STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004004328 Return Receipt Requested: v. 7002 2410 0001 4237 7392 7002 2410 0001 4237 7408 ANDIES, INC. d/b/a WILLOW MANOR RETIREMENT HOME Oe ( OT! (, Respondent. ‘ ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Andies, Inc. d/b/a Willow Manor Retirement Home (hereinafter “Willow Manor Retirement Home”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $10,000.00 pursuant to Sections 400.414 and 400.419, Florida Statutes for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 3. venue lies in Broward County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2003) and Chapter 58A-5 Florida Administrative Code. 5. Willow Manor Retirement Home operates a 165-bed assisted living facility located at 150 Stirling Road, Dania, Florida 33004. Willow Manor Retirement Home is licensed as an assisted living facility under license number 6122. Willow Manor Retirement Home was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I WILLOW MANOR RETIREMENT HOME FAILED TO PROVIDE PERSONAL SUPERVISION FOR A RESIDENT, INCLUDING GENERAL AWARENESS OF RESIDENT’S WHEREABOUTS. RULE 58A-5.0182(1) (b) and (c), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Willow Manor Retirement Home was cited with one (1) Class I deficiency due to a resident elopement/death appraisal conducted on January 20, 2004. 8. Based on a resident-elopement/death appraisal visit conducted on January 20, 2004 and based on record review and interview, the facility did not provide personal supervision, including general awareness for one of three residents in the sample (Resident #1). The findings are as follows. 9. On the morning of 1/16/04, Resident #1, who had a diagnosis of dementia, eloped from the facility and was hit by a car and died around 10:45 AM. The Medication Observation Record on 1/16/04 showed the resident's three 12:00 PM medications and one 1 PM medication were not given. On 1/20/04 at 9:35 AM, the Administrator stated the nurse assisting with these medications was aware the resident had missed the medications but did not follow-up on the resident's absence because of the nurse became busy meeting the needs of other residents. The facility continued in not being generally aware of this resident’s absence until after the evening meal. Based on the facility's notes, the resident was not present at the evening meal. The nurse checked his room and hallway. As the nurse was calling the front desk to inquire where the resident could be, the resident's daughter appeared asking for her father stating that the FHP had called the family to report he had been hit and killed. 10. The mandated correction date was designated as February 19, 2004. 11. Based on a revisit survey conducted on April 6, 2004 and based on additional information, record review, and interview, the facility failed to provide appropriate supervision for a confused resident as evidenced by the staff being unaware that the resident was missing during the noon time meal and yet not searching for the resident until dinner time. In addition, it could not be determined that the resident was wearing the secure alarm system ankle bracelet, as the facility had no system in place to ensure that it was being functional and being utilized. The findings are as follows. 12. Resident #1 was admitted to the facility on 05/05/03. The admission health assessment dated 05/12/03 documented that the resident was memory impaired. The resident was independent for ambulation, and independent for dressing, eating, transferring, and toileting, but required assistance for bathing. The resident was not in a room in the locked dementia unit. The record further documents that the resident was visited on a regular basis by both the primary physician and the psychiatrist. The last changes in the medications were in November when the resident had an episode of agitation. The psychiatrist documented on 01/15/04 that the resident was "alert, wanders looking for wife, less agitated." 13. The November monthly summary completed by staff documented that the resident was of independent ambulation, continent, had only occasional inappropriate responses, confused, poor memory, wanders, normal speech, interacts with peers. "Very nice person but confused and wanders around." 14. During review of the MOR, it was noted that on 01/16/04, the resident did not receive noontime medications or dinnertime medications. The nurses’ notes documented that the resident was not present at the evening meal and so they checked the resident's room. When the resident could not be located, the nurse instituted a search. When she started to call the family, the daughter arrived at the facility asking for her father, and stating that the family had been told by law enforcement that the resident had been hit by a car and died as a result. 15. Interview with the administrator revealed the following: While the resident was diagnosed with Dementia, the facility evaluated the resident as knowing his name, knowing staff names, being continent, no elopement behavior and so able to reside in the main part of the building and not requiring the more costly Alzheimer's wing. 16. The CNA is responsible for being aware of the resident's whereabouts, however on 01/16/04 she was given an extra assignment. The nurse who noted that the resident was not present for lunch medications became distracted and did not follow-up on his absence. The dining room staff who also noted the resident's unusual absence from lunch was going to check on the resident, but instead became sidetracked assisting another resident and so did not follow-up on his absence. According to staff interviews and record reviews, the resident was aware of his name and names of staff. He knew where the dining room was and where his room was. 17. The administrator reported that at the time of the incident there was a receptionist at the front door, but that the front door was not kept locked. The resident would frequently go to the front desk and ask for his wife. The receptionist would call the wife for the resident to speak to her. According to the administrator, the resident never tried to leave by the front door. 18. The resident's record contained a form titled "ALF Resident Monitoring System." The form was noted to be signed by the resident's wife and dated 05/05/03. This form stated that a 6 secure alarm ankle bracelet would be provided to the resident at no charge. However, further record review revealed that there was no mention of the ankle bracelet including whether the resident was wearing it or not. The administrator could not explain how the staff would ensure that the bracelet (which worked by triggering the front door to lock) was being worn by the resident. 19. The administrator reported that the resident must have left the facility sometime after breakfast. The search for the resident did not start until after 5pm even though several staff throughout the day noticed he was missing. The resident was fatally hit by a car that morning. 20. Based on the foregoing, Willow Manor Retirement Home violated Rule 58A-5.0182(1)(b) and (c), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $10,000.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Willow Manor Retirement Home on count I. 2. Assess an administrative fine of $10,000.00 against Willow Manor Retirement Home on Count I for the violation cited above. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORD BY THE AGENCY. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Maryann Signore, Willow Manor Retirement Home, 150 Stirling Road, Dania, Florida 33004; Mary Ann Signore, 210 SAE. 2™ Terrace, Dania, Florida 33004 on this [Sth day of {ur - 2004. ’ Margaret

Docket for Case No: 04-002716