STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2014001438 Return Receipt Requested: v. 7009 0080 0000 0586 0346 GV LAUDERHILL LLC d/b/a GRAND VILLA OF DELRAY EAST, 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 GV Lauderhill LLC d/b/a Grand Villa of Delray East (hereinafter “Grand Villa of Delray East”), pursuant to Chapter 429, Part I, Chapter 408, Part II, and Section 120.60, Florida Statutes (2013), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $5,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2013), for the protection of public health, safety and welfare, and a survey fee in the amount of $500.00 pursuant to Section 429.19(2)(c) and 429.19(7), Florida Statutes (2013). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2013), and Chapter 28-106, Florida Administrative Code (2013). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2013). 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 (2013), and Chapter 58A-5 Florida Administrative Code (2013). 5. Grand Villa of Delray East operates a 170-bed assisted living facility located at 14555 Sims Road, Delray Beach, Florida 33484. Grand Villa of Delray East is licensed as an assisted living facility under license number 5113. Grand Villa of Delray East 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 GRAND VILLA OF DELRAY EAST FAILED TO PROVIDE SUPERVISION TO RESIDENTS WHO WERE DIAGNOSED WITH DEMENTIA. RULE 58A-5.0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE AND SUPERVISION STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Grand Villa of Delray East was cited with deficient practice as the result of a complaint investigation survey that was conducted from December 12, 2013 to December 16, 2013. 8. A complaint investigation survey was conducted from December 12, 1013 to December 16, 2013. Based on observation, record review and interview, it was determined that the facility failed to provide supervision to 3 out of 5 sampled residents (Resident #s 1, #2, and #3) who were diagnosed with Dementia. The findings include the following. 9. In an interview with the Director of Nursing (DON) on 12-12-13 at 9:50am, she stated that Resident #1 was determined to have been missing from the facility — on 12-9-13 at approximately 9:00pm. She stated that due to the resident's condition, he was placed in the facility's memory care unit (MCU). She stated at this time that on 12-9-13 at around 11:00pm, the law enforcement staff found Resident #1 unconscious with his body floating inside the western-most lake of the facility property. 10. In an interview with the Administrator on 12-12-13 at 10:25am, she stated that on 12-9-13 at around 8:00pm, Caregiver #1 assisted Resident #1 to bed in his room (#166); Caregiver #1 then went to assist Resident #4 to bed in her room (#170), which is located next to #166. She stated at this time that on 12-9-13 at around 9:00pm, the supervising MCU nurse realized that Resident #1 was not in his room. The supervising MCU nurse mobilized an immediate search within the MCU of the facility, which upon not locating the resident there it turned into a facility-wide search. 11. She stated at this time that upon the supervising MCU nurse not being able to locate Resident #1 in the facility on 12-9-13 at around 9:30pm, the supervising MCU nurse notified her and then they contacted the local authorities to help find the resident. She stated at this time that on 12-9-13 at around 11:00pm, the law enforcement staff found the lifeless body of Resident #1 in the western-most lake of the facility property. 12. Review of Resident #1's record indicated that he was admitted to the facility on 10-30-13 with diagnoses including Dementia. Review of the resident's health assessment dated on 10-29-13 indicated that the resident needed supervision with ambulation (with “redirection” noted) and transferring (without any comments noted) and he also needed assistance with self- administration of medication. 13. Review of the resident's facility-developed memory support care-level assessment dated on 10-17-13 indicated that he did not need assistance with ambulation or transfers. Further review of the care-level assessment form revealed it had not been signed and dated by the required parties (the responsible party, the community representative and the Executive Director); the designated signature area for each party was left blank. 14. %In an interview with the MCU staff nurse on 12-12-13 at 12:05pm, she stated that Resident #1 would regularly walk around the MCU independently and without an assistive device, and he would rarely use his wheelchair to get around. 15. In an interview with the supervising MCU nurse on 12- 12-13 at 3:30pm, he stated that he continually saw Resident #1 walking independently without supervision or an assistive device all around the MCU and that on 12-9-13 at 7:30pm, the resident was walking around the MCU. He stated at this time that Resident #1 was well aware that if he holds any of the 4 MCU door bars for over 10 seconds, it will unlock and open. He stated at this time that the exit door next to the MCU nursing station would sometimes not buzz/alarm when forced open and would = stay deactivated for some time and that resident #1 would regularly open this and other coded entry doors in the MCU, without entering any codes or alarms going off. 16. He stated at this time that this would happen every day and that there was no care plan developed in order to mitigate this behavior for Resident #1. He stated at this time that Caregiver #1 reported to him on 12-9-13 at around 8:00pm, that she assisted Resident #1 into his bed. He further stated at around 8:15pm, Caregiver #1 requested his assistance to place Resident #2 in his bed who was in the same room as Resident #1. He stated at this time that although he did not look at Resident #1's side of the dimly lighted room at that time; Caregiver #1 confirmed to him that Resident #1 was in his bed when they assisted Resident #2 into his bed at that time. 17. He stated at this time that on 12-9-13 at around 9:00pm, he performed rounds in the MCU and realized that Resident #1 was not in his bed and he notified the 3 caregivers in the MCU to begin a search for Resident #1 within the MCU. He stated at this time that him and his MCU staff looked all around in the MCU for Resident #1 and could not find him, and that he did not hear any door alarms go off during the evening of 12-9- 13. He stated at this time that on 12-9-13 at around 10:00pm, they called 911 to aid in the search of the resident to which law enforcement staff responded to the facility and found the resident's body on 12-9-13 around 11:00pm. 18. In an interview with the supervising MCU nurse on 12- 13-13 at 4:15pm, he stated that he verbally notified his former MCU supervisor several times about the malfunctioning doors that would not alarm or reset in the MCU during the past month and that he relied on her to report this malfunction to administration for proper repair. He stated that up to 12-9-13, he had no reason to believe that the MCU security doors were “repaired. 19. In an interview with Caregiver #1 on 12-12-13 at 4:00pm, she stated that Resident #1 used to always walk around the MCU independently, without any assistive device and that on 12-9-13 shortly before 8:00pm, he was indeed walking around the unit and she assisted him to his bed. She stated at this time that shortly after 8:00pm, she helped Resident #1's roommate, Resident #2 into his bed and she remembers that Resident #1 was in his own bed at that time. She stated at this time that a short time thereafter, she was emptying the residents ‘garbage around the MCU activity area and she saw Resident #1 and #2 walking together in the memory care unit (MCU) hallway and then saw them go into their room together, and that this was not uncommon because both of these residents were avid walkers and would walk around the whole MCU. She stated at this time that around 8:45pm, she went on break outside of the MCU and into the main facility employee break room. She stated at this time that shortly thereafter, the supervising MCU nurse called her to notify her that resident #1 was not in his room and to assist him with a search of resident #1 in the MCU. She stated at this time that resident #1 was not found until after the law enforcement staff arrived to the facility and found resident #1's body in the lake. 20. In an interview with the Administrator on 12-12-13 at 12:20pm, she stated that based on the facility's investigation on the events surrounding Resident #1's elopement on 12-9-13, she could determine with moderate level of certainty that the resident left the locked MCU around 8:00pm, most likely following an employee out of the coded south door, which leads to the general facility hallway. 21. In an observation on 12-12-13 from 3:00pm to 3:15pm in the MCU, Resident #2 was walking independently with a rolling walker, in and out of the MCU dining room into the hallway and back into the dining room and he then went inside the MCU kitchen. It was observed at this time that no persons or staff members were present in aforementioned areas to supervise or assist Resident #2. 22. In an attempt to interview Resident #2 on 12-12-13 at 3:10pm, it was not possible because the resident presented to be alert and considerably confused. In an observation on 12-12-13 at 3:15pm, the Activity Director was notified that Resident #2 was inside the MCU kitchen and she immediately went to his side to assist him outside the kitchen and into the MCU activity area where other residents and staff members were present. 23. In an interview with the Activity Director on 12-12-13 at 3:15, she stated that Resident #2 is one of a few residents in the MCU which likes to walk all over the place, wanders and although he does not actively seek exit from the MCU, he would occasionally attempt to walk outside the MCU if a door was opened. She stated at this time that Resident #3 is another current resident who walks around independently. She stated Resident #1 used to also walk independently throughout the MCU and he would exhibit wandering and exit-seeking behaviors and Resident #1 would set off door alarms on a daily basis. 24. Review of Resident #2's record indicated that he was admitted to the facility on 11-26-13 with diagnoses including Dementia, Hypertension and Coronary Artery Disease. Review of his health assessment dated on 11-26-13 indicated that the resident needed assistance with ambulation (with “assistive device" noted) and transferring (with "for safety" noted) and needed medication administration. Review of the resident's facility-developed memory support care-level assessment dated on 11-6-13 indicated that he did not need assistance with ambulation or transfers. 25. Further review of the care-level assessment form revealed it had not be signed and dated by all 3 required parties (the responsible party, the community representative, and the Executive Director); the designated signature area for the responsible party and the Executive Director was left blank. 26. Review of the facility elopement drills dated on 4-3- 13, 7-18-13, and 10-24-13 indicated that the supervising MCU nurse participated in this training on 7-18-13 and caregivers #1, #2, and #3 did not participate in any of these elopement drills or trainings. 27. %In an interview with the Administrator on 12-13-13 at 9:45am, she stated that she was aware that all the 4 ingress/egress doors in: the MCU do unlock/open after holding their bars for an extended period to comply with fire codes and that they make a loud buzzing/alarming noise when opened. She stated at this time that she was not aware that any of these doors were not functioning correctly. 28. In an interview with Caregiver #2 on 12-13-13 at 10:30am, she stated that she knew Resident #1 well, she was working in the MCU on 12-9-13 and she last saw the resident in his room on 12-9-13 at approximately 8:00pm. She stated at this time that she did not hear any of the door alarms go off on the evening of 12-9-13, but she was aware that the ingress/egress door located next to the MCU nursing station had been 10 malfunctioning for about one month because it would sometimes not buzz or alarm when opened. She stated that she has mentioned this to her supervisor, the former MCU supervisor, but nothing had been done about it because the door was not fixed. 29. In an interview with the Administrator on 12-13-13 at 12:50pm, she stated that the facility has not yet examined the individual resident behaviors in the MCU to reduce the risk of elopements. She also stated at this time that the security door contractor was called on 12-10-13 to review the door security systems in the MCU so they can adjust the timing parameters in the doors, because the doors used to stay unlocked/open for a few more seconds after coded ingress/egress. 30. In an interview with the DON and the Administrator on 12-13-13 at 1:30pm, they both stated that they have not been informed or were aware of any of the MCU security doors to have been malfunctioning during the past 3 months. 31. In an interview with the Administrator on 12-16-13 at 10:05am, she stated that the facility's nurse performs a move- in/care-level assessment on every resident in the facility and every direct care staff member uses this assessment as the basis of the individual care extended to each resident. In an interview with the DON on 12-16-13 at 12:00pm, she confirmed that the MCU and general facility residents receive an initial 11 care-level assessment that is used as a care plan by the direct care staff. 32. In an observation on 12-16-13 at 11:00am, Resident #3 was walking independently without an assistive device in the MCU main hallway; he then went towards the MCU lobby's front door and attempted to open the door by pressing on the bar for approximately 5 seconds and the door sounded a barely-audible alarm to which the MCU staff nurse responded to and redirected the resident to the activity area. 33. Review of Resident #3's record indicated that he was admitted to the facility on 11-26-13 with diagnoses including Dementia, Alzheimer's disease and Hypertension. Review of his health assessment dated on 6-20-13 indicated that the resident needed assistance with ambulation (with "unaware of unsafe areas" noted) and supervision with transferring (with no comments noted) and needed assistance with self-administration of medication. 34. Review of the resident's move-in assessment dated on 8-6-13 indicated that he was not oriented to his surroundings or daily routine, and it was noted that he is a wanderer. 35. In an interview with former MCU supervisor on 12-16-13 at 12:25pm, she stated that she did not experience any malfunction with the MCU security doors, nor was she notified of any malfunction of the MCU doors by the staff. She stated at 12 this time that she understood every MCU resident to be an elopement risk and the facility did not perform any specific resident elopement assessments. 36. The facility failure to provide supervision appropriate to 3 residents that suffered from Dementia directly affected the safety and well-being of the residents (Resident #1, #2, and #3). The facility also failed to adequately assess each resident upon admission to ensure appropriate supervision. 37. Based on the foregoing facts, Grand Villa of Delray East violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $5,000.00. SURVEY FEE Pursuant to Section 429.19(7), Florida Statutes (2013), 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. 13 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 Grand Villa of Delray East on Count I. 2. Assess an administrative fine against Grand Villa of Delray East based on Count I for the violation cited above. 3. Assess a survey fee of $500.00 against Grand Villa of Delray East on Counts I and II for the violations 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 (2013). 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. 14 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 Cicer ase Lourdes A. Naranjo, Es@. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53°¢ Street Suite 300 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) 15 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 Judi Christiano, Administrator, Grand Villa of Delray East, 14555 Sims Road, Delray Beach, Florida 33484 on this BY say of fierce , 2014. Bae Lourdes A. Naranjo, Esq. f 16 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: GV Lauderhill, LLC d/b/a AHCA No.: 2014001438 Grand Villa of Delray East 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 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)___—Ss_ 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) [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 “h co PLE TE THIS'SECTION.ON DELIVERY: rifled Fee j . Postmark Retuyn Receipt Fee (Endorseenent Required) Restricted Delivery Feo (Endorsement Required) Total Postage & Fees BieEl A pr es “ —aenamns or PO Box No. K Clty; Sitals, ae 58 2009 gga O000 O58 O34 O00 0566 0345 r ebruary 2004 : Domestic Retum Receipt

Docket for Case No: 14-001922