‘STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . AHCA No. 2014010625 LAKESHORE LIVING INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Lakeshore Living Inc. ( the “Respondent”), pursuant to Section 120.569 and 120.57, Florida Statutes (2013), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s assisted living facility license and impose an administrative fine for $1,000.00 based upon one Class II deficiency, PARTIES 1. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapter 408, Part II, Chapter 429, Part I, F lorida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 2. The Respondent operates a licensed assisted living facility located at 10919 Mistletoe Drive, Thonotosassa, Florida 33592 and was at all times material required to comply — a) 7) with all applicable state and federal rules and statutes. COUNTI SUPERVISION 3. . Under Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 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 residents 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. 58A-5.0182(1), Fla. Admin Code. 4. On or about October 10, 2014, the Agency conducted a complaint survey of the Respondent. 5. Based on interview and record review the assisted living facility failed to provide appropriate care and supervision for 1 of 7 sampled (Resident #1) residents. The facility failed to ensure qualified staff was available to implement the facilities emergency action plan upon discovering that the resident was on fire. The employee ' s lack of action posed a direct threat to od the safety and well-being of the resident. 6. On September 12, 2014 at 9:57 AM a tour of the facility was completed. The facility main entry door was observed directly across from the exit door that leads to the " smoker's deck". A large fire extinguisher and fire alarm pull box was observed attached to wall adjacent to the entry door directly across from the door that leads to the " smoker 's deck " . (photo obtained) 7 : On September 12, 2014 at 9:11 AM an interview was conducted with the facility manager. The Manager stated "Employee A was working and found Resident #1 's shirt on fire. The Manager stated Employee A tried to put the fire out with her hands. Employee A ran next door to get the administrator. The administrator came with the fire extinguisher and at that time Resident #1 was in flames and the administrator put the flames out with the fire extinguisher. " 8. On September 12, 2014 at 10:21 AM an interview was conducted with Resident #2. Resident #2 stated Employee A was working by herself the night of the incident and Employee A had to go and get the administrator to come and take care of things. Resident #2 stated Resident #1 would fall asleep out on the deck while smoking and Resident #2 had to wake Resident #1 up several times. 9. On September 12, 2014 at 10:41 AM an interview was conducted with Resident #3. Resident #3 stated Resident #1 would often doze off while smoking. Resident #3 stated, " He would sit there with his head down with cigarette in hand and sleep. " 10. On September 12, 2014 at 12:30 PM an interview was conducted with Employee A. Employee A stated she has worked at the facility approximately one (1) year and never worked in an Assisted Living Facility before. Employee A stated she worked by herself the night of September 5, 2014. Employee stated she discovered Resident #1 was on fire when she brought o Resident #1 his pain medication. Employee A stated, " My first reaction was to use my hands and try to pat the fire out and I tried to take his jacket off but it burned my hands. " Employee A stated: " I ran to get my boss that lives there because I am not super woman and can ' t do everything on my." Employee A stated Resident #1 was still on fire when she entered the facility from the patio door and went through the front door directly across from the patio door to get the administrator. Employee A stated when she returned with the Administrator the Resident #1 was still on fire. 11. On September 12, 2014 at 1:06 PM an interview was conducted with Employee F. Employee F stated Resident #1 " nods off and I have caught him a few times. I have pulled cigarettes out of his hand and put them in the ash tray. " 12. On September 12, 2014 at 3:10 PM an interview was conducted with the facility Administrator. The administrator stated Employee A was the only staff on duty at the time of the incident. The Administrator stated Employee A ran over to his home and told him what was happening. The Administrator stated when he arrived at the facility "I got the fire extinguisher that was located right at the entrance door and put the fire out". The facility administrator stated Resident #1 " was over by the time I got there. " 13. On September 16, 2014 at 3:00 PM an interview was conducted with the facility Manager. The Manager stated she was unaware of Employee A received training on the facility emergency procedures in the case of a fire. The Manager reviewed the sign in logs for the facility's past training's and stated, "I don't see one with her in it. " 14. A record review of employee A's personnel file revealed employee A date of hire was 5/18/2013. Employee A ' s personnel file included no evidence that Employee A received training in facility emergency procedures, incident reporting and recognizing and i, ) reporting resident abuse, neglect and exploitation. a 15. A record review of the facility fire plan revealed the following steps to be taken in the event of a fire: 16. A, R.A.C.E. Plan will be followed 17. 1. R - Rescue residents. Remove resident closet to fire to outside using exit furthest from fire. Remove all other residents from the facility using exit furthest from fire. 18. 2. A - Alarm. Notify fire department by dialing 911 Remain on the phone and answer all questions asked. 19. 3. C - Contain fire by shutting all doors and by eliminating drafts. Turn off air conditioner or heating units (There are two units to shut off in facility) 20. 4. E - Evacuate residents to a pre-designated destination as noted on Emergency Data Sheet Notifying Aging and Adult Services, family/and or guardians of residents as to their condition and whereabouts. 21. Bz Extinguish the fire if 100% sure you can put it out without jeopardizing anyone's safety. 22. C. Notify Administrator or designee 23. Review of the facility fire drills dated between 5/2013 and 9/2014 revealed no evidence that Employee A attended any fire drills provided by the facility. * Sanction 24. — Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation.§ 408.813(2)(a), Fla. Stat. (2013). 25. Under Florida law, the Agency shall impose an administrative fine for a cited class I violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429.1 9(2)(b), Fla. Stat. (2013). Wherefore the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $1,000.00. /s/John Bradley John E. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. a) CERTIFICATE OF SERVICE J] HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this 5" day of January 2015. /s/John Bradley John E. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com Theresa DeCanio, Field Office Manager Local Field Office Agency for Health Care Administration (Electronic Mail) David Caldwell Administrator Lakeshore Living Inc. 10919 Mistletoe Drive Thonotosassa, Florida 33592 USS. Certified Mail - (7008 0500 0001 9503 9385) Catherine Avery, Unit Manager Licensure Unit Agency for Health Care Administration (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Lakeshore Living Inc. AHCA No. 2014010625 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency 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 may be returned by mail or by facsimile transmission, but must be filed within 21 days of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 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. Telephone: 850-412-3630 Facsimile: 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 Fee, Notice of Intent to Impose a Late Fine, 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, 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, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. a, + 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 obiain 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 agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. : 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate: 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available-in this matter if the Agency agrees. Licensee Name: a Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: | David Caldwel Administrator | Lakeshore Living Inc: | 10919 Mistletoe Drive Thonotosassa, Florida: 33592 BS5D0 0801 4503 4386

Docket for Case No: 15-000653