STATE OF FLORIDA o, uy 4 & AGENCY FOR HEALTH CARE ADMINISTRATION <6 4 Ao by, “MG, STATE OF FLORIDA, AGENCY FOR HUSSEY p40 HEALTH CARE ADMINISTRATION, “dpkg oe TONY, . O1-347¢ ote Petitioner, . vs. Case No. 2007006495 2007006494 CARROLLWOOD ASSISTED LIVING 2007006524 OPERATIONS, LTD, d/b/a HEARTHSTONE AT CARROLLWOOD, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against CARROLLWOOD ASSISTED LIVING OPERATIONS, LTD, d/b/a HEARTHSTONE AT CARROLLWOOD (hereinafter Respondent), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate an assisted living facility pursuant to Sections 408.815 and 429.14, Florida Statutes (2006) or, in the alternative, impose an administrative fine in the amount of thirty-three thousand dollars ($33,000.00), pursuant to Section 429.19(2)(a) and (b), Florida Statutes (2006), and a survey fee in the amount of five hundred dollars ($500.00) pursuant to Section 429.19(10), Florida Statutes (2006). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, 408.802, and 429.07, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes and Chapter 58A-5 Florida Administrative Code, respectively. 4. Respondent operates a 133-bed assisted living facility located at 2626 West Bearss Avenue, Tampa, Florida 33618, and is licensed as an assisted living facility, license number 9981. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, notwithstanding the minimum staffing requirements specified by rule, all facilities shall have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents scheduled and unscheduled service needs, resident contracts, and resident care standards as described in Rule 58A-5.0182, F.A.C. R. 58A-5.019(4)(b), Florida Administrative Code. 8. That on May 15, 2007, the Agency conducted a Complaint Survey (CCR# 2007005403) of the Respondent facility. 9. That based upon interviews of Respondent’s staff and confidential resident interviews, Respondent failed to ensure it had sufficient qualified staff to meet resident needs, the same being contrary to law. 10. That Petitioner’s representative interviewed Respondent’s staff on May 15, 2007, who indicated as follows: a. That one staff member indicated that the Respondent facility was understaffed; b. That the shortage was to staff members calling off and quitting; c. That Respondent could not maintain sufficient staff: d. That there were a few staff at the facility that were rude and harass both staff and residents; e. That two other staff indicated that the three (3) to eleven (11) shift is often short staffed which presents a problem with the assistance with self administration of medication passes; f. That there is only one (1) staff member to pass medications for one hundred eighteen (118) residents; g. That events occur which further make the medication pass difficult resulting in residents not receiving their medications in a timely manner; h. That these two (2) staff members also verified that certain staff are intimidating to other staff and residents; i. That all staff interviewed indicated that if staff call off or don't show up, extant staff have to work double shifts; j. That certain staff interviewed said that they have worked double shifts for several days in a row. 11. That the Petitioner’s representative conducted confidential resident interviews on May 15, 2007 who indicated as follows: That four (4) residents indicated that certain staff are nasty and rude and described the staff as rough and argumentative; . That one of the residents stated that the staff rush the resident and that staff are intimidating and order the resident around, that these particular staff are "...storm troopers and if I behave myself and am not a pain they will leave me alone;” That this resident indicated that the resident has asked his/her son to move him/her but has not told management about the problem for fear of retaliation; . That the resident further stated that the facility is short staffed on Sunday with only one (1) staff member on the shift, the staff was very nice but working very hard; . That another resident indicated that certain staff have an attitude and told this resident to "get it yourself" when the resident asked for assistance; That this resident told the administrator, who assisted the individual rather than confronting the staff person, making the resident conclude that the administrator was also intimidated by this staff member; . That another resident interviewed said that he/she had a problem with certain staff members who were nasty and argumentative. The resident said that on 1 or 2 occasions staff had forgotten to give him/her their medications, though this has not been recent, and sometimes the medications are late; . That another resident indicated that a couple of nights ago, the staff forgot to give him/her medications until the resident finally contacted the staff to get the medications at 9 PM for the medication that should have been taken at 5 PM. 12. That the Petitioner’s representative interviewed a resident’s family member on May 14, 2007 who indicated that on the evening of March 4, 2007, the family member attempted to call the facility on numerous occasions to find out the status of a relative who had been sent to the hospital and no one answered the phone and that it was not unusual to be unable to get through to the facility in the evenings. 13. That the failure to provide adequate qualified staff to timely meet resident needs is in violation of law and places residents at risk. 14. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 15. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2006). 16. That the Agency provided a mandated correction date of June 15, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2006). COUNT II 17. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. That pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility including, inter alia, personal supervision, as appropriate for each resident, including general awareness of the resident’s whereabouts. R. 58A-5.0182, Florida Administrative Code. 19. That on May 15, 2007, the Agency conducted a Complaint Survey (CCR# 2007002726) of the Respondent facility. 20. That based upon interviews the Respondent failed to provide care and services appropriate to the needs of residents, the same being in violation of law. 21. That the Petitioner’s representative interviewed resident number eleven (11) on May 15, 2007 who indicated that on one (1) or two (2) occasions staff had forgotten to give the resident medications and that sometimes the medications are late. 22. That the Petitioner’s representative interviewed resident number nine (9) on May 15, 2007 who indicated that a couple of nights ago, the staff forgot to give the resident the resident’s medications until the resident finally contacted the staff to get the medications at 9 PM for the medications that should have been taken at 5 PM. 23. That the Petitioner’s representative interviewed Respondent’s medication technician on May 15, 2007 who indicated as follows: a. That she cannot always get the meds to the residents on time due to having to give one hundred eighteen (118) residents medications and being either the only medication technician on duty and just one (1) other medication technician on duty; b. That if medication assistance is disrupted by having to assist a resident or even to talk to a resident or family member, medications won't be given out in a timely manner; c. That when she relieved the 11-7 shift one day last week the out-going medication technician stated that when he came on duty there were many red tabs sticking out of the medication observation record (MORs) indicating that several evening shift medications had not been given. 24. That the Petitioner’s representative interviewed a resident’s family member on May 14, 2007 who indicated that the family member had been informed by Respondent’s staff that resident medications were not distributed on March 11, 2007 and that resident medications are usually not provided in a timely manner. 25. That the Petitioner’s representative reviewed resident medication administration records on May 15, 2007 and noted that there were no blanks on any day or shift to indicate that meds had not been given and were all initialed to indicate the medications had been given contrary to interviews of the residents and staff. 26. That the Petitioner’s representative interviewed a resident’s family member on May 14, 2007 who indicated that on the evening of March 4, 2007, the family member attempted to call the facility on numerous occasions to find out the status of a relative who had been sent to the hospital and no one answered the phone and that it was not unusual to be unable to get through to the facility in the evenings. . 27. That the failure to timely provide assistance with medications is a failure to provide care and services and is in violation of law. 28. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 29. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2006). 30. That the Agency provided a mandated correction date of June 15, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2006). COUNT Il 31. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 32. That pursuant to Florida law, every resident of a facility shall have the right to live in a safe and decent living environment, free from abuse and neglect, and be treated with consideration and respect with due recognition of personal dignity... Section 429.28(1), Florida Statutes (2006). 33. That on May 15, 2007, the Agency conducted a Complaint Survey (CCR# 2007002726) of the Respondent facility. 34. That based upon confidential resident interviews, Respondent did not ensure that residents were treated with respect, consideration and dignity and were free from verbal intimidation, the same being in violation of law. 35. That the Petitioner’s representative confidentially interviewed three (3) alert and aware residents on May 15, 2007 and noted as follows: a. That certain staff were described as nasty and rude; b. That one of the residents said that staff refused to assist the resident on one recent occasion telling the resident to "get it yourself," and that the staff was rude and argumentative to his/her roommate who was unable to locate an item of necessity; c. That another resident stated that these staff were rough while assisting him/her with personal care; d. That this resident said that he/she did not complain to management due to fear of retaliation; e. That this resident wanted to move to another facility due to these particular staff who make the resident "feel like crap," order him/her around, and tell him/her to hurry due to the resident’s physical limitations; f. That this resident uses a mobility device; g. That this resident said that s/he tries to not to be “a pain” so the staff would leave him/her alone; h. That another resident had received a wrong entree for dinner and when requested the ordered entree one of the staff said, "Well, you're going to eat it anyway;" i. That another resident also said that a while ago s/he had problems with certain staff who were nasty, though this has not been lately. 36. That the Petitioner’s representative spoke with a resident’s family member who indicated that they were not notified when a resident had fallen and subsequently hospitalized, did not know of the event until the physician called this family member, and when the family member attempted to call the facility (about 8:30 PM) to find out which hospital the resident was taken to, was unable to get anyone at the facility to pick up the telephone. 37. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 38. That the Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2)(b), Florida Statutes (2006). 39. That the Agency provided a mandated correction date of June 15, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2006). COUNT IV 40. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 4l. That pursuant to Florida law, the administrator is responsible for monitoring the continued appropriateness of placement of a resident in the facility. R. 58A-5.0181(4)(d), Florida Administrative Code. That pursuant to Florida law, the owner or administrator of a facility is responsible for determining the appropriateness of admission of an individual to the facility and for determining the continued appropriateness of residence of an individual in the facility. A determination shall be based upon an assessment of the strengths, needs, and preferences of the resident, the care and services offered or arranged for by the facility in accordance with facility policy, and any limitations in law or rule related to admission criteria or continued residency for the type of license held by the facility under this part. A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the resident’s representative or designee or the resident’s family, guardian, surrogate, or attorney in fact. In the case of a resident who has been placed by the department or the Department of Children and Family Services, the administrator must notify the appropriate contact person in the applicable department. §429.26(1), Florida Statutes (2006). The admission criteria are provided in Florida law, inter alia, as follows: An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: (a) Be at least 18 years of age. ... (c) Be able to perform the activities of daily living, with supervision or assistance if necessary. ... (g) Not be a danger to self or others as determined by a physician, or mental health practitioner licensed under Chapters 490 or 491, F.S. (h) Not require licensed professional mental health treatment on a 24-hour a day basis. (n) Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator shall base the decision on: 1. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, F.S., and subsection (2) of this rule; 2. The facility’s admission policy, and the services the facility is prepared to provide or arrange for to meet resident needs... Rule 58A-5.0181(1), Fla. Admin. Code. 42. — That on June 6, 2007, the Agency conducted a Complaint Survey (CCR #2007006147) of the Respondent facility. 43. That based upon the review of records and interview, the Respondent failed to ensure one (1) of seven (7) sampled residents was appropriate for continued residency where the resident displayed inappropriate sexual behavior and was permitted to remain in the facility despite staff knowledge of the resident's inappropriate behavior, Respondent’s inability or intentional failure to meet the supervision, treatment, and or the placement needs of the resident, the same being contrary to the placement and continued residency requirements of law. 44. That the Petitioner’s representative reviewed the Respondent’s records relating to resident number one (1) during the Petitioner’s survey and noted the following: a. That the resident was admitted to the facility on February 23, 2007 from the hospital; b. That the hospital documentation reflected that the resident had undergone a psychiatric evaluation dated February 15, 2007 which states that the resident was admitted to the hospital on a Baker Act after the resident was found to be fondling residents and sexually preoccupied at another assisted living facility; That the resident's health assessment dated February 16, 2007 indicates no memory impairment type diagnosis and notes under cognitive or behavioral status that the resident is alert - forgetful and has vascular dementia and that the resident is independent in all activities of daily living; . That Respondent’s chart notes for the resident contained an entry dated February 22, 2007 which states that an admission meeting was held with the resident's family, that the resident is pleasant, has moderate dementia, and will wander; That the chart note does not make mention of the sexual behavior for which the resident underwent involuntary psychiatric admission nor does it mention any special precautions or supervision to be provided by facility staff; That the resident was admitted to the facility on February 23, 2007 into the unsecured assisted living unit; . That a chart note entry dated March 17, 2007 at 2:35 p.m. records that the resident was found on top of another resident, resident number two (2), and recorded the resident stated we are two consenting adults; . The note reflects that the resident was removed from the room of resident number two (2) and resident number one’s (1) family was contacted; That the resident’s records contained an informed consent form for sexuality with dementia completed on March 19, 2007 by the resident's power of attorney; That this form states that the resident has begun to make sexual advances towards members of the opposite sex and has begun to engage in inappropriate sexual 12 conversations; that the facility does not provide twenty-four (24) hour supervision of its residents; that residents are often left unattended and/or are able to walk into other residents rooms and common areas without facility personnel being present; that the resident’s power of attorney consented to the resident engaging in sexual activity in the community; that the facility will seek an informed consent from the resident the community believes resident number one (1) has shown a sexual interest in; and lastly provides "If the Community is unable to obtain such consent, the undersigned agrees that for the protection of other residents, the Resident will be asked to immediately leave the Community and/or the responsible party will need to provide a 24 hour sitter (at their own cost) until the Resident leaves.” 45. That the Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the petitioner’s survey and noted the following: a. That a chart note entry dated March 17, 2007 at 2:35 p.m. indicates that the resident was found lying in the supine position on bed with pants and underwear off; that resident number one (1) was on top of resident number two (2) with his/her pants down; that resident number one (1) stated that "we are both consenting adults;" that resident number two (2) was asked if s/he was compliant and stated yes; b. That the family of resident number two (2) was contacted in regards to this incident; c. That the resident’s health assessment dated December 14, 2006 indicated a diagnosis of hypertension, osteopenia, Parkinson's, and depression; d. The assessment reflects that the resident requires assistance with ambulation, bathing, dressing, and toileting, while requiring supervision with grooming and transferring and was independent with eating; e. That absent from the records of resident number two (2) was any indicia of the resident’s consent to sexual activity with resident number one (1). 46. That the Petitioner’s representative interviewed resident number two (2) on June 6, 2007 who indicated as follows: a. That the resident recalls the incident with resident number one (1); b. That resident number one (1) first entered the room of resident number two (2) and started pleasant conversation; c. That at some point resident number one (1) grabbed hold of resident number two (2); d. That resident number one (1) was overpowering and forceful and that it was very frightening; e. That resident number two (2) was not a willing participant and was relieved when staff came to the room and removed resident number one (1); f. That no intercourse had occurred; g. That resident number one (1) continued to come back after that incident but resident number two (2) would turn the call light on and staff would come and remove resident number one (1); h. That resident number two (2) had heard that resident number one (1) was trying to get into other residents rooms as well. 47. That the Petitioner’s representative conducted a confidential telephone interview on June 7, 2006 with a staff member who cares for resident number two (2) who indicated that the resident’s mental capacity fluctuates due to the progression of the Parkinson's disease. 48. That the Petitioner’s representative interviewed the Respondent’s administrator on June 6, 2007 who indicated : a. That she has only been at the facility for a couple of weeks; b. That she is not aware of any other resident signing a form purporting to consent to sexual activity; c. That based on this information, she believes that arrangements should have been made for the discharge of resident number one (1); d. That there is no discharge information or notice in the record. 49. That the Petitioner’s representative interviewed the Respondent’s assistant administrator on June 6, 2007 who indicated as follows: a. That the family of resident number one (1) did get a twenty-four (24) hour sitter for the resident, but at some point the family could no longer afford the private sitter; b. That at that time, the decision was made to move the resident into the secured dementia unit and to begin hormone treatment to decrease sexual drive and behavior; c. That the resident was moved to the dementia unit on April 23, 2007 and remained there until June 5, 2007 when the resident was Baker Acted; d. That she and the administrator had just found out on June 5, 2007 that resident number one (1) had never started the planned hormone therapy. 50. That the Petitioner’s representative interviewed Respondents nine (9) resident care assistants during the Petitioner’s survey who indicated as follows: a. That these care assistants all work on the Respondent’s secured unit and cover all three (3) shifts; That resident number one (1) did not appear to be cognitively impaired, was independent with all activities of daily living, would microwave his/her own meals, and used a computer in his/her room; That no other residents on the secured unit are able to do these types of activities and they could not understand why resident number one (1) was placed in the secured unit with such "defenseless" people; That no staff members were specifically assigned to provide 1:1 care to resident number one (1), but they knew they had to keep a close eye on this resident as s/he "was always trying to get" with residents of the opposite sex; That the resident was very sneaky about this and would wait until staff were caring for someone and out of the area before s/he would go and get a resident or call on a resident to come to his/her room. One staff member stated that she recently found resident number one (1) with resident number five (5), both residents with their pants down and touching one other; This staff member also stated that she had found resident number one (1) with resident number four (4) when resident number one (1) was kissing the other resident and had his/her fingers inside of the resident's diaper; In addition, this staff member stated she had found resident number one (1) on June 5, 2007 touching resident number six (6) in the resident’s bed; i. Another staff member revealed she had found resident number one (1) in bed groping and kissing resident number five (5) who had his/her pants down; j. This staff member also stated that she found resident number one (1) in bed groping both residents numbered five (5) and six (6) on June 2, 2007; k. Several of the staff members stated they had reported the behavior to management but nothing was done until around June 5, 2007 when the resident was placed on half hour checks and then later Baker Acted due to this behavior. 51. That the Petitioner’s representative reviewed Respondent’s records for the residents observed with resident number one (1) by staff and resident inside of the secured unit and noted the following: a. Resident number four (4): i. The health assessment dated December 11, 2006 indicated a diagnosis of dementia and is confused; ii. The health assessment indicates the resident requires total care with bathing, dressing, and grooming and assistance with eating, toileting, and transferring and is able to ambulate with supervision; b. Resident number five (5): i. The health assessment dated November 10, 2006 indicated the following relevant diagnoses: cerebral vascular accident, dementia, and seizures; ii. The health assessment indicates that the resident requires assistance with all activities of daily living. c. Resident number six (6): 17 i. The health assessment dated November 12, 2006 indicated the following relevant diagnosis: Dementia and Alzheimers; ii. The health assessment indicated that the resident requires assistance with all activities of daily living with the exception of eating for which the resident requires total care. 52. That resident number one (1) was inappropriate for initial or continued residency in this assisted living facility for the following reasons: a. The resident was known to engage in sexual behaviors without other resident’s consent; b. The resident’s behavior presented a danger to self or others; c. The Respondent could not or would not provide services, including supervision, to meet the resident’s needs; d. That the resident’s presence presented a risk of abuse to other residents. 53. That the Respondent failed to appropriately evaluate resident number one (1) for residence in the facility in light of the initial information reflecting the resident’s inappropriate behavior and the Respondents ongoing inability or unwillingness to adequately address the supervision or psychiatric needs of the resident necessary to prevent such behaviors. 54. That the Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 55. The Agency provided Respondent with a mandatory correction date of June 9, 2007. 18 56. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(a), Florida Statutes (2006). COUNT V 57. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. That pursuant to Florida law, facilities shall offer personal supervision, as appropriate for each resident. R. 58A-5.0182(1), Florida Administrative Code. 59. That on June 6, 2007, the Agency conducted a Complaint Survey (CCR #2007006147) of the Respondent facility. 60. That based upon the review of records and interview, the Respondent failed to provide supervision appropriate to the needs of each resident in its failure to supervise a resident who displayed inappropriate sexual behavior failing to meet the self protection needs of the resident and to supervise other residents who were or may have been victims of the resident’s inappropriate behaviors, the same being in violation of law. 61. The Agency re-alleges and incorporates paragraphs forty-four (44) through fifty-one (51) as if fully set forth herein. 62. That the Respondent had clear knowledge of the behaviors of resident number one (1) and failed to take steps to provide the supervision required to ensure the safety and well-being of the resident and other residents of the facility including, but not limited to, the failure to 19 supervise on a one-to-one basis, placing vulnerable residents residing in the secured dementia unit in harms way. 63. That the Respondent took no steps to meet the safety and security needs of residents in a secure unit suffering from cognitive impairments when Respondent chose to place resident number one (1) in the secured unit with said cognitively impaired residents. 64. That this failure is in violation of law. 65. | The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 66. The Agency provided Respondent with a mandatory correction date of June 9, 2007. 67. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(a), Florida Statutes (2006). COUNT VI 68. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 69. That pursuant to Florida law, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or 20 the Constitution of the United States as a resident of the facility. Every resident of a facility shall have a right to, inter alia, live in a safe and decent living environment, free from abuse and neglect, and be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. §429.28(1), Florida Statutes (2006). 70. That on June 6, 2007, the Agency conducted a Complaint Survey (CCR #2007006147) of the Respondent facility. 71. That based upon the review of records and interview, the Respondent failed to ensure residents were free from sexual abuse by another resident. 72. The Agency re-alleges and incorporates paragraphs forty-four (44) through fifty-one (51) as if fully set forth herein. 73. | That Respondent knew resident number one (1) exhibited sexually inappropriate behaviors with other residents and chose to place the resident in a secured unit with a resident population of dementia and other cognitive deficiencies, allowing resident number one (1) access to the other residents and the abusive behaviors of resident number one (1). 74, That residents in the Respondent’s secured unit were known by Respondent to suffer from cognitive deficits and were in a secured unit at least in part due to said deficits which would prohibit the residents from engaging in consensual sexual behaviors, subjecting residents to abuse and placing them at risk of abuse. 75. That Respondent knew resident number one (1) exhibited sexually inappropriate behaviors with other residents and chose to place the resident in a secured unit with a resident population of dementia and other cognitive deficiencies, thereby intentionally or negligently creating an unsafe environment for the other residents of the unit who were subjected to inappropriate activities of resident number one (1) where the Respondent failed to provide 21 supervision appropriate to the behaviors of resident number one (1). 76. The Agency determined that this deficient practice was related to the operation and maintenance of the facility, or to the personal care of the resident, which the Agency determined presented an imminent danger to the resident or a substantial probability that death or serious physical or emotional harm would result therefrom and cited the Respondent for a State Class I deficiency. 77. The Agency provided Respondent with a mandatory correction date of June 9, 2007. 78. That pursuant to § 429.19(2)(a), Florida Statutes (2006), the Agency is authorized to impose a fine in an amount not less than five thousand dollars ($5,000.00) and not exceeding ten thousand dollars ($10,000.00) for each violation. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(a), Florida Statutes (2006). COUNT VU 79, The Agency re-alleges and incorporates Paragraphs one (1) through five (5) and Counts IV through VI as if fully set forth herein. 80. That pursuant to Section 429.19(10), Florida Statutes (2006), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section.429.28(3)(c), Florida Statues (2006), to verify the correction of the violations. 22 81. That on or about June 6, 2007, the Agency conducted a complaint investigation at the Facility that resulted in violations that were the subject of the complaint to the Agency. 82. That pursuant to Section 429.19(10), Florida Statues (2006), such a finding subjects the Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or $500.00. 83. That Respondent is therefore subject to a complaint survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(10), Florida Statutes (2006). WHEREFORE, the Agency intends to impose an additional survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(10), Florida Statutes (2006). COUNT VIII 84. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 85. The Agency re-alleges and incorporates the entirety of this complaint as if fully set forth herein 86. That the Agency may revoke any license issued under Part I of Chapter 429 Florida Statutes (2006) for the citation of one (1) or more cited Class I deficiencies, three (3) or more cited Class II deficiencies, or five (5) or more cited Class III deficiencies that have been cited on a single survey and have not been corrected within the specified time period. Section 429.14(1)(e) Florida Statutes (2006). 87. That the Respondent has been cited with three (3) Class I deficiencies on an Agency survey of June 6, 2007. 23 88. That the Agency may revoke any license issued under Section 408.815(1)(d), Florida Statutes (2006) for a demonstrated pattern of deficient performance. 89. That the Respondent has been cited with three (3) Class I deficiencies on an Agency survey of June 6, 2007 and with multiple deficient practices cited within the body of this complaint and its attachment. 90. That based thereon, the Agency seeks the revocation of the Respondent’s licensure as its primary relief. 91. That should the Respondent admit the facts herein by action or inaction, the Petitioner shall enter an Order revoking the Respondent’s license. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815(1)(d) and 429.14(1)(e) , Florida Statutes (2006). . Respectfully submitted this 2b day of June, 2007. ag. Walsh II ‘Bar. No. 566365 Sefiior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727-552-1525 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. 24 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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 ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7004 1350 0004 2776 1229 on June ZG_, 2007 to John F. Gilroy III, Esq., 1435 East Piedmont Drive, Suite 215, Tallahasse, FL 32308 and by U.S. Mail to Horodecka, Administrator, Hearthstone at Carrollwood, 2626 West Bearss Avenue, Carrollwood, FL 33618. Copies furnished to: John F. Gilroy III, Esq. Counsel for Respondent 1435 East Piedmont Dr. Suite 215 Tallahassee, Florida 32308 (USS. Certified Mail) Kathleen Varga Facility Evaluator Supervisor 525 Mirror Lake Drive, 4" Floor St. Petersburg, Florida 33701 (Interoffice) Joanna, Horodecka Administrator Hearthstone at Carrollwood 2626 West Bearss Avenue Carrollwood, Florida 33618 (U.S. Mail) Thomas J. Walsh II, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) 25 USPS - Track & Confirm Page 1 of 1 Ea esas a wi Home | Help | Sign | zh, ga Confirm FAQs 7, Search Results Label/Receipt Number: 7004 1350 0004 2776 1229 Status: Delivered Track & Confirm Enter Label/Receipt Number. Your item was delivered at 1:35 PM on June 29, 2007 in TALLAHASSEE, FL 32308. Notification Options Track & Confirm by email * Get current event information or updates for your item sent to you or others by email. { G> } fre POSTALINSPECTORS sitemap contactus governmentservices jobs National & Premier Accounts : is Preserving the Trust Copyright © 1999-2004 USPS. All Rights Reserved. Terms of Use Privacy Policy http://trkcnfrm1.smi.usps.com/PTSInternet Web/InterLabelInquiry.do 07/23/2007

Docket for Case No: 07-003476