STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012011203 Return Receipt Requested: Vv. 7009 0080 0000 0586 0063 ISLF WESTCHESTER OF SUNRISE, LLC d/b/a WESTCHESTER OF SUNRISE, 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 ISLF Westchester of Sunrise, LLC d/b/a Westchester of Sunrise (hereinafter “Westchester of Sunrise”), pursuant to Chapter 429, Part I, Chapter 408, Part II, and Section 120.60, Florida Statutes (2011), and alleges: NATURE OF THE ACTION 1, This is an action to revoke the specialty license, to impose an administrative fine of $5,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2011), for the protection of public health, safety and welfare, and to impose a survey fee in the amount of $500.00 pursuant to Section 429.19(2)(c) and 429.19(7), Florida Statutes (2011). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and Chapter 28-106, Florida Administrative Code (2011). 3, Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2011). 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, Chapter 408, Part II, Florida Statutes (2011), and Chapter 58A-5 Florida Administrative Code (2011). 5, Westchester of Sunrise operates a 150-bed assisted living facility located at 9701 W. Oakland Park Blvd., Sunrise, Florida 33351. Westchester of Sunrise is licensed as an assisted living facility under license number 7440, Westchester of Sunrise was at all times material hereto a licensed facility under the licensing authority of ANCA and was required to comply with all applicable rules and statutes. COUNTI WESTCHESTER OF SUNRISE FAILED TO ENSURE RESIDENTS LIVE IN A SAFE ENVIRONMENT, FREE FROM NEGLECT, WHICH RESULTED IN THE DEATH OF A RESIDENT. SECTION 429.28, FLORIDA STATUTES RULE 58A-5.0182(6), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE ~ FACILITY PROCEDURES STANDARDS) CLASS IT VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Westchester of Sunrise was cited with one (1) Class II deficiency as the result of complaint investigation surveys that were conducted on December 21, 2011 and Aril 2, 2012. 8. A complaint investigation survey was conducted on December 21, 2011, Based on observation, record review, and interview, it was determined that the facility failed to ensure residents live in a safe environment, free from neglect, which resulted in a death of a resident, for 1 of 4 sampled residents (Resident #3), The findings include the following. 9. Resident #3 was admitted to the facility on 9/24/11 with a diagnosis to include depression, anxiety, and osteoporosis. A review of the AHCA form 1823 dated 9/15/11 documented the resident ambulates independently with a walker. A review of the facility resident summary sheet dated 9/24/11 documents the resident's need for partial assistance witha walker while ambulating. 10. Continued review revealed a physician order dated 11/9/11 for Tylenol 650 mg daily three times a day and a rib series "dx: S/P Fall" (diagnosis: status/post fall). Further review of the resident's record revealed no documentation regarding a fall. 11. A review of the medication observation record (MOR) documented resident #3 began taking Tylenol 325 mg 2 tabs three times a day on 11/10/11. During an interview on 12/21/11 at 11:30 AM with the risk manager, Director of Nurses (DON) and administrator, the facility was unable to determine when the resident had a fall. 12. During an interview on 12/21/11 at 12:00 PM with the physician and the physician assistant, who wrote the order on 11/9/11, she stated the resident was complaining of rib pain "he said he had fallen but did not say when". The physician stated she reviewed an old X-ray from a left rib fracture, but since the resident was complaining of right rib pain and has a history of falls she ordered the rib series. 13. A review of the facility's adverse incident reports identified Resident #3 as an alert and oriented resident, who was discovered unresponsive on the floor in a vacant room. During an interview on 12/21/11 at 2:45 PM with the DON and risk manager, it was determined Resident #3 was found in a room that had been vacant since 10/3/11. The DON stated the door to vacant rooms should always be locked, During the interview, the maintenance director confirmed the facility had not done any work in the room between 10/3/11 & 11/11/11. The facility did not have a policy related to resident supervision or securing/monitoring vacant rooms. 14. The risk manager also reviewed documentation from staff reporting the resident did not come down for morning medications or breakfast on 11/11/11. Continued review noted the facility contacted the resident’s family to ask if they had taken the resident from the facility. _There is no evidence the facility implemented their elopement protocol. 15, According to the facility documentation the last time a staff member saw resident #3 was 11/10/11 at 9:00 PM. The resident was discovered on 11/11/11 at approximately 12:20 PM in a vacant room across the hall from their room. 16. During the interview at 3:45 PM on 12/21/1 1, the risk manager confirmed the room was vacant and stated the headboard of the bed was not attached to the wall, the bed was falling off the frame, and the resident was found unresponsive on the floor beside the bed with their head entrapped between the bars of the walker, A telephone interview on 12/21/11 with the medical examiner, revealed the cause of death as Asphyxia due to Cervical Compression, 17, A revisit survey was conducted on April 2, 2012. Based on observation, record review, and interview, it was determined that the facility failed to ensure residents live in a safe and decent living environment, free from abuse and neglect, ensure residents receive access to adequate and appropriate health care consistent with established and recognized standards within the community, and be treated with consideration and respect and with due recognition of personal dignity, for 1 of 4 sampled residents. (Resident #1) The findings include the following, 18. During an interview on 4/2/12 at 10:30 AM with Resident #1, the resident's room was observed in disarray, Empty food containers were on the resident's side table beside her nebulizer, food was in the draws of the wall unit, and in a box on the table. The resident's clothes were hanging on rods in broken boxes in the corner of the room. Four unidentified pills in a plastic bag were noted on the bedside table, and an empty insulin bottle and 4 empty pill bottles on the counter in the bathroom. The floor in the room was also soiled, 19, The resident stated she felt like nobody likes her, staff is mean, and nobody ever comes to check on her. The resident also Stated she is missing medication, the aides don't shower her, and she feels like "the staff are mad at me". Then the resident began crying. 20. At 10:35 AM on 4/2/ 12, the call light was tested and pressed by the surveyor with the facility manager present. Fifteen minutes later, at 10:45 AM, the call light was answered, The call light was answered by a med tech, who stated nobody was in the medication room when the light went off so they did not see it. 21. During an interview on 4/2/12 at 11:40 AM with the 2 facility med techs, they stated resident #1 does not have any home health services and self-administers their medications, The med techs also stated they did not store any of the resident's medications and they should all be kept in her room. At that time observation was made of the call light system which is located inside the first floor medication room/nurse station. If no staff is present in this room, there is no way to know if a resident activates the call system. 22, A review of resident #1's record revealed an admission date of 1/31/11 and a diagnosis to include diabetes, renal insufficiency, and asthma. The AHCA form 1823 dated 1/26/11 documents the residents need for assistance with medications. The AHCA form 1823 dated 2/17/12 documents the resident's need for assistance with bathing and need for help taking their medications. The form did not document if the resident needs assistance with self- administration or medication administration. 23. The resident's medication observation record (MOR) for February through April 2012 was reviewed and included the following medications: Lantus 100 units/ml vial inject sub- Q 25 units 3 times a day, "Home Health Care". Iprat-Albut .5~3(2.5) mg use 1 vial via nebulizer twice daily. Wellbutrin XL 150 mg 1 tablet daily. Glipizide 10 mg 1 tablet daily. Singulair 10mg | tablet daily. Bupropion hel 150mg 1 tablet twice daily. 24. The MOR's were blank. The facility did not document resident #1 had tefused or received their medications as ordered by the physician for 14 months, A plan of care for skilled services to administer the resident's insulin was requested as well as the home health record. The facility manager stated the resident does not receive home health services and the facility has not been monitoring the resident's diabetes. 25. Further review of the record did not contain physician's orders for the resident to self-administer any medications, or documentation the resident was being assisted with bathing. There was no evidence the facility notified the physician with any concerns. 26. During an interview on 4/2/12 at 2:40 PM with the facility manger and Resident #1 in their room, the resident stated she gives herself the insulin 2 or 3 times a day depending on what she eats and does not check her glucose levels. At that time observation was made of 2 bottles of Lantus insulin in a plastic bag in the resident's refrigerator. The resident also stated she was missing medications, and needed to get to the bank because she did not have the money for the copayments. She reported the facility does not get her medications and was not in possession of any of the above listed medications. 27. During an interview on 4/2/12 at 4:00 PM with the facility manager and nurse consultant to review resident #1's record, it was confirmed the facility does not have a physicians order for resident #1 to self administer their medications. It was also confirmed the facility does not supply or store any of resident #1's medications. The facility could not provide documentation resident #1 had received any of their physician ordered medications from 2/1/11 through 4/2/12 or home health services as ordered by the physician for diabetic management. This is an uncorrected tag from survey on 12/21/11. 28. Based on the foregoing facts, Westchester of Sunrise violated Section 429,28 Florida Statutes, and Rule 58A-5.0182(6), Florida Administrative Code, herein classified as a Class HI violation, which warrants an assessed fine of $5,000.00. SURVEY FEE Pursuant to Section 429.19(7), Florida Statues (2011), AHCA may assess a survey fee in the amount of $500.00 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. 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 Westchester of Sunrise on Count I. 2. Assess an administrative fine of $5,000.00 against Westchester of Sunrise on Count I for the violation cited above, 3. Assess a survey fee of $500.00 against Westchester of Sunrise on Count I for the violation cited above. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable, 5. 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 (2011). 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 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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER « Alba M. Serta fede, Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53” Street Suite 300 Miami, Florida 33166 305-718-5906 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, Peter A. Lewis, Esq., Attorney for Respondent, 3023 N. Shannon Lakes Drive, Suite 101, Tallahassee, Florida 32309 on this / 9 Hs day of gees. , 2013. Qb bos uk Ro Alba M. Rodriguez, Esq. 10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: ISLF Westchester of Sunrise, LLC d/b/a AHCA No.: 2012011203 Westchester of Sunrise ELECTION OF RIGHTS This Election of Rights form is attached to a proposed 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 must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued, (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 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. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive ny right to object and to have a hearing. 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 penalty, fine or action, OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (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 should be reduced. OPTION THREE (3)___——I- dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 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 administrative 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, Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3, A statement of when you received notice of the Agency’s proposed action. 4, A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC August 16, 2013 Re: ISLF Westchester of Sunrise LLC d/b/a Westchester of Sunrise AHCA No.: 2012011203 Hi Sarah - The administrative complaint for the above-referenced case was delivered by e-mail to the’ attorney for the facility. I am including a copy of the e-mail that establishes date of receipt of the administrative complaint. the Torres, Lorraine Freom: Rodriguez, Alba . Sent: . Thursday, July 18, 2013 3:03 PM To: Torres, Lorraine Su bject: . FW: Service of Administrative Complaint ISLF Westchester of Sunrise 2012011203 Please update FRAES that AC was served today. From: Peter Lewis ‘mailto: palewis@petelewislaw. com] Sent: Thursday, July 18, 2013 2:55 PM Tos Rodriguez, Alba Subject: RE: Service of Administrative Complaint ISLF Westchester of Sunrise 2012011203 Sure that would be great Connected by DROID on Verizon Wireless -----Original message----- From: "Rodriguez, Alba" To: Peter Lewis Cc: "Torres, Lorraine" Sent: Thu, Jul 18, 2013 18:50:33 GMT+00:00 Subject: RE: Service of Administrative Complaint ISLF Westchester of Sunrise 2012011203 Is today Ok? From: Peter Lewis [ [mailto:pa :palewis@petelewistaw. com] Sent: Thursday, July 18, 2013 8:34 AM To: Rodriguez, Alba Cc: Torres, Lorraine a Subject: Re: Service of Administrative Complaint ISLF Westchester of Sunrise 2012011203 | have it Alba, Thank you. What day do you want to set as the day of service? Yesterday or today. Pete Peter A. Lewis Law Offices of Peter A. Lewis, P.L. 3023 N. Shannon Lakes Drive, Suite 101 Tallahassee, Florida 32309 Phone: 850.668.7141 Fax: 850.668.7199 palewis@petelewislaw.com none aga Message ~ _ Fr ve 7 To: cea doelabwtiow, com Ce: Torres, Lorraine Sent: Wednesday, July 17, 2013 12:29 PM Subject: Service of Administrative Complaint ISLF Westchester of Sunrise 2012011203 Hi Pete, ae’ set This is the AC for the second case. Please let us know when you receive so we can make sure you got it. Regards, Alba

Docket for Case No: 13-003182

Issue Date	Proceedings
Apr. 17, 2014	Agency Final Order filed.
Apr. 17, 2014	Agency Final Order filed.
Oct. 11, 2013	Order Closing Files and Relinquishing Jurisdiction. CASE CLOSED.
Oct. 10, 2013	Motion to Close File and Relinquish Jurisdiction filed.
Sep. 12, 2013	Order Re-scheduling Hearing by Video Teleconference (hearing set for December 10, 2013; 9:00 a.m.; Lauderdale Lakes, FL).
Sep. 12, 2013	Response to the Order of Consolidation filed.
Aug. 30, 2013	Order of Consolidation (DOAH Case Nos. 13-2452 and 13-3182).
Aug. 30, 2013	Order of Consolidation (DOAH Case Nos. 13-2452 and 13-3182).
Aug. 26, 2013	Joint Response to Initial Order filed.
Aug. 21, 2013	Initial Order.
Aug. 20, 2013	Administrative Complaint filed.
Aug. 20, 2013	Election of Rights filed.
Aug. 20, 2013	Petition for Formal Administrative Hearing filed.
Aug. 20, 2013	Notice (of Agency referral) filed.

Orders for Case No: 13-003182

Issue Date	Document	Summary
Apr. 17, 2014	Agency Final Order
Apr. 17, 2014	Agency Final Order