STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No.: 2013009439 CALFLO SERVICES, INC. d/b/a CITRUS GARDEN ALF," 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 ” Calfle Servicews, Inc. d/b/a Citrus Garden ALF (hereinafter “Respondent”), pursuant to Section § 120.569 and Section § 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $3,000.00 based upon one State Class II deficiency pursuant to Section § 429,19(2)(b), Florida Statutes (2012). . JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to Section §-20.42, Section § 120.60 and Chapters 408, Part II, 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 16-bed assisted living facility (hereafter “ALF”) located at 4805 East Lake Drive, Winter Springs, Florida 32708. It is licensed as an ALF, license number 9138. 5. Respondent was at all times material hereto a licensed facility under the licensing . authority of the Agency, and was tequired nen comply with, all E appliabl ra rules and statutes. COUNT I - tag 40025 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein, 7, Pursuant to Florida law: Fla. Admin. Code R. 58A-5.0182(1) - 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, F.A.C. (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. ka Section 429.28, Fla. Stat. (2012) - Resident bill of rights (1) No resident.of a facility shall be deprived of any civil or legal rights, benefits, ...or privileges guarariteed by law, the Constitution of the State of Florida, or the te Constitution-of the: United States as a resident of.a facility. Every resident of a *: facility shall have the right to: (a) Live in a 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 unsaie, impractical, or an infringement 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. (ec) 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. (f) 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, nor any 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 fr from the facility unless, for medical reasons, the:resident'is certified bya. physician to require an emergency:# elocation to-a ‘facility providing a more skilled level of care or the resident engtigessin.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 recomménd 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 shail 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. 8. On June 13, 2013, the Agency conducted a complaint inspection, CCR 42013003099, of Respondent's assisted living facility, and found it out of compliance with the above statute and rule. 9. Based on record review and interviews, the facility failed to provide adequate supervision and general awareness of the whereabouts at all times for a resident with dementia who eloped. Findings included: Resident #2 Resident #2 was admitted on March 14, 2013. He had a March 26, 2013, AHCA Health Assessment Form 1823 that listed diagnoses of dementia, hypertension and elevated liver enzymes and noted that the resident had a poor memory. The resident was independent with ambulation, bathing, dressing, eating, toileting and transferring but rieeded supervision with grooming. In the late morning, the resident was observed sitting in a chair on the back porch of the common living area. He was alert, pleasant but confused. He could not recall how long he had lived at the facility. He was also seen in the dining room eating lunch with other residents, Records revealed that a guardian had been appointed on March 11, 2013. An Order Determining Total Tneapacity was signed and dated o on n April 17, 2013. Docuthentation é in facility notes tevealed that he went, missing on March 16; 2013 when he was-last seen at.7:15 PM. After unsuccessfully searching the property, the caregiver notified the resident's guardian at 8:15 PM but did not notify the _ administrator. The facility called 911 at 8:30 PM. Police arrived and its search and rescue squad found the resident in a wooded area in the neighborhood at 1:52 AM (Police Case #2013CJ002992). The Police called paramedics to the scene who cleared the resident and documented that he was:stable and free from harm. The resident’s legal guardian, who had come over during the search, left the facility at 2:20 AM. The Police left ten minutes later. The administrator was not notified about the event until 7:53 AM the next morning. The Seminole County Sheriff's Office (“SCSO”) wrote an Elder Intervention report on Marcin 16, # 201381000142. It noted that it had dispatched tothe ALF in . response to a missing persons report. It documented that, once on the scene, they came into contract with Resident #2’s legal guardian who told them the resident - was last seen around dinner time at 7:00 PM. The resident was last seen wearing a blue hat, blue long sleeve-shirt, khaki pants and black sneakers and had left the facility in an unknown direction. The guardian had informed them that the resident had dementia, was on medications for hypertension and had been on a very steady decline of capacity over the last few years. She gave them the resident's prior address so that the Apopka Police Department could search to sce whether the resident had returned there. The police reported back that no one was at that residence. The local hospital and taxi services were called but had not come into contact with anyone matching Resident #2's description. An advisory was sent out at 10:45PM to Seminole and surrounding counties, They were able to “ping” Resident #2's cell phone. A SCSO Alert 2 helicopter was called and assisted in locating Resident #2. Search and rescue was paged at 11:06 PM. The Orange County Sheriff's K-9 unit with a bloodhound arrived at 11:30 PM. The K-9 searched the surrounding area for approximately 2 hours but were unsuccessful. Eventually, the resident was located within 25 feet of his cell phone in some very thick brush deep in the woods. He was escorted out, evaluated by the Seminole County Fire Rescue and released back to the guardian in the early morning. All units on the scene were debriefed and cleared out. The owners of the ALF were advised to secure the rear gate so this does not happen again. Physician progress notes from March 26, 2013, noted the resident’s dementia, anxiety and unsteady gait. Risperdal (an antipsychotic), 0.5 milligrams, twice a day was ordered. The facility’s adverse incident report stated that the resident eloped from the cility.on 3/16/13, was found by search and rescue, and was returned safely, a eo ~ During an interview, Staff A, the owner/caregiver:said-that, though he lived at the facility, he had been out at the time of the elopement: He had returned to the facility to assist before the resident was found unharmed. The administrator thought that the elopement occurred because the resident, who was new at the facility, had not been taking his medications before he moved in. He was exit-seeking when he moved in and only at the facility a few days before he eloped. She said that, when he was found, he thought he was camping and cutting down Christmas trees. It was fortunate that he had his cell phone with him. After this event, the facility contacted the physician and the resident’s medications were adjusted. He is no longer exit-secking at this time, she said. 10. The Respondent’s failure to provide adequate supervision for a resident with dementia who was exhibiting exit-seeking behavior and who could have been harmed as a result of an elopement is unacceptable and violation of law. 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 three thousand dollars ($3,000.00), 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. The-Respondent.is further-netified that:the failure to request a hearing within 21 days of “receipt of this Complai kt wii! 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 Certified Mail, Return Receipt #7012 1640 0000 0115 0974 to Abraham A. Deguzman, Registered Agent, 4805 East Lake Drive, Winter Springs, FL 32708, and by regular U.S. mail to Melissa Deguzman Santos, Administrator, Citrus Garden ALF, 4805 East Lake Drive, Winter Springs, FL 32708, this OO tay of November, 2013. STATE OF FLORIDA, AGENCY FOR HEALTHCARE ADMINISTRATION 525 Mirror Lake Dr. N., Suite 330H St. Petersburg, Florida 33701 (727) 552-1945; Fax: (727) 552-1440 suzanne.hurley@ahca.myflorida.com Copy to: Lorraine Henry, Orlando Area Office STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: CALFLO SERVICES, INC. d/b/a CASE Nos. 2013009439 CITRUS GARDEN ALF 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!20, 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 my 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) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Cate Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC sole ‘sfuidg. squm oo, SAL YET ISe3 $088.

Docket for Case No: 14-000008