we _ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION . STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . Case No.: 2012013728 433 ORANGE DRIVE, INC. d/b/a GRAND VILLA OF ALTAMONTE SPRINGS, Respondent, ADMINISTRATIVE COMPLAINT . The State of Florida Agency for Health Care Administration (hereinafter “Petitioner” or “Agency”), by and through the undersigned counsel, files this Administrative Complaint against 433 Orange Drive, Inc, d/b/a Grand Villa of Altamonte Springs (hereinafter “Respondent’) , putsuant to Section § 120. 569 and Section § 120.57, Fla, Stat. (2012), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $1,000.00 based upon _ ‘one State Class II deficiency pursuant to Section § 429.19(2)(b),.Fla. Stat. (2012). JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to Section § 20.42, Section § 120.60.and Chapters 408, Part Il, and 429, Part I, Fla. Stat, (2012); 2. __ Venue lies pursuant to Florida Administrative Code Rule 28-106.207. | . PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable 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. 4, Respondent operates a 180-bed assisted living facility (hereafter “ALF”) located at 433 Orange Drive, Altamonte Springs, FL 32701, and is licensed as an ALF, license number 7103 (hereafter “Facility”), 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 - tag A0025 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. Pursuant to Florida law: Resident Care Standards: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. SUPERVISION. Facilities shall offer personal supervision, as appropriate . for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5. 020, RAC. | (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident's whereabouts. The resident may travel independently in the community. (d) Contacting the resident's health care provider and other appropriate party such as the resident's family, guardian, health care surrogate, or case - manager if the resident exhibits a significant change; contacting the resident's family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any-illnesses which resulted in medical attention, major incidents, changes in the method of ‘medication administration, or other changes which resulted in the provision of additional services. Fla, Admin. Code R. 58A-5.0182(1) eae Resident bill of rights (1) 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 the Constitution of the United States as a resident of a facility. Every resident of a ~ facility shall have the right to: “@) Live ina safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical; of an-inftingertient upon the rights of other residents. (d) Unrestricted private communication, including receiving and sending: unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations, (e) Freedom to participate in and benefit from community services and activities and to achieve the highest possible level of independence, autonomy, and interaction within the community. ‘(£) Manage his or her financial affairs unless the resident or, if applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided in s. 429.27. (g) Share a room with his or her spouse if both are residents. of the facility. (h) Reasonable opportunity for regular exercise several times a week and ‘to be outdoors at regular and frequent intervals except when prevented by inclement weather. . (i) Exercise civil and religious liberties, including the right to independent personal decisions, No religious beliefs or practices, norany attendance at religious services, shall be imposed upon any resident, (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. (k) At least 45 days’ notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days’ notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good cause in-a court of competent jurisdiction. (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. Section 429.28, Fla. Stat. (2012) 8. On October 25, 2012, the Agency conducted a biennial re-licensure survey. including Limited Nursing Services (LNS) of Respondent’s assisted living facility and found it out of compliance with the above statute and rule. 9. Based on observation, record review and an interview, the facility failed to offer appropriate personal supervision for a resident with a history of exit-seeking and elopement. Findings included: Resident #6 had a Health Assessment Form 1823 dated August 17, 2012, which listed diagnoses of denientia and hypothyroidism. The cognitive or behavior status was listed as: “exit-seeking, confusion, forgetful." Special precautions included: "impaired safety awareness due to-dementia, exit-seeking." The resident was admitted into the facility on August 16, 2012. Resident 6's condition log noted the following: 8/17/12, 8 AM 8/18/12, 8 AM 8/20/12, 12:30 PM 8/21/12, 9 AM 8/22/12, 7 AM ' 8AM 8/22/12, 12 PM 8/22/12, 7:30 PM: 8/23/12 Exit-seeking, alert but pleasantly confused. - Continues exit-seeking. Pleasantly confused, Continues exit-seeking. States he is going to call his lawyers and have me arrested. Very confused. Refused breakfast and lunch stating I am going home because my wife is sick. Resident continues exit-seeking, Refused food and drink for 3 days. The resident’s doctor called and prescribed _ Namenda and Levothyroxine. Resident started Ativan and actually slept. - Behavior much improved, Exit-seeking has stopped. Much more relaxed. Resident has started exit-secking again, Not easily redirected and somewhat agitated. Returned with his belongings to the elevator area. Keeps telling me his wife had surgery and he must get home. This resident is insisting on leaving our facility. All caregivers and Grand Villa departments notified that he is standing by the elevators. Resident was nowhere to be found in the memory support unit, Elopement drill process was put into effect. All management notified. “911” was called. Staff searched the campus and also sent out vehicles to search nearby streets and businesses, The search continued until the resident was located by the police at 9:10 AM. We were immediately notified and resident was transported to the emergency room for examination, The resident did not return to the facility. The facility did not have documentation to show that interventions were in place to ensure an awareness of the resident's whereabouts. He was essentially allowed to leave the secured memory care unit after daily episodes of exit-seeking. ~ we During an interview, the administrator said that the staff did not know how the tesident- could have left the secured unit, because the doors were equipped with a lock which needed a code to enter or exit. Only the staff knew the code. After this event, the code was changed to increase security. 10. The Respondent failed to provide adequate care, supervision and services appropriate to _ meet-the needs of residents with a history of elopement and to ensure their safety through __- . properly functioning proactive measures. 11. The Agency determined that this deficient practice was related to the operation and. maintenance of the Facility, or to the personal care of Facility residents, and directly threatened the physical or emotional health, safety, or security of the Facility residents, 12. The Agency cited the Respondent for a Class II violation in accordance with Section 429,19(2)(b), Florida Statutes (2012). | , WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($1,000.00), against Respondent, an ALF in the State of Florida, pursuant to Section 429.19(2)(b), Florida Statutes (2012). NOTICE OF RIGHTS Respondent is notified of its right to request an administrative hearing pursuant to §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) 412-3630. 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 Administrative Complaint has been served by U.S. Certified Mail, Return Receipt No. 7011 0470 0000 7951 6 aes rod 3081, to Dennis Forte, Registered Agent, 13770 58" Street North, Suite 312, Clearwater, FL 33760, and by regular U.S, Mail to Jonathan S. McIntosh, Administrator, Grand Villa of Altamonte Springs, 433 Orange Drive, Altamonte Springs, FL 32701, this | } day of January, 2013, "525 Mirror Lake Dr.N; Sut 330H St. Petersburg, Florida 33701 (727) 552-1945; Fax: (727) 552-1440 4 ; : ; ; suzanne.hurley@ahca.myflorida.com ‘Copy to Lorraine Henry ~ USPS.com® - Track & Confitm™ - a Page | of 1 Englleh Gustomer Service USFS Mobile Reglater/8ignin mIUSPSCOM ‘Search USPS.com oF Track Packages Quick Tools . Ship a Package Send Malt Manage Your Mall Shop Business Sotutions Track & Confirm GETENDIL UPDATES = PRINY DETAILS ' | YOUR LABEL NUMBER SERVICE STATUSOR YOURITEM =—-OATE.A TINE LOCATION FEATURES { {ror osvoons0vestaose | Delivered | January 22,2013, 42pm | CLEARWATER, FL99760 | Conited Mail" . | ot i CLEARWATER, FL 33760 Notice Left (Business | January 12, 2013, 8:03am denuary 10, 2043 | eawr | PETERSBURG, FL. 39790 | i | sanuary 1B, 2049, 2:02am i | | ! 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Docket for Case No: 13-000741