arrived, the resident was unaware of how long he had been on the floor. The staff members : reported to Fire Rescue they found the resident on the floor during routine cleaning, but did not know how long he had been on the floor. The resident's clothes were soiled with urine and feces. The staff reported to Fire Rescue the resident was independent and did not have any information on him. Captain also reports the resident's room was dirty and unkempt." 137. That hospital records regarding resident number one (1) reflect the resident was admitted on November 11, 2015; had suffered a mechanical fall due to loss of balance and fell on the ground.; had no energy to get up; and has been lying on the ground for four (4) days. 41 138. That Petitioner’s representative interviewed resident number one (1) on January 27, 2016, and the resident indicated as follows: a. "I felt on the floor and I was unable to reach my phone. I stayed on the floor for 4 days. No staff came to check me because at that time I was an independent resident. b. “On the four day the staff and rescue came. I was transferred to the hospital. c. “T do not remember how long I stayed at the hospital. I was admitted in the ALF when I returned from the hospital." 139. That Petitioner’s representative interviewed a family member of resident number one (1) on January 27, 2016, who indicated "The facility contacted me. My [relative] told me that [the relative] was left on the floor for four days. I asked the facility staff why [the relative] was left on the floor for four days. No one called me back." 140. That on January 27, 2016, Respondent’s records were reviewed and Respondent did not have any adverse incident reports reflecting transfer to a higher level of care for resident number four (4). | 141. That the above reflects Respondent’s failure to timely file with the Agency adverse incident reports as required by law. 142. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 143. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2015), and Respondent was cited with a Class III deficient practice. 42 144. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2016). COUNT IX 145. The Agency re-alleges and incorporates paragraphs (1) through (5) and Counts VI through TX as if fully set forth herein. 146. That pursuant to Section 429.19(7), Florida Statutes (2015), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2015), to verify the correction of the violations. 147. That Respondent was subject to the citation of one or more Class II deficient practices or the citation of a violation that was subject of the complaint which requires the imposition of a survey pursuant to law. See, Section 429.28(3)(c), Florida Statues (2016). 148. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2016). / Respectfully submitted this g Kay of December, 2016. 43 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1947 / Fax: (727) 552-1440 walsht@ahca.mryflorida.com < af By: 4)" Thorhas J. Walsh II, Esq. Fla. Bar No. 566365 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If 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. The 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 final order will be entered. The Election 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 U.S. Certified Mail, Return Receipt No. 7013 2250 0001 4950 3707 on December “7 X, 2016, to Gilda Dentico, Administrator, AM Grand Court Lakes, LLC, 280 Sierra Drive, North‘Miami Beach, Florida 33179, and by Regular U.S. Mail to VCorp Services, LLC, Registered Agent for AM Grand Court Lakes, LLC, 5011 South State Road 7, Suite 106, Davie, Florida 33314. I HEREBY CERTIFY that a true and correct copy of the foregoing has been a by yt /Tpémas I. Walsh T “ 4 Copy furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 45 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: AM GRAND COURT LAKES, LLC AHCA Nos. 2016004641 2016012835 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It 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 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 J 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 requirements 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 Respondent. 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 complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contac t Person: Title: Address: Number and Street City Zip Code 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:

Docket for Case No: 18-000293