STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos. 2016010220 GV DUNEDIN, LLC d/b/a GRAND VILLA OF DUNEDIN, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, GV Dunedin LLC d/b/a Grand Villa of Dunedin, pursuant to Sections 120.569 and 120.57, Florida Statutes (2011), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of twenty thousand dollar ($20,000.00), in addition to a survey fee of five hundred dollars ($500.00), for a total assessment of twenty-five thousand dollars ($20,500.00) based upon two (2) class etic 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part Il, JURISDICTION AND VENUE and 429, Part I, Florida Statutes (201 1). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal 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, respectively. Respondent operates a one hundred twenty (120) bed assisted living facility located at 880 Patricia Avenue, Dunedin, Florida 34698, and is licensed as an assisted living facility, license number 5404. 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 The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. That Florida law provides: (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: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due reco gnition 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, 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. (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, nor any attendance at religious services, shall be imposed upon any resident. Gj) Access to adequate and appropriate health care consistent with established and recognized standards within the community. Section 429.28(1)(a through j), Florida Statutes (2011). 8. That Florida law provides: (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.AC. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible to all residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1(888)831-0404; the Advocacy Center for Persons with Disabilities, 1(800)342-0823; the Florida Local Advocacy Council, 1(800)342-0825; and the Agency Consumer Hotline 1(888)419-3456. (d) The statewide toll-free telephone number of the Florida Abuse Hotline “1(800)96-ABUSE or 1(800)962-2873” shall be posted in full view in a common area accessible to all residents. (e) The facility shall have a written statement of its house rules and procedures which shall be included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. The rules and procedures shall 3 11. address the facility’s policies with respect to such issues, for example, as resident responsibilities, the facility’s alcohol and tobacco policy, medication storage, the delivery of services to residents by third party providers, resident elopement, and other administrative and housekeeping practices, schedules, and requirements. (f) Residents may not be required to perform any work in the facility without compensation, except that facility rules or the facility contract may include a requirement that residents be responsible for cleaning their own sleeping areas or apartments. If a resident is employed by the facility, the resident shall be compensated, at a minimum, at an hourly wage consistent with the federal minimum wage law. (g) The facility shall provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to Section 429.28(1)(d), F.S. The facility shall not prohibit unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there shall be, at a minimum, an accessible telephone on each floor of each building where residents reside. (h) Pursuant to Section 429.41, F.S., the use of physical restraints shall be limited to half-bed rails, and only upon the written order of the resident’s physician, who shall review the order biannually, and the consent of the resident or the resident’s representative. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance shall not be considered a physical restraint. Rule 58A-5.0182(6), Florida Administrative Code. That on August 18, 2016, the Agency completed a complaint survey (CCR # 2016009499) of Respondent’s facility. Based on interview, record review, and review of Advanced Directives, the facility failed to honor the rights of 1 out of 6 sampled Residents (#1), specifically by staff failing to administer CPR to an unresponsive resident. On or about August 16, 2016, at approximately 9:05 a.m. a phone interview with Resident #4 revealed that on Sunday July 31, 2016 the resident was seated at the smoking patio with Resident #1. Thereafter, between approximately 1:05 pm and 1:16 p.m., Resident #4 stated that he noticed Resident #1 was "not looking well and looked as if she was going to pass out." Resident #4 reached over to try to help her when Resident #1 collapsed from her wheelchair and onto the ground. Resident #4 4 12. 13. picked Resident#1 up from the ground, placed her back inside her wheelchair, and immediately brought her to the nearby wellness center a few feet away. Resident #4 stated it took approximately one minute to transport Resident #1 to the wellness center. Once they arrived, he pushed Resident's #1 wheelchair to nearby Staff A (Certified Nurse Assistant) and requested that Staff A immediately perform CPR (cardiopulmonary resuscitation). Resident #4’s request for CPR went ignored. Resident #4 then tumed to the visiting nurse (whose identify was unknown at the time) and asked if she could immediately perform CPR (cardiopulmonary resuscitation). His request was ignored for a second time. Finally, Resident #4 asked both Staff A and visiting nurse whether he could be of any assistance and perform CPR. His request was ignored for a third time. Resident #4 recalled the visiting nurse stating, "I would do CPR but I am not getting down on the floor because I have a bad back." He also recalled staff A standing near the desk and on the phone (likely to 9-1-1) during the entire incident. Resident #4 later witnessed Staff B (license practical nurse) attempt to wake Resident #1, however without performing CPR. Approximately ten to twelve (10-12) minutes passed before paramedics arrived to assist Resident #1. At no point during the incident did Resident #4 observe any staff attempt to perform CPR. Moreover, Resident #4 observed Staff B tilting Resident #1 backwards while inside her wheelchair for some unknown reason. On or about August 16, 2016 at approximately 2:52 p.m., a phone interview with Staff A revealed that she worked at the facility on the incident date July 31, 2016. Staff A recalled being present in the wellness center with a nurse (from an unknown outside agency), when she witnessed Resident #4 transporting Resident#1 into the 14, 15. wellness center. Staff A stated she immediately knew something was wrong because the Resident #1 appeared to be lifeless, with no noticeable discoloration or bruising of the skin. Staff A stated she immediately called 9-1-1 and was instructed to initiate CPR on Resident #1. However, she claimed that she then called Staff B (LPN) for assistance, who arrived within one or two (1-2) minutes. Staff A stated "prior to calling for any assistance I yelled Resident #1's name and tried to wake her up by moving her arms and shaking her, but she remained unresponsive." Staff A confirmed she did not initiate CPR on Resident #1 when instructed to do so by 911. Staff A stated "I can't recall anything else that happened." Staff A stated "I can’t recall how much time had elapsed between the time I called 9-1-1 and the time EMS arrived to the scene." On or about August 18, 2016 at approximately 2:13 p.m., a second phone interview with Staff A revealed that she completed an incident report regarding the incident involving Resident #1 on July 31, 2016. Staff A was asked to clarify the documentation on the incident report and whether the notes related to the administration of CPR were accurate. The incident report claimed that he (Staff A) “started CPR." Staff A responded, "No I don't know why I put that, I meant initiated CPR, I did not do CPR." When asked to explain what “initiated CPR” meant, she replied, "I removed the oxygen hose and seat buckle from Resident #1 and began to place her on the floor, that's it." Staff A could not recall how much time elapsed between when she made initial contact with distressed Resident #1 and when the paramedics arrived. Staff A confirmed she completed and signed the incident report and acknowledged the error on her part. On or about August 18, 2016 at approximately 2:38 p.m. a phone interview with Staff 16. B revealed that he worked at the facility from 7:00 am to 3:00 p.m. on July 31, 2016. On July 31, 2016, Staff A called Staff B to the wellness center for assistance with an unresponsive Resident. It took Staff B approximately two (2) minutes to arrive for assistance. There was a home health nurse present (name/company unknown) along with Staff A by the time staff B arrived. Staff B stated he observed Staff A on the phone with 9-1-1 and observed the nurse standing behind Resident #1 holding her hand and trying to awake the Resident #1. Staff B stated he observed "Resident #1 sitting in her wheelchair with her seat belt fastened and oxygen hose attached to her in a tangled position.” Staff B stated he proceeded to untangle the oxygen hose and seat belt off Resident#1 with help from the visiting nurse. Staff B stated Resident#1 was "unresponsive and looked really pale." He stated, "That’s when I tried to place her on the floor so I can start CPR on her, no I didn't do compression." Staff B confirmed he did "not perform CPR on Resident #1, nor did any other persons present at the time. On or about August 15, 2016 at approximately 9:45, the facility admitted Resident #1 on November 10, 2015. According to Resident#1's 1823 Health Assessment form (dated November 10, 2015) the 79-year-old female had a medical history and diagnosis that included peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, hyperlipidemia ,stable angina, congestive heart failure, Cardiac arrhythmia, Bilateral below knee amputations, tobacco dependence, history of falls, Oxygen dependent, Osteoporosis, and Anxiety disorder. Section 1, under activities of daily living, found the resident required assistance with bathing, dressing, ambulation, toileting, transferring and self-care (grooming). The examiner signed and dated the form on May 17, 2016. 18. 19. 20. On or about August 15, 2016, review of Resident #1's records (resident notification of community's do not resuscitate orders and advance directives policy) revealed an initial and check mark next to statement that read "I have NOT executed a Florida Do Not Resuscitate Order (DNRO) DH (department of health) FORM 1896." According to the document, both Resident #1 and the Executive Director signed and dated the form on March 18, 2016. A review of fire department records from (local Fire Department) revealed Resident #1 was not provided CPR care and services until the fire department truck engine 61 arrived on the scene July 31, 2016 at approximately 1:38 PM. They began CPR at 1:41 p.m. On July 31, 2016, Fire department engine 61 reported that the facility staff were "poor historians" and they were not given the resident’s down time. They documented the use of an AED (automated external defibrillator), no shock advised, airway placed and confirmed. Monitor revealed asystole and gave cardiac arrest medication. On or about July 31, 2016 at approximately 1:52 PM, Sunstar vehicle 67 arrived at on scene. The narrative read "Resident #1 was found by staff (specific staff not identified) unresponsive upon arrival. Fire Department attempting to establish an airway with an et tube. Resident #1 lifted to and from stretcher. Transportation to hospital occurred without incident. No change in patient condition.” On July 31, 2016 2:06 pm, Resident #1 arrived at hospital via SUNSTAR ambulance. Resident #1 was pronounced dead at the Hospital on July 31, 2016 at 2:19 PM. A record review of Emergency medical service report, facility records and hospital record showed evidence that 25 minutes elapsed from the time Resident #1 was identified as unresponsive (by staff A) until the time paramedics arrived on the scene 21. 22. 23. 24, 25. and initiated CPR (cardiopulmonary resuscitation). That the above reflects respondent’s failure to ensure residents reside in a safe and decent living environment free from abuse and neglect. That the Agency determined that this deficient practice created conditions or occurrences related to the operation and maintenance of a provider or to the care of clients, which presented an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom, and cited the Respondent with a Class I violation. Based upon the foregoing the Respondent has committed a Class I violation. Under Florida law, the Respondent as the licensee is legally responsible for all aspects of the provider operation. § 408.803(9), Fla. Stat. (2016). Under Florida law, in pertinent part, class I 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. § 408.813(2)(a), Fla. Stat. (2016). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2){a), Florida Statutes (2016). 26. 27, COUNT II The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. That Florida law provides: (1) POLICIES AND PROCEDURES. (a) Each assisted living facility (ALF) must have written policies and procedures, which delineate its position with respect to state laws and tules relative to DNROs. The policies and procedures shall not condition treatment or admission upon whether or not the individual has executed or waived a DNRO. The ALF must provide the following to each resident, or resident’s representative, at the time of admission: 1. A copy of Form SCHS-4-2006, “Health Care Advance Directives — The Patient’s Right to Decide,” April 2006, or with a copy of some other substantially similar document, which incorporates information regarding advance directives included in Chapter 765, F.S. Form SCHS-4-2006 is available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 34, Tallahassee, FL 32308, or the agency’s Web site at: http://ahca.myflorida.com/MCHQ/Health_Facility Regulation/HC_Advan ce_Directives/docs/adv_dir.pdf; and 2. Written information concerning the ALF’s policies regarding DNROs; and 3. Information about how to obtain DH Form 1896, Florida Do Not Resuscitate Order Form, incorporated by reference in Rule 64J-2.018, F.AC. (b) There must be documentation in the resident’s record indicating whether or not he or she has executed a DNRO. If a DNRO has been executed, a copy of that document must be made a part of the resident’s record. If the ALF does not receive a copy of a resident’s executed DNRO, the ALF must document in the resident’s record that it has requested a copy. (2) LICENSE REVOCATION. An ALF shall be subject to revocation of its license pursuant to Section 408.815, F.S., if, as a condition of treatment or admission, it requires an individual to execute or waive a DNRO. (3) DNRO PROCEDURES. Pursuant to Section 429.255, F.S., an ALF must honor a properly executed DNRO as follows: (a) In the event a resident experiences cardiopulmonary arrest, staff trained in cardiopulmonary resuscitation (CPR), or a licensed health care provider present in the facility, may withhold cardiopulmonary resuscitation. (b) In the event a resident is receiving hospice services and experiences cardiopulmonary arrest, facility staff must immediately contact the hospice. The hospice procedures shall take precedence over those of the assisted living facility. (4) LIABILITY. Pursuant to Section 429.255, F.S., ALF providers shall not be subject to criminal prosecution or civil liability, nor be considered to have engaged in negligent or unprofessional conduct, for following the procedures set forth in subsection (3) of this tule, which involves withholding or withdrawing cardiopulmonary resuscitation pursuant to a Do Not Resuscitate Order and rules adopted by the department. Rule 58A-5.0186, Florida Administrative Code. 10 28. 29. 30. That on August 18, 2016, the Agency completed a complaint survey (CCR # 2016009499) of Respondent’s facility. On or about August 15, 2016 at approximately 9:45 a.m., the facility admitted Resident #1 on November 10, 2015. According to Resident#l's 1823 Health Assessment form (dated November 10, 2015) the 79-year-old female had a medical history and diagnosis that included peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, hyperlipidemia ,stable angina, congestive heart failure, Cardiac arrhythmia, Bilateral below knee amputations, tobacco dependence, history of falls, Oxygen -dependent, Osteoporosis, and Anxiety disorder. Section 1, under activities of daily living, found the resident required assistance with bathing, dressing, ambulation, toileting, transferring and self-care (grooming). The examiner signed and dated the form on May 17, 2016. On or about August 15, 2016, a review of the facility C-9 Do Not Resuscitate & Advance Directives Policies and Procedures revealed the policy had been revised on September 2011 to reflect the following: "it is the policy of the company to honor our resident rights to refuse medical treatment through advance directive and do not resuscitate orders." Advance directives and/or Florida DNRO (Do Not Resuscitate) DH (Department of Health) form 1896 procedures were documented as the following; upon discovery and/or witnessing a resident in distress: 1. Assessed scene for safety. 2. If the resident is in medical distress call 911. 3. Determine unresponsiveness by opening airway and check for breathing. Check for signed of circulation such as pulse, coughing, or moving. 31. 32. 4, If there are NO signs of circulation request a second staff member to bring the AED (automated external defibrillator) and the DNRO (Do Not Resuscitate ) binder. Perform CPR and or first aid and unitize the AED (automated external defibrillator) as necessary. Section C reads " if you are unable to locate advance directives and DNRO (Do Not Resuscitate), DO NOT withhold life saving techniques." On or about August 16, 2016 at approximately 2:52 p.m., a phone interview with Staff A revealed that she worked at the facility on the incident date July 31, 2016. Staff A stated she immediately knew something was wrong because the Resident #1 appeared to be lifeless, with no noticeable discoloration or bruising of the skin. Staff A stated she immediately calied 9-1-1 and was instructed to initiate CPR on Resident #1. However, claimed she then called Staff B (LPN) for assistance, who arrived within one or two (1-2) minutes. Staff A stated "prior to calling for any assistance I yelled Resident #1's name and tried to wake her up by moving her arms and shaking her, but she remained unresponsive." Staff A confirmed she did not initiate CPR on Resident #1 when instructed to do so by 911. Staff A stated "I can't recall anything else that happened." Staff A stated "I can’t recall how much time had elapsed between the time I called 9-1-1 and the time EMS arrived to the scene. On or about August 18, 2016 at approximately 2:13 p.m., a second phone interview with Staff A revealed that she completed an incident report regarding the incident involving Resident #1 on July 31, 2016. The Agency asked Staff A to clarify the documentation on the incident report and whether the notes related to the administration of CPR were accurate. The incident report claimed that he Staff A 12 33. 34, "started CPR." Staff A responded, "No I don't know why I put that, I meant initiated CPR, I did not do CPR." When asked to explain what “initiated CPR” meant, she replied, "I removed the oxygen hose and seat buckle from Resident #1 and began to place her on the floor, that's it." Staff A could not recall how much time elapsed between when she made initial contact with distressed Resident #1 and when the paramedics arrived. Staff A confirmed she completed and signed the incident report and acknowledged the error on her part. On or about August 16, 2016 at approximately 2:38 p.m., a phone interview was with Staff B (Licensed Practical Nurse-weekend supervisor) revealed that he worked from 7:00 am to 3:00 p.m. on July 31, 2016. Staff B recalled being summoned to the wellness center on July 31, 2016 around 3 pm by staff A for assistance with resident #1, who was unresponsive. Staff B stated he observed "resident #1 sitting in her wheelchair with her seat belt fastened and oxygen hose attached to her in a tangled position." Staff B stated he proceeded to untangle the oxygen hose and seat belt off the resident #1 with help from the visiting nurse. Staff B stated resident #1 was "unresponsive and looked really pale." He stated, "That’s when I tried to place her on the floor so I can start CPR on her, no I didn't do compression. “Staff B confirmed he did "not perform CPR on resident #1, nor did any other persons that was present at the time of the event." The Surveyor identified time discrepancy with staff B. However, staff B insisted that this event took place at 3:00 p.m. on 7/31/2016. Resident was pronounced dead at the hospital on 7/31/16 at 2:19 p.m. On or about August 15, 2016, review of Resident #1's records (resident notification of community's do not resuscitate orders and advance directives policy, exhibit 6) revealed an initial and check mark next to statement that read "I have NOT executed a 13 Florida Do Not Resuscitate Order (DNRO) DH (department of health) FORM 1896." According to the document, both Resident #1 and the Executive Director signed and dated the form on March 18, 2016. 35. That the above reflects respondent’s failure to ensure that residents choice to receive medical care, including CPR, are honored. 36. That the Agency determined that this deficient practice created conditions or occurrences related to the operation and maintenance of a provider or to the care of clients, which presented an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom, and cited the Respondent with a Class I violation. 37. Based upon the foregoing the Respondent has committed a Class I violation. 38. | Under Florida law, the Respondent as the licensee is legally responsible for all aspects of the provider operation. § 408.803(9), Fla. Stat. (2016). 39. | Under Florida law, in pertinent part, class I 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. § 408.813(2)(a), Fla. Stat. (2016). WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(a), Florida Statutes (2016). COUNT III 32... The Agency re-alleges and incorporates Paragraphs one (1) through five (5) and Counts I, II, and II as if fully set forth herein. 33. That pursuant to Section 429.19(7), Florida Statutes (2016), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, 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 conducted under Section 429.28(3)(c), Florida Statues (2016), to verify the correction of the violations. 35. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes (2016). aw Respectfully submitted this 43 day of June, 2017. —Cadiden >. Raphael M. Ortega, Esq. Fla. Bar. No. 1000503 Counsel for Petitioner Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1945 (Office) 727.552.1440 (Fax) Raphael.Ortega@ahca.myflorida.com DISPLAY OF LICENSE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 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 attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg. #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR 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 has been served by U.S. Certified Mail, Return Receipt No. 7013 2250 0001 4950 4988 on June Bm” 2017 to Dawn Winder, Administrator, Grand Villa of Dunedin, 880 Patricia Avenue, Dunedin, FL 34698, and by regular U.S. Mail to Timothy Barns, Registered Agent GV Dunedin, LLC, 13770 58" Street North, Suite 312, Clearwater, FL 33760. iu A Raphael M. Ortega, Esq: Copy furnished-to: Timothy Barns Dawn Winder Raphael M. Ortega, Esq. Registered Agent GV Dunedin, Administrator Senior Attorney LLC Grand Villa of Dunedin Agency for Health Care Admin. 13770 58" Street North 880 Patricia Avenue 525 Mirror Lake Drive, #330D Suite 312 Dunedin, FL 34698 St. Petersburg, FL 33701 Clearwater, FL 33760 (US Certified Mail) (Interoffice Mail) (Regular U.S. Mail) Paul Brown Region 5, 6 ALF Manager STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: GV Dunedin, LLC d/b/a AHCA No. 2016010220 Grand Villa of Dunedin 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) J 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. 17 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 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 Gif 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. License Type: (ALF? Nursing Home? Medical Equipment? Other Type?) Licensee Name: License Number: Contact Person: Title: a Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) [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: SENDER: comple} ™ Compiete items 1,. und 3. Also complete item 4 if Restricted Delivery Is desired. l Print your name and address on the reverse ¥ rit So that we can return the card to you. B Received by ( Printed Nam © Attach this card to the back of the mailplece, = ecived by ( 7 or on the front if space permits. D. Is delivery address different from item 17 1 Yes 1. Article Addresse¢t-to: IfYES, enter delivery address below: C1 No f° Dawn Witider~ i *-” Administrator _ i . Grand Villa of Dunedin round Villa a Dunediy 880 Patricia Avenue ~ 3. Service Type SxCertified Mail 1 Express Mall din, FL 3 4698 CO Registered 1 Retum Receipt for Merchandise . + 0 insured Mat. Oc.o. 4, Restricted Delivery? (Extra Fee) 0 Yes 7013 2250 0001 4950 4944 °° - Oo. AO1LO1O2a® PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 Tracking Number: 70132250000149504988 Delivered Product & Tracking Information See Available Actions Postal Product: Features: Certified Mail” Your item was delivered to an individual at the address at 12:08 pm on June 15, 2017 in DUNEDIN, FL 34698. Date & Time Status of Item Location June 15, 2017, 12:08 pm Delivered, Left with DUNEDIN, FL 34698 Individual

Docket for Case No: 17-003807