STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2010001995 Return Receipt Requested: v. 7002 2410 0001 4236 3234 7002 2410 0001 4236 4484 ARC DELRAY BEACH, LLC d/b/a HOMEWOOD 7002 2410 0001 4236 4491 RESIDENCE AT DELRAY BEACH, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (‘“AHCA”), by and through the undersigned counsel, and files this administrative complaint against ARC Delray Beach, LLC d/b/a Homewood Residence at Delray Beach (hereinafter “Homewood Residence at Delray Beach”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2009), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $10,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2009), for the protection of public health, safety and welfare. Filed May 21, 2010 9:29 AM Division of Administrative Hearings. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2009), and Chapter 28-106, Florida Administrative Code (2009). 3. Venue ilies pursuant to Section 120.57, Florida Statutes (2009), and Rule 28-106.207, Florida Administrative Code (2009). 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 429, Part I, Florida Statutes (2009), and Chapter 58A-5 Florida Administrative Code (2009). 5. Homewood Residence at Delray Beach operates a 94-bed assisted living facility located at Homewood Residence at Delray Beach. Homewood Residence at Delray Beach is licensed as an assisted living facility under license number 9881. Homewood Residence at Delray Beach 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 HOMEWOOD RESIDENCE AT DELRAY BEACH FAILED TO ENSURE THAT THE ENVIRONMENT WAS MAINTAINED IN A SAFE AND SANITARY MANNER. RULE 58A-5.023(1) (a), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Homewood Residence at Delray Beach was cited with one (1) Class I deficiency as a result of a licensure survey and a complaint investigation survey that were conducted on March 12, 2008 and December 30, 2009. 8. A licensure survey was conducted on March 12, 2008. Based on observations and interview, during the tour of the facility with the facility's Director of Wellness during the initial tour of the facility conducted on 03/12/08 at approximately 10 AM, it was determined that the facility failed to ensure that the environment was maintained for the safe and sanitary care of the residents at the ‘facility. The findings include the following. 9. During the tour of the Dementia Building conducted on 3/12/08 at approximately 10 AM, the Kitchen areas on the 1°* and gna floors, the Beauty Salon and the Laundry Room were observed unattended and unsecured with free accessibility to all. During the tour, one resident was observed in the surrounding area. Residents were observed unsupervised in these areas with these unsafe conditions: 10. Kitchen Area - 1°* floor (between the Dining Room and the Common Area- all one room) was left unsecured and in plain view: a. Large Coffee Pot Machine on the counter with hot coffee inside 1 pot (both burners on). 7 b. Steam Table with 3 food warmer sections filled with boiling hot water. 11. Beauty Salon - 1% floor was left open and in plain view: a. Hot curling irons and other electrical items left on. b. Numerous hair chemical products. 12. Laundry Room - 18* floor was left open and in plain view: a. 3 laundry baskets with soiled linen. b. 1 large linen bin/garbage bin. Cc. Cleaning products and laundry cleaning products. 13. During a tour of building #1 with the Administrator of the facility at approximately 10 AM, the following unsecured medications were observed: a. Room 1204- 2 sample boxes of Razadyne ER 8 mg, each box containing 28 tablets were observed unsecured on a table. The boxes of medications were not labeled with the resident's name or directions for use. One of the two residents in this room, upon interview, stated the other resident's (wife's) physician gave him/her a sample to try. Four bottles of Fluticasone-50 mcg nasal spray were also observed unsecured and unlabeled. The two residents occupying this room both require assistance with their medications. b. Room 1109- The resident in this room did not properly secure the following medications: These bottles of medications were found laying in plain sight on the resident's bed-Lasix 20 mg-bottle was empty; Fish Oi1 capsules, B complex vitamins, Multi-vitamins, Aspirin 81 mg; Metolazone 5 mg every other day; and Potassium CL 20 meq daily. The room was not locked and the medications were not secured out of sight. 14. During a tour of Building #3 the following was observed: Room #3108 - was unattended’ with the room door open. During a further observation of Room #3108, it was noted that the designated medication drawer was unlocked, unsecured, and easily accessible containing the following medications: Aspirin, Atenolol, Lisinopril, Omeprazole, Ibuprofen, Loperamide, Seroquel, Zoloft, Entocort EC. 15. Upon interview with the Director of Wellness, at approximately 11:00 AM, it was revealed that Resident #1, the occupant of Room #3108, suffers from memory impairment and receives assistance from facility staff with his/her self- administered medications, as previously mentioned. 16. Upon further observation during the tour of Building #3, it was noted that the "Caregiver Associate Room", located on the 274 floor, was observed unlocked and unsecured. 17. There were several hazardous materials observed in this room, including: three 1-gallon containers of " Brown Out " stain remover, three 1-gallon containers of "Citra Quick" paint and ink stain remover, and one 1-gallon container of ceiling stain and mildew remover. 18. The mandated date of correction was designated as April 12, 2008. 19. A complaint investigation survey was conducted on December 30, 2009. Based on record review and interview, it was determined that the facility failed to maintain. a safe environment for 1 out of 3 sampled residents (Resident #1), resulting in the death of a resident. The findings include the following. 20. Record review revealed Resident #1 was admitted to the facility on 11/16/09. Review of the resident’s health assessment signed and dated by his/her physician on 10/14/09 documented the following diagnosis: Dementia, CAD s/p MI, SSS and s/p Pacer. The health assessment indicated that the resident "needs assistance" with self-care tasks and requires "daily oversight" in regards to the resident's general oversight such as observing the individual's well being, whereabouts, and reminders of important tasks. 21. Review of a physician note dated 12/18/09 revealed on 11/15/09, the day prior to admission to the facility, the vesident was "found eating paste at home". 22. Further record . review and interview with the Administrator on 12/30/09 revealed during the early morning hours of 12/28/09, Resident #1 had trouble sleeping and was reportedly sitting in the TV area of the memory care secured unit located on the second floor, under the care of Care Associates #1 and #2. Care Associate #1 was reportedly in another resident's room providing toileting care. Further interview revealed Care Associate #2 left the TV area to assist Care Associate #1 with toileting care, leaving Resident #1 unattended. 23. During further investigation, the Administrator reported that Resident #1 gained access to the satellite kitchen (located on the second floor of the memory care secured unit) through a split door. It was reported the top portion of the split door was open and the bottom half was locked. The resident reportedly reached through the door, unlocked it and obtained access to dishwasher detergent after removing a hosing container connected to the dishwasher inside of a cabinet. 24. Further interview with the Administrator revealed that at approximately 2:30 AM, she received a phone call from a care associate, stating that she found Resident #1 standing in the satellite kitchen over a container of dishwasher detergent. The care associate stated the resident was unable to tell her if he/she ingested any of the liquid. The Administrator stated she advised the associate to look in the resident's mouth for any redness, 25. At 2:35 AM, the care associate called the Administrator again and reported Resident #1's lips were swollen and pink. The Administrator then advised the care associate to call 911. The paramedics arrived at the facility and found the resident lying on the couch in the living room area drooling. The resident was assessed and the paramedics called poison control. The paramedics transported the resident to the hospital for evaluation. The Administrator was reportedly on site at approximately 2:50 a.m. The resident’s family was notified of the incident at approximately 2:55 a.m. 26. The Administrator reported she met the resident's family at the hospital where the family gave consent to perform an endoscopy. After leaving the hospital, the Administrator reported that she called the hospital later on that morning and was informed the resident suffered from 2™ and 3*4 degree burns of the esophagus; the resident was placed on a ventilator. The Administrator reported the resident passed away due _ to complications on 12/29/09, as a result of Resident #1's consumption of the dishwasher detergent. 27. The surveyor conducted. an exit conference with the regional office representative on 12/30/09 at approximately 11:30 AM and the findings were reviewed. 28. During a telephone interview with the a representative from Department of Children and Families on 01/05/2010 at approximately 11:30 AM, it was revealed the medical examiner's office confirmed that Resident #1's death was caused by the consumption of the dishwasher detergent. This is a repeat deficiency from the survey of March 12, 2008. 29. Based on the foregoing facts, Homewood Residence at Delray Beach violated Rule 58A-5.023(1) (a), 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 Homewood Residence at Delray Beach on Count I. 2. Assess an administrative fine of $10,000.00 against Homewood Residence at Delray Beach 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 (2009). Specific options for administrative action are set out in the attached Flection 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 ORDER BY THE AGENCY. 10 Ir YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER LMA A, a Esq. Wea-cose Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. 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 Lori Nelson, Administrator, Homewood Residence at Delray Beach, 8020 W. Atlantic Avenue, Delray Beach, Florida 33446; ARC Delray Beach, LLC, 330 N. Wabash, Suite 1400, Chicago, Illinois 60611; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this AO ~~ Jli22, Qlencarey, Lourdes A. Naranjo, Esq. day of see ( , 2010. 11 COMPLETE THIS SECTION ON DELIVERY D Agent {21 Addressee C., Date of Delivery He B. Received by (Printed nae] 7 WYes” D. Is delivery address different from item 4 N If YES, enter delivery address below: lo n A omplete & Complete items 1, 2, and 3. Also comp! iter 4 If Restricted Delivery Is desired. m@ Print your name and address on the reverse turn the card to you. so that we can re Ou piace, @ Attach this card to the back of the or on the front if space permits. _ 1, Article Addressed to: hori, TL Henwastid Ausidonce 6s Daley Gop i) Grtankes, Cerne . Daiay Pench. Fito ab Certliled Foe Retum Reclept Fe (Endorsement Reduired) Restricted Delivery Fee (Endorsement Required} . 9, Service Type Ci certified Mail (1 Express Mall 1 Registered 1 Return Receipt for Merchandise Di insured Mail = 6.0.0, sted Delivery? (Extra Fee) LOE 144A 7002 2410 O001 423b 3234 (itansfer from service label). *- ~ SENDER: COMPLETE THIS SECTION ", een CE) Agent : \ 0 Addressee B,,Recelved by ( Printed Name Kolatece J oe bifte C. Date of Delivery rhb rh) D. Is delivery address differant fromitem 12 C1 Yes {f YES, enter delivery address below: [1 No @ Complete items 1, 2, and 3. Aliso complete item 4 If Restricted Delivery Is desired. B Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mallplece, or on the front if space permits. 1, Article Addressed to: ARC Daleay Meocl, Le 43 N. Wurdle. ~ Guat, (Hoo Chics ‘Mona, Postage | Cartitled Feo Return Reclapt Fee (Endorsement Required) Restricted Delivery Feo (Endorsemont Required) 3. Service Type C1 Certifted Mall ) Express Mal! C1 Registered CI Return Recelpt for Merchandise Cl insured Malt 1 C.0,D. 4nd Delivery? (Extra Fea) 1] Yes earl 2440 nooL 4e3b 4HOH sanaal WA eet neue ene IA 4 Agent i Addressee Total Postage & Fees ~bslngy Deaeks..LaL FO02 2410 OOOL 423b 4444 ; 7 SENDER: COMPLETE THIS SECTION ™ Complete Items 1, 2, and 3. Also complete Item 4 If Restricted Delivery Is desired, ™ Print your name and address on the reverse so that we can return the card to you. A. Signature : 8. Recslgt by (Pri te} Name) Sug], oP m ® Attach this card to the back of the mallpiece, a > i or on the front If space permits. 3 Lhe het hl Mat tes 7 D. Is delivery address differertt fort 3 ' 1. Articte Addressed to: onal YES: enter, delivery address bel —_ 7 . ~ ee De ENB SRM eas tthe [=] , a Corperactesn Suolin, ™ a a eter Reclept Fea = i ee marsement Required) asn Souths Pore Lallond Read Pesticted Delivery Fe . * g (Endorsement Reauiredh ep. 4 af ‘ } cr "1 . {) 33 EYL 4 mu ‘ 4D aed = 3. Service Type Total P fi , a ru ‘al Postage & Fees C] Certifled Mall [1 Express Mall Qo Cl Registered 1 Return Recelpt for Merchandise e (1 tnsured Mail == G.0.D. «_™ ** ‘ed Delivery? (Extra Fea) TI Yes 7oo2 2410 OOO 4236 44a gas pa Ee I The Grstirtomsavcenwy Yas ume Aaa Bonz a Daa . PS Farm 88110 Fehruary enna Domestic Return Recelot 7?) A are 402595-02-M-1540

Docket for Case No: 10-002794

Orders for Case No: 10-002794