STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Nos.: 2018008390 v. 2018009078 2018009082 FT MYERS ALF BSLC, LLC d/b/a License No.: 5096 LAMPLIGHT INN Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against Respondent, Ft. Myers ALF BSLC, LLC d/b/a Lamplight Inn (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action to impose a fine of $48,500.00 on Respondent based upon: nine (9) Class II violations, three (3) uncorrected Class III violations, and a survey fee. PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida. Ch. 408, Part II, and Ch. 429, Part I, Fla. Stat. (2017); Ch. 59A-35, Ch. 58A- 5, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.812, 408.813, 408.815, 429.14, 429.19, Fla. Stat. 2. Respondent was issued a license by the Agency to operate an assisted living facility (“the Facility”) located at 1896 Park Meadow Drive, Ft. Myers, Florida, 33907, and was at all times material required to comply with the applicable state statutes and rules. § 429.11, Fla. Stat. (2017). COUNT I Resident Supervision 3. Under Florida law, “the facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and service to treat the condition.” § 429.26(7), Fla. Stat., (2017). 4. Pursuant to Florida law, in pertinent part: An assisted living facility must provide care and_ services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for each resident, including the following: (a) Monitoring of 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 resident. (c) Maintaining a 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) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services. Rule 58A-5.025, F.A.C., (2017). Survey Findings 5. On or about January 4 and 5, 2018, the Agency conducted a complaint survey of Respondent’s Facility. 6. Based on observation, record review, and interview, the Agency determined that Respondent failed to provide supervision in the prevention of falls and elopement for one (1) resident (Resident #14), failed to supervise memory care residents, and failed to ensure two (2) cognitively impaired residents were wearing shoes or non-skid socks (Residents #18 and #20). Resident #14 7. On or about January 4, 2018, the Agency interviewed Respondent’s Administrator. The Administrator stated the following regarding Resident #14: a. Resident #14’s father, who was also Resident #14’s power of attorney, died in June 2017. b. Resident #14 was not able to make medical decisions for him/herself due to brain injuries. c. Resident #14’s stepmother had refused to act as the Resident’s guardian after his/her father passed away. Resident #14’s phone was turned off by the resident’s stepmother because he/she could not communicate on the phone due to the cognitive deficits. d. Resident #14 was allowed to sign him/herself out of the facility and leave the building until being placed in the Memory Care Unit on October 27, 2017. 8. The Agency then reviewed Respondent’s sign-out sheet. The Administrator identified six lines of illegible scribbles from October 25, 2017 until October 27, 2017 as Resident #14 signing him/herself out of the facility. No notation was recorded as to when Resident #14 left, or when Resident #14 returned on those dates. 9. The Agency reviewed a “Health Care Provider Communication Form” (“HCPC Form”) dated August 3, 2017 for Resident #14 which stated the resident is “becoming more anxious/busy acting-on the go more. Monday there was feces on [the resident’s] floor, wall, outside [the] back door. [The Resident] is collecting garbage (empty bottles, cereal boxes, coffee) more than usual and it’s all outside [the] back door. [Resident #14]’s hygiene is slacking. Only medication is Celexa.” 10. On August 4, 2017, medical records reflected that Resident #14 was placed on Depakote, four (4) capsules by mouth twice daily. 11. A second notation in the HCPC Form dated August 22, 2017 noted “[c]oncerned that [Resident #14] is not eating since Depakote started. Evening Nurse stated [Resident] won’t eat.” 12. Then on September 1, 2017 the HCPC Form noted the residents “behaviors have not changed with Celexa, Depakote, and Remeron.” 13. Further on September 1, 2017, the Advance Registered Nurse Practitioner (“ARNP”) ordered Risperdal at 0.5 milligrams to be taken twice daily, then increased to 1 milligram twice daily for Resident #14. 14. The Agency then reviewed the monthly weights for Resident #14. The weight records showed Resident #14 weighed one hundred ninety-eight pounds (198 lbs) on June 6, 2017, but had dropped to one hundred sixty-eight pounds (168 Ibs) on October 5, 2017. The documentation showed a loss of 30 pounds in a four month period. 15. Additional documentation review of the Resident’s record revealed the following dated for September 28, 2017: a. A “Service Note” timed at 10:00 a.m. documented Resident #14 was walking outside the facility and became overheated. At 10:30 a.m., staff documented, the resident was reeducated to not walk when the temperature outside is so warm and to go on shorter walks. b. Asecond “Service Note” timed at 2:00 p.m., documented the resident fell in the facility parking lot twice and was sent to the hospital. c. The HCPC Form noted that Resident #14 was sent to the ER for evaluation for an altered mental status and two falls. 16. Resident #14 received an updated health assessment on September 30, 2017, which diagnosed the resident with dementia, concussions, anxiety, and depression. Resident #14 was listed as nonverbal and a fall risk. 17. A “Service Note” dated October 1, 2017 at 2:00 p.m. stated that Resident #14 was “out walking and had an incident and went to ER with EMS for evaluation. 18. A “Triage Note” from the hospital dated October 1, 2017 at 1:54 p.m. stated the following: a. The registered nurse (RN) documented that Resident #14 arrived at the emergency department via EMS. b. A Bystander called 911 because the resident was walking down the road with blood all over him/her. c. The resident lives at Respondent’s Facility in the memory care unit. d. According to the staff Resident #14 is allowed to leave the facility but states he/she usually signs him/herself out but didn’t sign out today (October 1, 2017). e. Resident #14 was found about six (6) blocks away from the Facility. f. Resident #14 was alert and oriented to name and date of birth only. 19. A second “Triage Note” dated October 10, 2017 was reviewed. The second triage note stated: a. Resident #14 arrived via EMS after an unwitnessed fall outside the Facility. b. The resident has a history of head injury and is non-verbal. c. Per EMS the resident is diaphoretic and abrasions are noted to left shoulder, palms and knees. d. The resident is unable to report complaints and does not respond to palpating abrasions. 20. A third “Triage Note” from the hospital, dated October 16, 2017, was reviewed and stated the following: a. Resident #14 was transferred to the hospital after he/she was found in the bushes. b. A hospital nurse noted the resident was not able to communicate verbally and had abrasions at various stages of healing throughout his/her body. 21. Documentation from the hospital showed Resident #14 was discharged from the hospital to another assisted living facility on October 21, 2017. 22. On or about January 4, 2018 the Agency interviewed Respondent’s Administrator. The Administrator stated that Resident #14 was found in hurricane debris on October 16, 2017, several blocks away from the facility. The Administrator said the resident was sent to a sister facility after being discharged from the hospital because there was no space in the memory care unit at the Respondent’s Facility. 23. A fourth “Triage Note” dated October 27, 2017 from the hospital was reviewed. This note stated that: a. Per EMS the resident has a history of brain injury and falls. b. The resident lives at a nursing facility where he/she escaped. c. The resident was spotted by a bystander that saw him/her fall and hit his/her head. d. Resident is nonverbal, but responds to voice. 24. In other hospital documentation dated October 27, 2017 at 12:38 p.m. a Case Manager at the hospital documented that she called the sister facility and was told they had transferred Resident #14 back to the Respondent’s Facility after one (1) day. The Case Manager documents speaking with the Administrator at Respondent’s Facility, who said the resident has always had walking behaviors but there have been more lately and the resident has become non directional. The Administrator said he had reached out to other facilities that had not been able to meet the resident's needs. 25. On January 5, 2018, the Agency interviewed Respondent’s Administrator again. The Administrator stated: a. Resident #14 was sent to the hospital after falling outside the facility on October 1, 10, 16, and 27, 2017. b. Resident #14 was placed in the locked unit of memory care on October 27, 2017, after returning from the hospital. c. On December 10, 2017, the resident fell in the memory care unit and was hospitalized. d. Resident #14 has not returned to the Facility and remains in a skilled nursing facility. 26. On January 5, 2018 the Agency interviewed the ARNP. The ARNP stated: a. Resident #14 was cognitively impaired due to encephalopathy (altered mental state), caused from brain injury. b. Resident #14 should have been assessed as an elopement risk on October 1, 2017, when he/she fell outside the facility. c. The ARNP felt the reason the resident was not assessed as an elopement risk is because there were staffing issues and there was no director of nursing at the time for the Respondent. Failure to Supervise Memory Care 27. On January 4, 2018 the Agency surveyor observed the fence around the memory care unit to be in disrepair. There was a hole observed in the fence large enough for a resident to get through. Several of the memory care residents were observed unsupervised in the area of the damaged fence. 28. Later on January 4, 2018, three (3) residents were observed going out of the rear door of the memory care unit unsupervised. The residents were ambulating near the area of the damaged fence. The staff remained inside of the memory care unit. 29. The Agency interviewed Respondent’s Administrator on January 4, 2018 about the fence. The Administrator stated the fence had been damaged since September of 2017. The Administrator acknowledged residents in the memory care unit were allowed out of the memory care and near the damaged fence without supervision. 30. The Agency interviewed Respondent’s Administrator again on January 5, 2018. The Administrator said the hole in the fence had been repaired, but also said there were still repairs to be completed on the fence. Resident #18 and Resident #20 31. On January 4, 2018, the Agency surveyor lobserved Resident #18 ambulating in the hallway. Resident #18 was wearing only socks and no shoes. 32. Later on the same day, the Agency surveyor observed Resident #20 ambulating with a walker. Resident #20 did not have shoes and wore only regular white socks. 33, Several other residents in the memory care unit were observed at this time without shoes and wearing regular socks. 34, On January 4, 2018, the Agency interviewed Resident Aide Staff C. Staff C stated several of the memory care residents were not wearing because one of the residents keeps taking the other residents shoes and putting them in his/her closet. 35. The Agency then interviewed the Administrator on January 4, 2018 about the shoes. The Administrator stated that a memory care resident was taking other resident’s shoes. The Administrator verified it was a fall risk for residents to ambulate in socks without shoes. The Administrator also acknowledged that he has had staffing issues. He said staff will come to work but no one wants to do their job. 36. On January 5, 2018, the Agency interviewed Resident #18's spouse. Resident #18’s spouse said Resident #18 never has shoes on during their visits at the Facility. The spouse said he/she has been complaining for six (6) months about the resident not having his/her shoes on. Resident #18's spouse said he/she was never told why Resident #18 was not wearing shoes. 37. Based on the actions and inactions, the Agency cited Respondent with a Class II violation. Sanction 38. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 39, Under Florida law 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 determines 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 IT violation. A fine shall be levied notwithstanding the correction of the violation. § 408.813(2)(b), Fla. Stat. (2017). 40. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 41. Under Florida law, each violation of Part I of Chapter 429 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 10 follows: ... (b) Class “II” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. COUNT II Elopement Standards 42. Under Florida law: (8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention must be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease or related disorders assessed at high risk. 2. At a minimum, the facility must have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The facility’s file must contain the resident’s photo identification within 10 days of admission or within 10 days of being assessed at risk for elopement subsequent to admission. The photo identification may be provided by the facility, the resident, or the resident’s representative. (b) Facility Resident Elopement Response Policies and Procedures. The facility must develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures must provide for: 1. An immediate search of the facility and premises, 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities, 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to 11 subparagraph (8)(b)1.; and, 4. The continued care of all residents within the facility in the event of an elopement. (c) Facility Resident Elopement Drills. The facility must conduct and document resident elopement drills pursuant to Sections 429.41(1)(a)3. and 429.41(1)(), F.S. Rule 58A-5.0182(8), F.A.C., (2018). Survey Findings 43. The Agency re-alleges, and incorporates by reference, all the facts in Count I of this complaint. 44. On or about January 4 and 5, 2018, the Agency conducted a complaint survey of Respondent’s Facility. 45. Based on record review, interview, and observation, the Agency determined that Respondent’s Facility failed to ensure six (6) residents at risk for elopement were identified as an elopement risk, had photo identification in their chart, and identification on their person. (Resident #14, #15, #16, #17, #18, and #20). Resident #14 46. The Agency reviewed documentation that showed Resident #14 was declining in mental ability starting in June of 2017. 47. Resident #14's monthly weight record showed from June 4 to October 5, 2017 the resident lost 30 pounds. 48. Resident #14 experienced falls while walking outside the Facility on September 28, October 1, October 10, October 16, and October 27, 2017. 49. A hospital note stated Resident #14 had “escaped” a nursing facility before suffering a fall on October 27, 2017. 12 50. Resident #14 had a Resident Health Assessment (“1823”) dated September 30, 2017, which showed diagnoses of dementia, concussions, anxiety, and depression. The 1823 documented Resident #14 as nonverbal and a fall risk. 51. On or about January 5, 2018, the Agency interviewed Respondent’s Administrator about Resident #14’s elopement status. The Administrator stated the following: a. Resident #14 was sent to the hospital after falling outside of the facility on October 1, 10, 16, and 27, 2017. b. Resident #14 was placed in the locked unit of memory care on October 27, 2017, after returning from the hospital. c. Resident #14 was not assessed as an elopement risk by the Facility until he/she was placed in the memory care unit. d. Resident #14 was allowed to leave the facility on his/her own until that time (October 27, 2017). e. The Facility uses whatever is documented on the most recent 1823 to identify at risk residents for elopement. f. There is a new assessment tool, that will be implemented within a few days, that will include questions regarding history of elopement. g. Any person in the locked memory care unit would be considered an elopement risk. h. The Administrator was currently updating all the photos of the residents in the memory care unit. 13 i. The Facility had identification bracelets that he had ordered to be placed on residents at risk for elopement. The identification bracelets were currently on his desk. Residents #15 and #16 52. On January 4, 2018, the agency reviewed Resident #15’s 1823 dated September 27, 2017. The 1823 stated Resident #15 has dementia, is confused, forgetful, and unable to use a call light to call for assistance. 53. Resident #15 was not listed as an elopement risk. Resident #15 does not reside in the memory care unit. 54. On January 4, 2018 the Agency interviewed Respondent’s employee Staff B, a medication aide. Staff B stated the following: a. She felt Resident #15 would be at risk for eloping from the facility. b. Resident #15 had not been the same mentally since he/she had fell and hit his/her head about a week ago. c. Medication Aide Staff D had reported to her (Staff B) that Resident #15 was walking out the door saying he/she was going to see a person and had to be brought back into the facility. 55. On January 4, 2018, the Agency surveyor observed Resident #15 without an identification band on either wrist. The Agency did not observe a identification photo in the resident’s record. 56. On January 5, 2018, the Agency interviewed Respondent’s employee Staff D, a medication aide. Staff D stated the following: a. She has stopped several residents from attempting to leave the facility. 14 b. This morning (January 5, 2018) Resident #16 was stopped from attempting to leave the facility. c. Resident #16 has tried on more than one occasion to go out and get into cars in the parking lot. 57. The Agency reviewed Resident #16’s 1823 dated October 31, 2017. The 1823 was listed as having “intermittent confusion.” Resident #16 was not identified as an elopement risk. 58. On January 5, 2018, the Agency interviewed Respondent’s Administrator about Residents #15 and #16. 59. The Administrator stated he had not been made aware Resident #15 had been attempting to leave the facility. 60. The Administrator also said he had not been made aware of Resident #16’s attempts to leave the building and get into cars in the parking lot. The Administrator then verified, if the resident was having these actions, he/she was at risk for elopement. Resident #17 61. On January 4, 2018, the Agency’s surveyor observed Resident #17 in the memory care unit. Resident #17 did not have any identification present on his/her person. 62. The Agency then reviewed Resident #17’s record. The Agency did not find any identification photo. 63. Resident #17’s 1823, dated November 10, 2017, listed the resident as an elopement risk. Resident #18 64. On January 4, 2018, the Agency surveyor observed Resident #18 walking in the hall of the Facility’s memory care unit. The resident walked up to an open door as a staff member 15 was leaving the facility. The staff member shut the door to prevent the resident from leaving the memory care unit. No identification band was on the resident. 65. The Agency reviewed Resident #18’s 1823 dated June 27, 2017, which showed the resident had a history of dementia. However, the 1823 did not identify Resident #18 as an elopement risk. 66. No photo was observed in Resident 18's medical record. Resident #20 67. On ljanuary 4, 2018, the Agency surveyor observed Resident #20 in the memory care unit. Resident #20 did not have any identification on his/her person. 68. Resident #20’s record did not have an identification photo. 69. On January 4, 2018, the Agency reviewed Resident #20’s 1823 dated December 11, 2015. The 1823 listed Resident #20 as having dementia and being alert and oriented times two. However, Resident #20’s 1823 did not list the resident as an elopement risk. 70. On January 4, 2018, the Agency interviewed Resident #20’s adult son. The resident’s son stated Resident #20 was admitted to the facility because he/she was attempting to elope from the previous facility. The Son also verified that Resident #20 was admitted to the Facility since December of 2015. 71. Based on the actions and inactions listed above, the Agency cited Respondent with a Class II violation. Sanction 72. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 16 73. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 74. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 75. Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. COUNT III Physical Plant 76. Under Florida law, 17 (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and, 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident, 2. A closet or wardrobe space for hanging clothes, 3. A dresser, chest or other furniture designed for storage of clothing or personal effects, 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and, 5. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. (d) Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be threadbare Rule 58A-5.023(3), F.A.C., (2018). Survey Findings 77. On January 4 and 5, 2018, the Agency conducted a complaint survey of Respondent’s facility. 78. Based on observation and interview, the Agency determined that Respondent’s Facility failed to provide a safe living environment, free of hazards, and ensure that existing structures are in good working order, creating the potential for resident injury, elopement, and/or discomfort. 18 79. On January 4, 2018, the Agency surveyor observed the perimeter fence around the Facility’s memory care unit in disrepair. There was a hole in the fence large enough for a resident to get through. Other areas of the fence were leaning over and propped up by pieces of wood on both sides of the fence. 80. During the observations on the survey, several of the Facility’s memory care residents were unsupervised in the area of the damaged fence. In particular, three (3) residents were observed going out the rear door of the memory care unit unsupervised. The residents were ambulating near the area of the damaged fence. The Facility’s staff remained inside of the memory care unit at this time. 81. On January 4, 2018, the Agency interviewed Respondent’s Administrator about the fence. The Administrator stated the following: a. The fence had been damaged since a hurricane in September of 2017. b. The fence was scheduled to be fixed on January 19th, 2018, but was unable to show a contract with the fencing company to verify this. c. When the hurricane damaged first occurred, the staff was texting him hourly, with checks on head counts, but that had slipped through the cracks lately. d. Hourly head counts should have been put on paper but the Administrator couldn’t find where the documentation would be. e. Residents in the memory care unit were allowed out of the memory care, in the fenced area without supervision. 82. Later on January 4, 2018, the Agency interviewed the Administrator about the heating and cooling systems in the Facility. 19 a. The hurricane of September 2017 affected the heating and cooling system in the building. He explained the facility has four (4) units and the air conditioning (“A/C”) company said it would be better to replace the units as a whole. b. The Facility has replaced two (2) compressors at this time (January 4, 2018). There are portable AC units are throughout the facility. c. The Facility has received two (2) quotes since the first of December for A/C repairs, but the facility is in the process of sale. d. The Real Estate Investment Trust (REIT) is working with the old owners to figure what is covered by them and what is covered by the new owners. There was nothing set in stone as to when the repairs will occur. e. The last four to five rooms on each wing are still affected by the lack of heating and cooling systems. f. He asked staff to keep doors open to those rooms so the cool and/or heat will migrate into the rooms from the areas where the system does work. He also asked staff to appropriately dress the residents according to the weather. 83. On January 5, 2018, the Agency surveyor observed Resident #23 and Resident #24 in a hallway outside of the dining room. Both residents were seated in chairs wrapped in blankets. 84. The Agency interviewed the residents and Resident #23 said “Oh its terrible, its freezing.” Resident #24 said “I was cold until I got this blanket.” 85. On January 5, 2018, at 10:26 a.m. a random temperature check was conducted throughout the building with Respondent’s Maintenance Director using the facilities digital thermometer. The following temperatures were recorded: a. Memory Care hallway was 68 degrees. 20 b. Memory Care Room 54 was 60 degrees. Resident #28, who resides in this room, was observed to be wearing long pants, a hoodie with the hood pulled up on his head and baseball cap on top of that, pacing, wringing his hands together. Resident #28 stated “Yes its cold.” c. Memory Care Room 59 was 62 degrees. d. Memory Care activity room was 70 degrees. e. Room B30 was 70 degrees. Resident #25, who resides in this room, stated “T'd like it warmer in here.” f. Room B36 was 73 degree. Resident #12, who resides in this room, was observed to be wearing a jacket and stated that the sun helps, but it gets cold enough the resident keeps a jacket on all the time. Resident #12 wishes something would be done about the cold. Resident #12’s adult son talked to the administrator but it had been 3 months of no working heat or a/c. g. Room B37 was 68 degrees. Resident #26, who resides in this room, said “It's cold in here, I just had to put on an extra sweater.” h. Room A19 was 70 degrees. Resident #27, who resides in this room “It's cold, that's why I have my jacket on.” i. Room A16 was 72 degrees. j. Room D77 was 70 degrees. 86. On January 5, 2018, the Agency interviewed Respondent’s maintenance director. The maintenance director stated the heat was completely on in building and the areas are cold because residents open the doors to the outside. 87. The Agency surveyor did not observe any doors to the outside open during the tour. 21 88. On January 5, 2018, the Agency interviewed Respondent’s employee Staff H, a medication aide. Staff H stated the following: a. The building has been cool since the cold weather came. b. Residents are being dressed with extra clothing and there are extra blankets available. c. When the weather is hot outside, it is hot in the building and residents do complain that it’s hot. d. The Facility gives the residents water and brings the fan over towards them when the temperature is hot. e. Staff H had been working for the facility for a little less than a year and felt the temperature problems had been going on for the duration of her employment. 89. The following observations of Respondent’s Facility were made during the course of the survey on January 4 and 5, 2018: a. The Memory Care dining room banquet table was scuffed, the walls had scratches and were missing paint, and the door was scuffed and had dirt built up. There was a soiled diaper on lawn outside memory care fence. The Memory Care fence Emergency Exit with a punch code was not working and was padlocked shut. The Memory Care patio had rubbish strewn about; McDonalds bags, soiled chair padding, and downed palm trees. The outdoor entry to Memory Care dining room door was dirty. 22 The Memory Care hallway and dining room door frames were gouged and walls were missing paint throughout. The Memory Care Room #51 had floor tiles that were missing and peeling. The Memory Care Room #55 had no toilet paper holder. The Memory Care Room #57 had the towel holder missing. The Memory Care Room #49 had missing floor tile, the corner of the wall was marred with plastic piece that was falling off. The Memory Care Room #45 had broken blinds. Room A3 had floor tile that was peeling at entry door. . Room A11 had stained caulking around toilet and holes in the floor tile. Room A16 had cracked and stained flooring. Room A19 had a hole in wall behind bed, a hole in floor tile, and there was soiled garbage left on floor. Room B30 had staining on the floor. Room B31's bathroom door was missing a large piece of wood. The hallway outside Room B39 had a large plaster patch and the carpeting had water stains. There was a large pile of debris outside of building near Room B39. The door at the entry to the kitchen had tape holding together the bottom and was dirty, along with the floor with built up dirt. Room D62 had a recliner with soiled choux, and fluid on floor in front of recliner. Room D64 had cracked floor tile. 23 v. Room D68 had no toilet paper holder. w. Room D69 had multiple holes in tile floor. x. Room D70 had peeling on the bathroom vanity and the bathroom door frame was heavily marred. y. Room D71 had a loud bathroom fan, the closet door was broken, there was peeling on the bathroom vanity, and the bathroom door frame was heavily marred. z. Room D74 had floor tiles with holes and was discolored. aa. Room D78 had holes in the floor tile and caulk was peeling around toilet. bb. Room D80 had cracked caulk around toilet, the door to outside did not have the proper seal and the back of entry door was dirty. 90. On January 4, 2018 the Agency interviewed Respondent’s Administrator about the physical plant. The Administrator admitted he was aware of the problems with the floors, and said he had been dealing with that but only getting small amounts of money at a time for repairs. 91. The Administrator also said he was told he could do two floors a month, but then something seems to come up and it gets delayed. He admitted that he doesn’t have control of the Facility’s budget. 92. Interviewed again on January 5, 2018, the Administrator stated the following: a. He was aware of the issues with the maintenance of the building, debris around the building, the heating/cooling system failure, and the damaged fence. b. The Maintenance Director had put some temporary boards over the holes in the memory care fence that day, so residents will not be injured or be able to get through the fence. 24 c. His hands are tied as far as getting money released for repairs and he said he has told the owners he needs people out here to fix these issues. d. He feels hopeful that the new company taking over will be more proactive with repairs. 93. Based on Respondent’s actions and inactions, the Agency cited Respondent with a Class II deficiency. Sanction 94. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 95. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 96. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 25 97. Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. COUNT IV Survey Fee 98. The Agency re-alleges and incorporates by reference Counts I, II, and III 99. Pursuant to Florida law, in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of the 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 400.428(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(10), Fla. Stat. (2017). 100. The Agency received a complaint about Respondent’s Facility. 101. In response to the complaint, the Agency conducted a complaint survey of Respondent’s Facility. 102. The Agency found a violation that was the subject of the complaint while conducting the survey. 103. The Agency is entitled to a survey fee under Florida statutory authority. 26 WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks a survey fee of $500.00 against the Respondent. COUNT V Resident Supervision 104. Under Florida law, “the facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and service to treat the condition.” § 429.26(7), Fla. Stat., (2017). 105. Pursuant to Florida law, in pertinent part: An assisted living facility must provide care and_ services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for each resident, including the following: (a) Monitoring of 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 resident. (c) Maintaining a 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) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services. 27 Rule 58A-5.025, F.A.C., (2017). Survey Findings 106. The Agency re-alleges, and incorporates by reference, Count I of this complaint. 107. On January 19, 2018, the Agency sent Respondent a statement of deficiencies, which notified Respondent of the deficiencies found on the January 4 through 5 survey, as well as required the Respondent to correct the cited deficient practice in Count I by January 29, 2018. 108. On March 19, 2018, the Agency conducted a revisit complaint survey of Respondent’s Facility. 109. Based on record review and staff interview, the Agency determined that Respondent’s Facility failed to document a change in status for one (1) resident. (Resident #37). 110. On March 19, 2018, the Agency reviewed the records for Resident #37. The review revealed a check request form showing that the resident passed away and family removed the belongings on January 18, 2018. 111. Resident #37’s January 2018 Medication Observation Record (“MOR”) simply noted “hospital.” on January 12, 2018. 112. The last “Service Notes” for Resident #37 were dated December 9, 2017. 113. The record had no documentation of a change in status requiring a higher level of care or information about the death of the resident. 114. The record had no physician’s order for a transfer of Resident #37. 115. On March 19, 2018, the Agency interviewed Respondent’s Administrator. The Administrator stated that Resident #37 went to the hospital and never returned. 116. Based on the above, Respondent failed to correct the deficient practice within the thirty days specified by the Agency. Sanction 28 117. 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 this part, part II of chapter 408, or applicable rules. § 429.14(1), Fla. Stat. (2017). 118. Under Florida law, 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: Class “III” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly 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 III 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. § 408.813(2)(c), Fla. Stat. (2017). 119. Under Florida law, 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. § 429.19(2)(c), Fla. Stat. (2017). 120. The Agency cited the Respondent for a Class II violation in accordance with applicable statutes and authorizing rules. Upon a revisit, the deficiency remained uncorrected at a Class III level. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $1,000.00 against the Respondent. COUNT VI Elopement Standards 29 121. Under Florida law: (8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention must be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease or related disorders assessed at high risk. 2. At a minimum, the facility must have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The facility’s file must contain the resident’s photo identification within 10 days of admission or within 10 days of being assessed at risk for elopement subsequent to admission. The photo identification may be provided by the facility, the resident, or the resident’s representative. (b) Facility Resident Elopement Response Policies and Procedures. The facility must develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures must provide for: 1. An immediate search of the facility and premises, 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities, 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to subparagraph (8)(b)1.; and, 4. The continued care of all residents within the facility in the event of an elopement. (c) Facility Resident Elopement Drills. The facility must conduct and document resident elopement drills pursuant to Sections 429.41(1)(a)3. and 429.41(1)(D), F.S. Rule 58A-5.0182(8), F.A.C., (2018). Survey Findings 30 122. The Agency re-alleges, and incorporates by reference, all the facts in Count II of this complaint. 123. On January 19, 2018, the Agency sent Respondent a statement of deficiencies, which notified Respondent of the deficiencies found on the January 4 through 5 survey, as well as required the Respondent to correct the cited deficient practice in Count II by January 29, 2018. 124. On March 19, 2018, the Agency conducted a revisit complaint survey of Respondent’s Facility. 125. Based on staff interview, observation, and review of the Facility’s policy and procedure, the Agency determined that Respondent’s Facility failed to ensure residents who are identified as an elopement risks have identification on their persons. 126. On March 19, 2018, the Agency interviewed Respondent’s Administrator about the elopement procedures. The Administrator stated the following: a. The residents that are identified as an elopement risk live in the memory care unit. b. The Facility made identification bracelets for these residents showing their name, the facility name, and phone number. c. At this time, the residents are not wearing the identification bracelets. d. Since the change of ownership in December of 2017, the facility phone number was changed but and the Administrator has not changed the bracelets as of yet. 127. On March 19, 2018, the Agency surveyor observed residents living in the memory care unit not wearing any type of personal identification showing who they are, where they live, or the phone number of the Facility. 31 128. On March 19, 2018, the agency interviewed Respondent’s employee, Staff M. Staff M stated the Memory Care residents are not wearing identification bracelets at this time. She then confirmed all residents living in the Memory Care unit are at risk for elopement. 129. On March 19, 2018, the Agency reviewed Respondent’s policies and procedures entitled “elopement protocol for prevention and response to resident elopement” revised date of November 2013. The policy and procedure did not mention anything about persons who are identified as elopement risk having identification on their person. 130. Based on the above, Respondent failed to correct the deficient practice within the timeframe specified by the Agency. Sanction 131. 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 this part, part II of chapter 408, or applicable rules. § 429.14(1), Fla. Stat. (2017). 132. Under Florida law, 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: Class “III” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly 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 III violation must specify the time within which the violation is required to be 32 corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. § 408.813(2)(c), Fla. Stat. (2017). 133. Under Florida law, the agency shall impose an administrative fine for a cited class II violation in an amount not less than $500 and not exceeding $1,000 for each violation. § 429.19(2)(c), Fla. Stat. (2017). 134. The Agency cited the Respondent for a Class II violation in accordance with applicable statutes and authorizing rules. Upon a revisit, the deficiency remained uncorrected at a Class III level. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $1,000.00 against the Respondent. COUNT VII Medication Records 135. Under Florida law: (5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed in subsection (2), the facility must keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider’s name, the resident’s name, the date dispensed, the name and strength of the drug, and the directions for use. (b) The facility must maintain a daily medication observation record (MOR) for each resident who receives assistance with self- administration of medications or medication administration. A medication observation record must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The medication observation record must be immediately updated each time the medication is offered or administered. (c) For medications that serve as chemical restraints, the facility must, pursuant to Section 429.41, F.S., maintain a record of the 33 prescribing physician’s annual evaluation of the use of the medication. Rule 58A-5.0185(5), F.A.C. (2018). Survey Findings Survey of January 5, 2018 136. On January 4 and 5, 2018, the Agency conducted a complaint survey of Respondent’s Facility. 137. Based on record review and interview, the Agency determined that Respondent’s facility failed to immediately document medications given for nine (9) residents ( Resident #1, #2, #3, #5, #6, #7, #9, #21, and #29). 138. On January 4, 2018, the Agency interviewed Resident #13. Resident #13 stated he/she does not get his/her medications on time, sometimes the medication can be an hour or two late. Resident #13 said the past week, he/she was given medications an hour late on the evening shift. Resident #13 further stated that sometimes he/she is told medications will be given when he/she calms down. 139. The Agency then reviewed Respondent’s medication books for residents. The Agency found one book had blank squares on the MOR sheets where medication aides should have charted their initials to indicate medications were given to residents. 140. On January 4, 2018, the Agency interviewed Respondent’s employee Staff I, a medication aide. Staff I said he/she forgot to mark the MOR. 141. On January 4, 2018, the Agency interviewed Respondent’s employee Staff J, a medication aide. Staff J said he/she forgot to mark the MOR. 142. The Agency reviewed Resident #13’s MOR. The Agency found that Resident #13 did not have charting by a medication aide for Lopressor (blood pressure medication) on 34 November 2, 2017 at 4:00 p.m. The health care provider order was for Metoprolol (Lopressor) 1 tab twice daily. 143. The Agency reviewed Resident #7’s MOR. Resident #7 had blank charting on his/her MOR for the following: a. On January 1, 2018 for 6:00 a.m., Synthroid (thyroid medication). The health care provider order was for Levothyroxine (Synthroid) | tab every morning. b. Again on January 1, 2018 for 6:00 a.m., Tramadol-Acet (pain medication). The health care provider order was for one tab by mouth three times daily. Scheduled by pharmacy to be given at 6:00 a.m., 2:00 p.m., and 10:00 p.m., daily. 144. The Agency reviewed Resident #1’s MOR. Resident #1 had blank charting by medication aides on January 2, 3, and 4, 2018 at 8:00 a.m. for Aspirin. The health care provider order was for Resident #1 to take one tablet by mouth once daily. 145. The Agency reviewed Resident #2’s MOR. Resident #2 had the following blank charting on his /her MOR: a. On January 1, 2018 at 8:00 a.m., 12:00 p.m., and 4:00 p.m., and again on January 2, 2018 at 8:00 a.m. for Lyrica. The health care provider order was for Lyrica three (3) times daily. b. On December 13, 2017 at 8:00 a.m. for Cymbalta. The health care provider order for medication was for Duloxetine (Cymbalta) twice daily. c. From December 6, 2017 until December 26, 2017 Resident #2’s MOR had circled initials, meaning medication was not given by medication aides on those 35 dates. No reason documented by the medication aides as to why medication was not given. Finally, Resident #2’s MOR had blank charting at 8:00 a.m. on December 17, 2017 and December 22, 2017 through December 28, 2017. 146. The Agency reviewed Resident #21’s MOR. Resident #21 had the following issues: a. Resident #21 had a health care provider order for Levothyroxine (thyroid medication) to take one (1) tablet every morning upon arising. There was blank charting on January 1, 2018 at 6:00 a.m. The health care provider order Mucinex (for congestion) to be taken one (1) tablet twice daily. There was blank charting for 8:00 a.m. on January 3, 2018 through January 4, 2018. The health care provider order Protonix (an ulcer medication) to be taken one (1) tab every day. There was blank charting by a medication aide on January 1, 2018 at 6:00 a.m. 147. The Agency reviewed Resident #9’s MOR. Resident #9 had a health care provider order for Levothyroxine for Synthroid (thyroid medication) to be taken one (1) tablet once daily. There was blank charting by a medication aide on January 1, 2018 at 6:00 a.m. 148. The Agency reviewed Resident #5’s MOR. Resident #5 had a health care provider order for Levothyroxine for Synthroid (thyroid medication) to be taken one (1) tablet every morning. There was blank charting by a medication aide on January 1, 2018 at 6:00 a.m. 149. The Agency reviewed Resident #6’s MOR. Resident #6 had a health care provider order for Symbicort (an inhaler) to inhale two (2) puffs by mouth twice daily. There was blank charting by a medication aide from January 2, 2018 through January 4, 2018 at 8:00 a.m. 36 150. The Agency reviewed Resident #29’s MOR. Resident #29 had a health care provider order for Hydralazine (blood pressure medication) to take (1) tab three times daily with food. There was blank charting by a medication aide on January 1, 2018 at 6:00 a.m. 151. Accordingly, the Agency cited Respondent with a Class III violation. Revisit Survey of March 19, 2018 152. On January 19, 2018, the Agency sent Respondent a statement of deficiencies, which notified Respondent of the deficiencies found on the January 4 through 5 survey, as well as required the Respondent to correct the cited deficient practice above by January 29, 2018. 153. On March 19, 2018, the Agency conducted a revisit complaint survey of Respondent’s Facility. 154. Based on record review and interview, the facility has failed to ensure Medication Observation Records (MOR) accurately documented residents receiving medication for four (4) residents. (Resident #27, #31, #32, and #33). 155. The Agency reviewed Resident #27’s March 2018 MOR. The Agency found the following: a. Resident #27’s MOR had no documentation of Aspirin 81 milligrams (mg) being given on March 18, 2018. b. The MOR did not have any documentation on the reverse side indicating the resident received or did not receive the medication. c. The MOR documented the Metformin ER (a diabetic medication) medication was not given on March 9, 10, 11, 17, 18, and 19, 2018. The medication was documented as given on March 12, 14, 15, and,16, 2018. 37 156. following: d. The back page of the MOR notes Metformin was not available on March 7, 10,11, and 18, 2018. There was no documentation explaining why the medication was not available. The Agency reviewed Resident #31’s March 2018 MOR. The Agency found the a. The MOR had no documentation for receiving the medication Celecoxib (an anti-inflammatory drug) at the 4:00 p.m. dose on March 11, 2018. b. The MOR had no documentation for Metoprolol (a blood pressure medication) on march 14, 2017. c. The MOR had no documentation that Paroxetine (an antidepressant) was or was not given on March 14 and 16, 2018. d. The MOR documented the morning dose of Paroxetine was not given on From Amrch 7 through the 9, 2018, and noted on the back that it was not available. The MOR documented the evening doses were given for these same dates. e. There was no documentation that Resperidone (an antipsychotic) was or was not given on March 11, 2018 at 8:00 p.m. f. The MOR did not document that Depakote (an anti-seizure drug) was or was not given on March 15 and 16, 2018. g. The MOR did not document the Mirtazapine (an antidepressant) was or was not given on March 11, 2018. h. These totaled eleven (11) doses missed over nineteen (19) days for Resident #31. 38 157. The Agency reviewed Resident #32’s March 2018 MOR. The MOR did not document whether or not the resident received Sertraline (an antidepressant) on March 8, 2018. It also did not document whether or not the resident received the morning dose of Labetalol (a blood pressure medication) on March 8, 2018. 158. The Agency reviewed Resident #33’s March 2018 MOR. The MOR did not document whether or not Resident #33 received all seven (7) morning medications for March 14, 2018. The medications included Aspirin 81 mg, Amlodipine and Ramipril (blood pressure medications), Isosorbide Mono ER (for chest pain), Glipizide, and Metformin (diabetic medications), and Vitamin D3. 159. On March 19, 2018, the Agency interviewed Respondent’s Administrator. The Administrator stated that they have a nurse auditing the MORs daily to identify medications that are not noted as given. 160. Based on the above, Respondent failed to correct the deficient practice in the timeframe specified by the Agency. Sanction 161. 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 this part, part II of chapter 408, or applicable rules. § 429.14(1), Fla. Stat. (2017). 162. Under Florida law, 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: Class “III” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the 39 care of clients which the agency determines indirectly 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 III 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. § 408.813(2)(c), Fla. Stat. (2017). 163. Under Florida law, 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. § 429.19(2)(c), Fla. Stat. (2017). 164. The Agency cited the Respondent for a Class II violation in accordance with applicable statutes and authorizing rules, and it remained uncorrected. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $1,000.00 against the Respondent. COUNT VI Physical Plant 165. Under Florida law, (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and, 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident, 40 2. A closet or wardrobe space for hanging clothes, 3. A dresser, chest or other furniture designed for storage of clothing or personal effects, 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and, 5. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. (d) Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be threadbare Rule 58A-5.023(3), F.A.C., (2018). Survey Findings 166. On March 19, 2018, the Agency conducted a revisit complaint survey of Respondent’s Facility. 167. Based on observation and staff interview, the Agency determined that Respondent’s Facility failed to provide a safe living environment, free from hazards and structures in good working order, creating the potential for resident injury and/or discomfort. 168. On March 19, 2018 the Agency survey observed the following about Respondent’s fence: a. The fence outside of the memory care unit had three gates. b. Respondent’s maintenance staff was present at this time. c. He punched in the code on the second gate and the gate did not open. d. He said this gate had been like this for three weeks. e. The third gate had a cable and padlock keeping this gate from opening. f. The maintenance staff said this gate has been broken for four weeks and the padlock has been on this gate since then. 41 169. These gates would provide emergency egress in the event of a fire or emergency. 170. On March 19, 2018, the Agency interviewed Respondent’s Administrator about the Memory Care Unit gates. The Administrator stated that he was not aware that these two gates were not working, one of which had a padlock on it. 171. On March 19, 2018, the Agency surveyor took a tour of Respondent’s facility. The tour revealed the following: a. Outside on the patio, in the memory care unit, there were many snack wrappers on the ground, a palm tree cut down with tree sections and other horticulture lying on ground, and a broken wooden bracket lying on ground. Room 51 had floor tiles peeling, missing, and broken blinds. Room 55 had no toilet paper holder. Room 57 had no toilet paper holder, toilet seat loose sitting sideways. Room 49 had a missing floor tile, the corner of wall was marred with a plastic piece that was falling off, the closet doors were off hinges, there was clothes on the floor and the dresser drawers were empty. Room 60 had ripped tile by the back door. Room 45 had its blinds broken. Room 56 had a bathroom towel bar broken, and a hole in closet door from the front door knob. Room 54 had paint peeling on the wall in the bathroom. Room 52 had no toilet paper holder. Room 50 had tiles missing on the floor, and no toilet paper holder. Room 48 had tiles missing by bed and back door. 42 m. Room 46 had a towel bar missing in bathroom. n. Room A3 had its tile floor peeling by the front door and dressers. o. Room Al! had its floor tiles with holes. p. Room B30 had holes and stains on the floor. q. The hallway outside Room B39 had a carpet soaked with water. At 10:24 a.m., maintenance staff person said the facility staff used the shower in Room 39 and plugged up the drain. The water flowed out of the room and into the hallway. r. Room D69 had holes on the vinyl floor. s. Room D7! had closet doors off the hinges. t. Room D74’s floor has holes, discolored, and a large rip. Room D78 had holes in the floor tiles, ripped, and peeling tile. = 172. The above description of disrepair was consistent with the March 19, 2018 Department of Health inspection report. The DOH inspection was deemed “unsatisfactory”. 173. Accordingly, the Agency cited Respondent with a Class II violation. Sanction 174. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 175. Under Florida law 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 determines 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 IT violation. A fine shall be levied notwithstanding the correction of the violation. § 408.813(2)(b), Fla. Stat. (2017). 43 176. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 177. Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. COUNT IX Resident Supervision 178. | Under Florida law, “the facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and service to treat the condition.” § 429.26(7), Fla. Stat., (2017). 44 179. Pursuant to Florida law, in pertinent part: An assisted living facility must provide care and_ services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for each resident, including the following: (a) Monitoring of 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 resident. (c) Maintaining a 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) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, changes in the method of medication administration, or other changes that resulted in the provision of additional services. Rule 58A-5.025, F.A.C., (2017). Survey Findings 180. From May 29 through 31, 2018, the Agency conducted a second revisit complaint survey of Respondent’s Facility. 181. Based on record review, interview, and observation, the Agency determined the Respondent’s Facility failed to provide supervision and monitoring to meet the needs for four (4) residents. (Residents #52, #51, #54, and #9). 182. The Agency reviewed Respondent’s Elopement Policies and Procedures (revised date of November 2013), which defined elopement as exit-seeking behavior demonstrated by residents who are typically cognitively impaired. 45 183. The procedures and interventions included: every resident will be screened prior to admission; any resident diagnosed with a memory/cognitive impairment will not leave building without an escort; after an elopement reevaluate if appropriate to be retained in the facility and a complete investigation will be done of the elopement. Resident #52 184. On May 29, 2018, the Agency surveyor conducted a tour of the secure Memory Care unit. The surveyor observed the following: a. Resident #52 had a large bruise on the left side of his/her face extending from his/her forehead to the neck. b. A large localized area of swelling was also noted on his/her forehead over the resident’s left eye that was about 1.5 inches by 0.75 inches in size. c. Resident #52 was confused and unable to answer questions when interviewed. 185. On May 29, 2018, the Agency interviewed the Administrator about Resident #52. The Administrator said the following: a. There had been no elopements from any residents on the memory unit but a new resident (Resident #52) had went out towards the parking lot and had a fall with injury. b. Resident #52 had gone outside before and would walk around to the end of the driveway and come back in the front door. c. On May 23, 2018, Resident #52 had gone outside, went around the loop, and fell. 186. On May 29, 2018, the Agency reviewed Resident #52’s record including the resident health assessment (“1823”) dated March 13, 2018. The 1823 listed under “physical or 46 sensory limitations” that the resident was noted to have severe hearing loss and memory impairment. There was no Elopement Risk Assessment Form found in Resident #2’s record. 187. The Agency then reviewed “Service Notes” indicating the following: a. The resident was admitted to the Facility on March 30, 2018 and was alert with confusion. b. On April 7, 2018 at 6:00 a.m., LPN Staff N noted upon her arrival to the facility, that Resident #52 was outside walking saying he/she was going to work. After redirection, the resident was willing to come back inside the facility. c. On April 7, 2018 at 4:00 p.m., LPN Staff N noted the resident was found outside sitting on the bench by the front door. d. The resident was redirected inside and required constant redirection and monitoring. 188. On May 29, 2018 the Agency interviewed Respondent’s employee Staff N, a licensed practical nurse (“LPN”). Staff N stated noted that Resident #52 had a fall and sustained a lump on the left side of his forehead. Staff M then called 911 and Resident #52 was transported to the emergency room. The resident returned to the facility the next day (May 24, 2018). 189. On May 30, 2018, the Agency interviewed Staff N again. Staff N said the following: a. On May 23, 2018 one of the RCA’s came to get her and said Resident #52 had fallen. b. The resident at that time was sitting in a chair in the lobby. c. The resident said he/she fell, and got a lump on his head. d. Staff N was not sure if Resident #52 was inside or outside when he/she fell. e. The resident had been in bed around 7:30 p.m. 47 f. According to RCA staff the resident was outside near the bench area before the fall. g. Resident #52 has been confused since admission and staff had to watch him all the time. 190. On May 30, 2018 the Agency interviewed Respondent’s employee Staff M, a LPN. Staff M said the following: a. On April 7, 2018, the night shift Resident Care Assistant (“RCA”) reported Resident #52 had been found outside in the parking lot by the trees getting close to the road. b. There had been no injury to the resident. Staff M was not sure what time Resident #52 had been outside but was on the night shift (10:00 p.m. to 6:00 a.m.) when it occurred. c. Resident #52 was still allowed to go outside unescorted after this incident. d. The resident had been confused since admission, would want to go to work or to one of the exits and needed constant redirection. 191. On May 30, 2018 the Agency interviewed Respondent’s Wellness Director. The Wellness Director stated the following: a. Resident #52 needed frequent monitoring. b. Resident #52 would go and stand by the door and on one occasion the director went to retrieve him outside in the grassy area. c. She was not notified of the incident on April 7, 2018 where the resident was found outside by the night shift. 48 192. On May 30, 2018 the Agency interviewed Respondent’s employee Staff X, a medication technetium. Staff X said the following: a. All the staff would watch Resident #52 as he/she liked to go out but did not know where he/she was going. b. Sometimes Resident #52 would say he/she was going to see his/her spouse (who is deceased), or he/she was going home as his/her spouse is cooking. c. Every time Resident #52 went out the door, he/she said he/she wanted to go home. 193. On May 30, 2018 the Agency interviewed Respondent’s employee Staff J, a medication technician. Staff J said the following: a. On the evening of May 23, 2018, he was passing medications in the hallway where Resident #52 resided. b. He had last seen Resident #52 around 6:00 p.m., and about thirty (30) minutes later, the staff found the resident and brought him inside. c. Staff J saw staff walking Resident #52 back inside and put him/her in a chair in the lobby. 194. On May 31 at 11:00 a.m. the Agency interviewed Respondent’s Administrator. The Administrator stated: a. Resident #52 had been outside when he/she fell but the Administrator did not know how far the resident had walked, or where he/she fell. b. No identification bracelet had been placed on Resident #52 yet as he had not typed one up for the resident. 49 c. The identification bracelets were being used for the residents at risk for elopement. Resident #54 195. On May 29, 2018 the Agency interviewed Resident #54. Resident #54 said the following: 196. The food at the Facility is horrible and is so bad he/she does not even eat it. 197. The resident has lost six (6) pounds in a week from not eating. 198. The portions are getting smaller and pretty soon it will just be bread and water. 199. The food is too salty and he/she thinks the Staff are trying to give him/her high blood pressure. 200. The resident attends resident council meetings and complains about the food but nothing improves. 201. The Agency then reviewed Resident #54’s weight record. The record revealed the resident had lost ten pounds (10lbs) in five (5) months. Between February 13 and April 7, 2018 the resident lost seven pounds (7 lbs). 202. On May 31, 2018 the Agency interviewed Respondent’s employee Staff N. StaffN confirmed Resident #54's weight record indicated the resident had lost ten pounds (10 Ibs). Staff N said she was not aware of the weight loss and did not know any reason for it. 203. On May 31, 2018 the Agency interviewed Respondent’s Wellness Director. The Wellness Director said she was not aware of any weight loss for Resident #54. She said the resident is particular about what he/she eats but was not sure why he/she was losing weight. Resident #9 50 204. On May 29, 2018, the Agency surveyor observed Resident #9 sitting in his/her wheelchair self-propelling down the hallway. 205. The resident had a soiled gauze dressing sticking up over a sock on his/her right leg. A foul odor was noted from the area. The stocking over the dressing had a large area, approximately four inches by three inches (4” x 3”) of dried reddish/yellow drainage. 206. The Agency then interviewed the resident and Resident #9 stated he/she did not know what had happened to his/her leg. 207. Later in the day, the resident's soiled dressing was observed again to be present on his/her leg. The resident pulled down the stocking and the outside of the Kerlix rolled gauze dressing was soiled with dried reddish/yellow drainage. 208. On May 29, 2018 the Agency interviewed Staff M about Resident #9. Staff M said she was not aware of any wound on the resident's right lower leg and did not know Resident #9 had a dressing. 209. On May 29, 2018, the Agency interviewed Staff N about Resident #9. StaffN stated the following: a. She did not know of any wound or dressing on Resident #9's right lower leg. b. Resident #9 wears protective stockings so unless they were removed she would not see it. c. Staff N relies on the resident care assistants to let her know of any skin issues as they give the resident baths. d. Resident #9 gets a shower twice a week in the evenings and staff would have to remove the stocking on his/her leg. 51 210. On May 30, 2018, the Agency interviewed Respondent’s Wellness Director about Resident #9. The director stated the following: a. The dressing that was applied to Resident #9's leg was a regular dressing and not just first aid. b. The director confirmed she had not been able to identify who placed the dressing on Resident #9 and only has two (2) nurses on staff. c. There was no documentation of any showers after May 1, 2018. 211. On May 30, 2018, the Agency interviewed Respondent’s employee Staff X, a medication technician about Resident #9. Staff X said she takes care of Resident #9 and was aware the resident had a bandage on his/her right leg. She said the bandage has been there for about a week and the resident does refuse showers, so Resident #9 has been getting a sponge bath. 212. On May 30, 2018 the Agency interviewed the Advanced Registered Nurse Practitioner (“ARNP”) for Resident #9. The ARNP said he was not aware of any wound on the resident's right lower leg and had not given any order for a dressing. Resident #51 213. On May 29, 2018 the Agency observed Resident #51. Resident #51 was observed coming up the hallway in a power chair with no shirt. A reddened area was noted on his/her stomach area just below the rib cage. The area of redness was approximately three inches wide by four inches long (3” x 4”). 214. The area had a hole in the center where the resident had a feeding tube prior. The area was red and inflamed. Secretions were coming out of the hole when the resident talked and moved his stomach muscles. 52 215. Resident #51 was then interviewed by the Agency. Resident #51 indicated through gestures, writing, and attempting to talk that the area was sore and he/she needed to have someone look at it. Subsequently a staff member on duty said he would get the nurse. 216. In later interviews Resident #51 stated through gestures, writing, and attempting to talk the following: a. e. The resident had his/her feeding tube removed about four (4) weeks ago and it was not healing. Resident #51 was admitted to the Facility on May 11, 2018, and was caring for the site on his/her own since then. Resident #54 does not have the supplies, such as dressing, to care for the wound, but instead uses paper towels to cover it and puts paper tape around the wound. Resident #54 gets the paper tape from the Facility’s nurse. The area was very sore and he/she has told many staff members about it. 217. The following day, May 30, 2018, Resident #51 said that he/she was going to the doctor to have his/her feeding tube site looked at. 218. On May 30, 2018, the Agency interviewed Respondent’s Wellness Director about Resident #51. The Wellness Director stated the following: a. She did know about Resident #51’s feeding tube site and it had concerned her since the resident’s admission. She thought that it was something that the nurses should be monitoring, but when she brought it to the Administrator’s attention, he reported to her that the nursing home the resident was admitted from said the resident could care for the site on his/her own. 53 c. She was aware that the resident did not want added cost and said he/she would care for it on his/her own due to that point. 219. On May 30, 2018 the Agency interviewed Respondent’s LPN, Staff N about Resident #51. Staff N said the following: a. She was aware of Resident #51's feeding tube site, as the resident had come to her early last week. b. The resident had asked her for dressing supplies so he/she could take care of his/her peg tube site. c. At the time Staff N had noted the wound site was red and inflamed and had asked the ARNP to see the resident. 220. The Agency then reviewed nurse’s notes for Resident #51 dated May 23, 2018, which had no mention of the feeding tube site or that the nurse practitioner had been notified. 221. Resident #51’s 1823 dated May 11, 2018, revealed that there were no orders for dressing changes to feeding tube site, but did record that Bactroban ointment was need for his/her mid-abdomen daily and at bedtime. The title “nursing/treatment/therapy service requirements” for Resident #51 was indicated “as needed.” 222. Nurse’s notes for resident #5lonly recorded the resident’s PEG tube feeding site was covered, with no assessment of skin condition or if there was any signs of infection. 223. The Agency did not find any other facility progress notes regarding Resident #51’s feeding tube site condition for eighteen (18) days, until May 29, 2018. 224. Further record review showed a gastric doctor saw Resident #51 on May 22, 2018. The doctor’s notes stated the following: a. A chief problem was recorded as “tube site won't heal.” 54 b. An order was given for an antibiotic to be taken three (3) times a day for seven (7) days. 225. Resident #51 then returned to the gastric doctor on May 30, 2018 after the resident voiced concern on May 29, 2018 about his/her feeding tube site still being red and sore. 226. The doctor again ordered an antibiotic to be taken twice a day for ten (10) days and the site to be cleaned twice a day with dressing change. The doctor also requested the nurse call with an update on Resident #51’s condition on Thursday, Friday and Monday of next week. 227. On May 30, 2018, the Agency interviewed Resident #51 again after his/her doctor’s appointment. Resident #51 said the following: a. The resident was worried about having to pay more money to have his/her feeding tube site on his/her stomach taken care of by the Facility staff. b. This is the reason he/she has been taking care of it on his/her own. c. The resident does not have the supplies to take care of his/her wound and the Facility is unable to provide hime/her with the supplies, so the resident uses paper towels and tape received from the nurse. d. The resident changes the paper towel several times a day when it gets wet by the drainage coming out of the hole in his/her stomach. e. Resident #51 told the Wellness Director about his/her site several weeks ago, as well as LPN Staff N and Staff M. f. Resident #51 was never told by staff that the Facility had limited nursing services (“LNS”) available to take care of his/her wound. g. The resident then agreed to let Facility nurses take care of his/her wound if there was no additional charge to him/her. 55 228. Based upon the actions and inactions above, the Agency cited Respondent with a Class II deficiency. Sanction 229. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 230. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 231. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 232. Under Florida law, each violation of Part I of Chapter 429 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” violations are defined in s. 408.813. The agency shall impose an 56 administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent COUNT X Elopement Standards 233. Under Florida law: (8) ELOPEMENT STANDARDS. (a) Residents Assessed at Risk for Elopement. All residents assessed at risk for elopement or with any history of elopement must be identified so staff can be alerted to their needs for support and supervision. 1. As part of its resident elopement response policies and procedures, the facility must make, at a minimum, a daily effort to determine that at risk residents have identification on their persons that includes their name and the facility’s name, address, and telephone number. Staff attention must be directed towards residents assessed at high risk for elopement, with special attention given to those with Alzheimer’s disease or related disorders assessed at high risk. 2. At a minimum, the facility must have a photo identification of at risk residents on file that is accessible to all facility staff and law enforcement as necessary. The facility’s file must contain the resident’s photo identification within 10 days of admission or within 10 days of being assessed at risk for elopement subsequent to admission. The photo identification may be provided by the facility, the resident, or the resident’s representative. (b) Facility Resident Elopement Response Policies and Procedures. The facility must develop detailed written policies and procedures for responding to a resident elopement. At a minimum, the policies and procedures must provide for: 1. An immediate search of the facility and premises, 2. The identification of staff responsible for implementing each part of the elopement response policies and procedures, including specific duties and responsibilities, 3. The identification of staff responsible for contacting law enforcement, the resident’s family, guardian, health care surrogate, and case manager if the resident is not located pursuant to subparagraph (8)(b)1.; and, 4. The continued care of all residents within the facility in the event 57 of an elopement. (c) Facility Resident Elopement Drills. The facility must conduct and document resident elopement drills pursuant to Sections 429.41(1)(a)3. and 429.41(1)(), F.S. Rule 58A-5.0182(8), F.A.C., (2018). Survey Findings 234. The Agency re-alleges and incorporates by reference all facts alleged in Count IX of this complaint. 235. From May 29 through 31, 2018, the Agency conducted a second revisit complaint survey of Respondent’s Facility. 236. Based on record review, interview, and observation, the Agency determined that Respondent’s facility failed to ensure seven (7) residents who were identified as an elopement risk had identification on their person. (Resident #52, #56, #57, #58, #14, #59, and #60). Additionally, Resident #52 was not assessed for elopement risks upon admission to the facility per contract and facility policy. 237. The Agency reviewed the Facility’s Elopement Policies and Procedures (revised date of November 2013), which defined elopement as exit-seeking behavior demonstrated by residents who are typically cognitively impaired. 238. The procedures and interventions included: every resident will be screened prior to admission; any resident diagnosed with a memory/cognitive impairment will not leave building without an escort; after an elopement reevaluate if appropriate to be retained in the facility; and a complete investigation will be done of the elopement. 239. The Agency toured Respondent’s Memory Care unit on May 29, 2018. During the tour, the Agency surveyors observed he following: a. Resident #52 was observed not wearing any identification on his/her person. 58 b. Resident #60 was observed to have no identification bracket on his/her person. c. Residents #14, #56, #57, #58, and #59 were all observed not wearing any identification on their person. 240. The Agency interviewed Respondent’s employee Staff W, a medication technician, who was present with the surveyors on the tour. Staff W stated the following: a. The reason for Resident #51 to not have any identification bracelets was the resident had recently been moved into the secured unit. b. Staff W confirmed all residents residing in the memory care unit should have a identification bracelet with their name, name of facility, and phone number. c. Staff W confirmed Resident #60 had resided in the memory unit for about a month. d. Staff W also confirmed Residents #14, #56, #57, #58, and #59 all did not have identification bracelets. 241. Shortly after on May 29, 2018, the Agency interviewed the Administrator. The Administrator stated there had been no elopements by any residents from the memory unit, but a new resident (Resident #52) went out towards the parking lot and had a fall with injury. 242. On May 30, 2018, the Agency reviewed Resident #52’s resident contract. The contract was signed by the resident’s Power of Attorney on March 27, 2018. On page 14 of the agreement, under Elopement, the contract read, “[a]ll residents will be assessed at risk for elopement.” 243. The Agency then reviewed Resident #52’s 1823, dated March 13, 2018. Under “physical or sensory limitations”, the resident was noted to have severe hearing loss and memory impairment. 59 244. The Agency did not find an Elopement Risk Assessment Form in Resident #52’s records. 245. The Agency interviewed Respondent’s Administrator about Resident #52 again on May 31, 2018. The Administrator stated the following: 246. The Administrator did not do any investigation into the Resident #52’s fall on May 23, 2018. 247. Resident #52 had been outside but the Administrator did not know how far the resident walked, where he/she fell, or what staff were involved. 248. The Administrator confirmed Resident #52 had no bracelet yet, as the Administrator had not typed one up for the resident. 249. The Administrator acknowledged the identification bracelets were being used for the residents at risk for elopement. 250. The Administrator was not aware that Resident #52 did not have an Elopement Risk Assessment completed yet. 251. Based on these actions and inactions, the Agency cited Respondent with a Class II deficiency. Sanction 252. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 253. Under Florida law 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 determines 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 60 violation. A fine shall be levied notwithstanding the correction of the violation. § 408.813(2)(b), Fla. Stat. (2017). 254. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 255. Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent COUNT XI Medication Records - MORs 256. Under Florida law: (5) MEDICATION RECORDS. (a) For residents who use a pill organizer managed in subsection (2), the facility must keep either the original labeled medication container; or a medication listing with the prescription number, the name and address of the issuing pharmacy, the health care provider’s name, the resident’s name, the date dispensed, the name and strength of the drug, and the directions for use. 61 (b) The facility must maintain a daily medication observation record (MOR) for each resident who receives assistance with self- administration of medications or medication administration. A medication observation record must include the name of the resident and any known allergies the resident may have; the name of the resident’s health care provider, the health care provider’s telephone number; the name, strength, and directions for use of each medication; and a chart for recording each time the medication is taken, any missed dosages, refusals to take medication as prescribed, or medication errors. The medication observation record must be immediately updated each time the medication is offered or administered. (c) For medications that serve as chemical restraints, the facility must, pursuant to Section 429.41, F.S., maintain a record of the prescribing physician’s annual evaluation of the use of the medication. Rule 58A-5.0185(5), F.A.C. (2018). Survey Findings 257. On or about May 29 through 31, 2018, the Agency conducted a second revisit survey of Respondent’s Facility. 258. Based on observations, record review, and staff interviews, the Agency determined that Respondent’s Facility failed to maintain an accurate Medication Observation Record (“MOR”) for two (2) residents (Resident #50 and #52). Resident #50 259. On May 30, 2018, the Agency reviewed Resident #50’s MOR. The review revealed the following: a. Dexamethasone 0.75 milligram (mg) was ordered to be taken three (3) times a day for one (1) week, then two (2) times a day for one (1) week, then once a day for one (1) week. b. The MOR showed the medication was not given multiple days & given wrong on multiple days. 62 c. Resident #50 was not given the medication correctly since his/her admission. d. Pepcid (to reduce stomach acid), Lipitor (to reduce cholesterol), Melatonin (for sleep), Metformin (to reduce blood sugars), Lopressor (to decrease blood pressure), Eliquis (a blood thinner to reduce blood clots) all were written incorrectly on Resident #50’s MOR. e. The medications were written as double the amount or one and a half times the amount to be taken for the thirteen (13) days the resident was in the facility. 260. The Agency surveyor observed a medication pass for resident #50 on May 30, 2018. During the med pass a bottle of amlodipine (a blood pressure medication) at 5 mg daily was found. 261. The Agency’s review of Resident #50’s MOR failed to find amlodipine (Norvasc) listed as an ordered medication. 262. On May 30, 2018, the Agency interviewed Respondent’s employee Staff K, a medication technician, about the med pass for Resident #50. Staff K acknowledged her error in giving Resident #50 the medication (amlodipine) that was not written on the MOR. She also acknowledged that other medications were not being given according to doctors’ orders as written in the resident’s admission order. 263. On May 30, 2018, the Agency interviewed Respondent’s employee Staff N, a LPN. Staff N stated the following: a. She acknowledged that the medications written on Resident #50’s MOR were written incorrectly and she had written the amlodipine medication in error. b. She acknowledged that the doctor's orders were for twice a day or once a day and the medications were being given in error for thirteen (13) days. 63 c. She also acknowledged that some of the medications had missing signatures and appeared to not been given. 264. On May 30, 2018, the Agency interviewed Respondent’s Wellness Director. The Wellness Director stated the following: a. She acknowledged the error Staff K had made in giving Resident #50 a medication that was not ordered and not written on the resident’s MOR. She also acknowledged that the other medications were incorrectly written on the MOR and the resident appeared to have been given double the amount or one and a half times the amount ordered by the doctor. 265. On May 31, 2018, the Agency interviewed Resident #50. Resident #50 stated the following: e. The resident had pain in his/her left hip and in his/her wrist and hands. Resident #50 had an operation on both of his/her wrists and now was having a lot of pain in his/her hands. The resident described his/her pain level as a six (6) on a scale of one to ten (1- 10). Because of the pain the resident has a hard time doing simple tasks such as picking things up, eating, using the bathroom, or reading a book and turning the pages. The resident was unaware of the medications that the Facility is giving him/her. 266. On May 31, 2018, a Nurse Practitioner was notified that Resident #50 was not being given her medication for the pain and swelling in his/her hands in the way it was ordered. 64 267. The Nurse Practitioner acknowledged errors and ordered medication used for swelling and pain to be given two (2) times a day and ordered a new medication (Tramadol) for pain for Resident #50. Resident #52 268. On May 31, 2018 the Agency reviewed Resident #52’s MOR. According to the MOR, the resident was to receive Lasix 40 milligrams (mg) twice a day for seven (7) days. 269. There was no documentation on the MOR that the resident received the morning dose of Lasix on May 26 and 27, 2018. 270. Resident #52 was also to receive Tylenol 500 mg two (2) tablets twice a day. 271. There was no documentation that the resident received the morning dose of Tylenol on May 26, 27, and 28, 2018. 272. Finally, Resident #52 was to receive the antidepressant medication Zoloft 100 mg at bedtime. 273. There was no documentation on the MOR that the resident received the medication on May 25, 2018. 274. During an interview on May 31, 2018, Respondent’s Wellness Director confirmed the missing documentation of Resident #52’s medications. 275. Based on these actions and inactions, the Agency cited Respondent with a Class II deficiency. Sanction 276. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 65 277. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 278. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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. § 429.19(1), Fla. Stat. (2017). 279. — Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent COUNT XII Physical Plant 280. Under Florida law: 66 (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and, 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident, 2. A closet or wardrobe space for hanging clothes, 3. A dresser, chest or other furniture designed for storage of clothing or personal effects, 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and, 5. A comfortable chair, if requested. (c) The facility must maintain master or duplicate keys to resident bedrooms to be used in the event of an emergency. (d) Residents who use portable bedside commodes must be provided with privacy during use. (e) Facilities must make available linens and personal laundry services for residents who require such services. Linens provided by a facility must be free of tears, stains and must not be threadbare Rule 58A-5.023(3), F.A.C., (2018). Survey Findings 281. On May 29 through 31, 2018, the Agency conducted a second revisit complaint survey of Respondent’s Facility. 282. Based on observation and interview, the Agency determined Respondent’s Facility failed to provide a safe living environment, maintained free of hazards, and to ensure that existing structures are in good working order. 67 283. On May 30 and 31, 2018, the Agency toured Respondent’s Facility with the Administrator and two representatives from the Florida Department of Health (“DOH”). The following observations were made on the tours: a. Room C 45 - a live insect on the wall vent. The DOH staff identified the insect as a millipede. Room C 46 - the toilet caulk was cracked/stained, a bathroom vanity was peeling, and window blinds were in disrepair. Room C 47 — there was no towel rack and no toilet paper holder. Room C 48 — a hole in closet door, and half of closet door was missing. Room C 49 - a large length of exposed cable wire was on the wall. Room C 50 — the bathroom vanity was peeling, no outlet covers, and wires were exposed. Room C 51 - live insects/worms on the ceiling and floor. Room C 53 —a light switch taped off, live worms on floor, the bathroom vanity peeling, and a deadbolt on door to the outside was not working. Room C 55 - toilet caulking was cracked, and the bathroom vanity peeling. Room C 56 — worms/insects found on the floor. Room C 58 - multiple exposed nails at head/chest level throughout the room, holes in the wall, and the bathroom vanity peeling. Room C 59— A hole in the wall, the closet doors not flush together, and a closet knob was hanging off. m. Room C 60 — the ceiling was plastered, and an exposed screw at eye level. 68 Memory care hallway — the floor molding was blackened, live worms found on the floor, the dining room door in the hallway was dirty/scuffed, and a wall with hole was visible. Memory care activity room — presence of unfolded laundry/gloves, a McDonald’s cup was left on a table, a sheet was thrown on floor near the door to the outside, two tables in the activity room had missing paint/varnish with exposed wood/undersurface coming through. Memory care TV room — a ceiling tile by the light was hanging down. Memory care outdoor walkway/patio — the entry from the outdoors to the TV room was heavily soiled and the doorknob was hanging off; a screw connecting the memory care fence to the wall was not secure; an unattached spring on the memory care gate; a random metal piece was screwed to the memory care walkway; exposed stump/roots and rocks were around the yard; the outdoor entry to the dining room was heavily soiled; the outdoor wall was separated; the outdoor wall had multiple worms/insects; a planter box was placed next to the fence, which could facilitate a resident climbing over the fence. Room A2 — the flooring was peeling in the closet and in the room. Room A3 — more flooring was peeling. Room A 4 — the bathroom ceiling was in disrepair. Room A 5 — the closet door was bent, and the laminate flooring was peeling. Room A 6 — the paint was chipping from the trim, the door and the wall; live worms/insects were on the floor. . Room A 7 —a bathroom tile was chipped. 69 aa. ce. dd. ee. ff. gg. bh. ii. IL. Room A 9 - the bathroom door and closet molding had chipped paint; the toilet was loose with leaking water; some bathroom tiles were missing; there was gaps in the laminate floor. Room A 10 — the bathroom vanity was peeling/chipping, the door was off, and paint was chipping on the bathroom entry. Room A 12 — there were exposed nails in the walls and door. Room A 16 ~a strong foul odor lingered, the flooring was cracked/stained. . Room A 17 — the window blinds were in disrepair, and the paint was chipping in bathroom entry and closet. Room A 18 — the flooring was stained and peeling, the vanity was peeling, and paint was peeling/chipped in the bathroom entry. Room A 20 — there was a gap between the flooring and baseboard, and the floor was stained. Gym/Equipment room — the flooring was in disrepair. Room B 24 — worms/insects were on the floor, and the wall vent was taped over. Room B 25 — the cable wiring was loose. Room B 26 — the bathroom entryway was chipping, the smoke detector was missing, and wires were exposed. Worms/insects were also found in the room. Room D 63 — the bathroom vanity was peeling, the wall air vent was blocked. . Room D 65 — the flooring was peeling, and the bathroom vanity was peeling. . Room D 68 — the bathroom vanity was peeling. Room D 71 — worms/insects were on floor, and the floor was stained. 70 mm. Room D 73 —a brown substance was on the wall above the toilet. nn. Room D 74 - the flooring was stained. oo. Room D 75 — live worms/insects were on the floor, and the shower ceiling was leaking. pp. Room D 76 — the shower ceiling was peeling. qq. Room D 80 — worms/insects observed on the floor. tr. Common TV room/library — the internet connector was hanging off a wall, and exposed nails were over the doorway. ss. Coffee/refreshment room - small ants were noted to be crawling on the countertop and walls; live worms/insects were noted on the floor; and cabinets had areas of laminate missing. 284. On May 30, 2018, the Agency interviewed Resident #22 who stated his/her room has a problem with live worms/insects. The worms/insects come in under the door. Resident #22 said he/she runs over the worms/insects with his wheelchair to get rid of them. 285. On May 30, 2018, the Agency interviewed Resident #12, who said there is a problem with worms/insects throughout the building. Resident #12 woke up one night because he/she felt something near his ear, and when he/she reached up, he/she found a worm crawling on his/her face. 286. On May 31, 2018, the Agency interviewed Resident #62. Resident #62 stated that he/she has had insects/worms on him/her while in bed. 287. Another resident, Resident #64, said he/she has had ants on him/her while in bed. 288. On May 30, 2018, the Agency interviewed the Administrator about the pest control problems. The Administrator stated pest control comes once a month, and he can’t explain the 71 problem with the millipedes. He further said the Facility had been dealing with the milipedes for years. 289. The Facility provided pest sighting logs from exterminators, which indicated centipedes were all over a bed in Room 38 on May 14, 2018. 290. Per the pest control contract, the exterminators come once per month. 291. The last invoice provided showed service dated April 27, 2018. 292. Due to the actions and inactions of the Facility, the Agency cited Respondent with a Class II deficiency. Sanction 293. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 294. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 295. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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 72 seriously affecting the health, safety, or welfare of a resident of the facility. § 429.19(1), Fla. Stat. (2017). 296. Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. COUNT XIII Quality Control and Risk Assessment 297. Under Florida law: (1) Every facility licensed under this part may, as part of its administrative functions, voluntarily establish a risk management and quality assurance program, the purpose of which is to assess resident care practices, facility incident reports, deficiencies cited by the agency, adverse incident reports, and resident grievances and develop plans of action to correct and respond quickly to identify quality differences. (2) Every facility licensed under this part is required to maintain adverse incident reports. For purposes of this section, the term, “adverse incident” means: (a) An event over which facility personnel could exercise control 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 73 (b) Resident elopement, if the elopement places the resident at risk of harm or injury. (3) Licensed facilities shall provide within | 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. * * * (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. (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. § 429.23, Fla. Stat., (2017). Survey Findings 74 298. On May 29 through 31, 2018, the Agency conducted a second revisit survey of Respondent’s Facility. 299. The Agency re-alleges an incorporates by reference the allegations in Counts IX, X, XL, and XIL 300. Based on observation, record review and interviews, the Agency determined that Respondent’s Facility had failed to develop plans of action to correct deficiencies cited on previous surveys, and prevent reoccurrence of the same deficient practices. 301. The Agency conducted a survey of Respondent’s Facility on January 4 and 5, 2018. During this time, the Agency originally cited the Respondent with deficiencies in the following areas: a. A025 was cited for failure to provide supervision to prevent falls and a elopement; b. A032 for failure to ensure six residents identified as at risk for elopement had identification on their person and to prevent elopement; c. A054 for failure to document medications as being given; d. A152 for failure to keep the physical plant of the Facility in a safe condition. 302. Then, the Agency conducted an unannounced revisit survey of Respondent’s facility March 19, 2018. The following deficiencies were cited again: a. A025 for failure to document a change in status; b. A032 for failure to ensure residents at risk for elopement on the memory unit have identification on their person; c. A054 for failure to ensure the medications were being accurately documented; d. A152 for failure to keep the physical plant of the Facility in a safe condition. 75 303. Finally, the Agency conducted a second unannounced revisit survey on May 31, 2018. Once again, the same deficient practice was identified, as follows: a. A025 for the failure to provide supervision and monitoring to meet the needs of four residents. b. A032 because the Facility failed to ensure seven residents identified as an elopement risk had identification on their person. The Facility also failed to assess one resident for elopement risks. c. A054 because the Facility failed to maintain accurate documentation of assistance with medications and failure to provide medications as ordered. d. A152 was recited for an insect infestation and the inability to keep the physical plant in a safe condition. 304. On May 31, 2018, the Agency interviewed Respondent’s Administrator about these reoccurrences of deficient practice. The Administrator said the following: a. The facility did not currently have a quality assurance or risk management program. b. Part of his plan of action was to put identification bracelets on all the residents residing in the memory unit. c. He acknowledged the seven residents identified that did not have any identification on their person in the event they eloped. d. The Elopement Risk Assessment tool was initiated as part of the plan of correction and he confirmed Resident #52 was recently admitted to the facility and had no Elopement Risk Assessment Form completed. 76 e. He acknowledged Resident #52 had been allowed to wander outside unescorted and no interventions were in place to prevent accidents. f. In-services had been conducted in regards to medications and monitoring or residents. g. He acknowledged the medication training had not been effective if there were still missing documentation of medications. 305. The Agency cited Respondent with a Class II deficiency for this failure to implement a quality assurance program. Sanction 306. Under Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the Agency may impose an administrative fine. § 408.813(1), Fla. Stat. (2017). 307. Under Florida law 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 determines 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. § 408.813(2)(b), Fla. Stat. (2017). 308. Pursuant to Florida law, in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of Part I of Chapter 429, part II of chapter 408, and applicable rules by an assisted living 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 77 seriously affecting the health, safety, or welfare of a resident of the facility. § 429.19(1), Fla. Stat. (2017). 309. — Under Florida law, each violation of Part I of Chapter 429 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” 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 $5,000 for each violation. § 429.19(2)(b), Fla. Stat. (2017). WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Zs_ Andrew B. Thornquest Andrew B. Thornquest, Assistant General Counsel Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite 330 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 78 NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28- 106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this 17th day of August, 2018. ‘s_ Andrew B. Thornquest Andrew B. Thornquest, Assistant General Counsel Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite 330 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 79 Shaddrick Haston, Esquire Counsel for Respondent 1618 Mahan Center Blvd. Suite 103 Tallahassee, Florida 32308 shad@shadhaston.com (Electronic Mail) Keisha Woods, Manager Assisted Living Unit Agency for Health Care Administration (Electronic Mail) Jon Seehawer, Field Office Manager Local Field Office- Region 8 Agency for Health Care Administration (Electronic Mail) 80 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Ft. Myers ALF BSLC, LLC d/b/a Lamplight Inn AHCA Nos. 2018008390 2018009078 2018009082 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). 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 may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (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 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 waive the right to a hearing to contest the allegations of fact and conclusions of law contained in the Administrative Complaint. 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 fine, sanction or other agency action. OPTION TWO (2) I admit the allegations of fact contained in the Administrative Complaint, but wish to be heard at an informal hearing (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, sanction or other agency action should be reduced. OPTION THREE (3) I dispute the allegations of fact contained 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 81 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. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (Optional) Thereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: 82 Laguna, Elvis From: Thornquest, Andrew Sent: Monday, August 20, 2018 4:19 PM To: shaston@gmail.com; Shad Haston Ce: Laguna, Elvis Subject: (1/3) NOTICE OF SERVICE: Ft. Myers ALF BSLC, LLC d/b/a Lamplight Inn (AHCA No. 2018009078; 2018008390; 2018009082) Attachments: Lamplight Inn - MYSB11, MYSB12, MYSB13 A25 A32 A54 A152 A165 - Class Il ....pdf Follow Up Flag: Follow up Flag Status: Completed Shad, Please find the attached Administrative Complaint for the three complaint surveys of January 5, March 19, and May 31, 2018. Thank you, (REPORT MECICAID FRAUD Online or 866-966-7226 "REPORTE FRAUDE DE MEDICAID 2 Andrew Thornquest - SENIOR ATTORNEY AHCA Sebring Building, Room 330L - GENERAL COUNSEL 727-552-1942 (Office) - Andrew. Thornquest@ahca.myflorida.com Privacy Statement: This e-mail may include confidential and/or proprietary information, and may be used only by the person or entity to which it is addressed. If the reader of this e-mail is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution or copying of this e-mail is prohibited. If you have received this in error, please reply to the sender and delete it immediately.

Docket for Case No: 18-005629