STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2016006846 GV DELRAY WEST LLC d/b/a GRAND VILLA OF DELRAY WEST, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against GV Delray West LLC d/b/a Grand Villa of Delray West (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2016), and alleges: NATURE OF THE ACTION This is an action to impose administrative fines in the amount of six thousand dollars ($6,000.00) and a survey fee of five hundred dollars ($500.00), based upon Respondent being cited for two (2) Class II deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part Il, and 429, Part I, Florida Statutes (2016). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207, PARTIES The Respondent was issued a license (License number 123 62) by the Agency to operate an assisted living facility (“the Facility”) located at 5859 Heritage Park Way, Delray Beach, FL 33484. Respondent is licensed to operate a one hundred sixty-seven (167) bed facility. 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 statutes. COUNT I The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. That Florida law provides that no resident who requires 24-hour nursing supervision, except for a resident who is an enrolled hospice patient pursuant to part IV of chapter 400, shall be retained in a facility licensed under this part. § 429.26(11), Fla. Stat. (2016). That Florida law provides that: (1) ADMISSION CRITERIA. (a) An individual must meet the following minimum criteria in order to be admitted to a facility holding a standard, limited nursing or limited mental health license: 1. Be at least 18 years of age. 2. Be free from signs and symptoms of any communicable disease that is likely to be transmitted to other residents or staff} however, an individual who has human immunodeficiency virus (HIV) infection may be admitted to a facility, provided that the individual would otherwise be eligible for admission according to this rule. 3. Be able to perform the activities of daily living, with supervision or assistance if necessary. 4. Be able to transfer, with assistance if necessary. The assistance of more than one person is permitted. 5. Be capable of taking medication, by either self- administration, assistance with self-administration, or by administration of medication. a. If the resident needs assistance with self-administration, the facility must inform the resident of the professional qualifications of facility staff who will be providing this assistance. If unlicensed staff will be providing assistance with self-administration of medication, the facility must obtain written informed consent from the resident or the resident's surrogate, guardian, or attorney-in-fact. b. The facility may accept a resident who requires the administration of medication, if the facility has a nurse to provide this service, or the resident or the resident's legal Tepresentative, designee, surrogate, guardian, or atiomey-in- fact contracts with a licensed third party to provide this service to the resident. 6. Not have any special dietary needs that cannot be met by the facility. 7. Not be a danger to self or others as determined by a physician, or mental health practitioner licensed under Chapters 490 or 491, F.S. 8. Not require 24-hour licensed professional mental health treatment. 9. Not be bedridden. 10. Not have any stage 3 or 4 pressure sores. A resident requiring care of a stage 2 pressure sore may be admitted provided that: a. Such resident either: (I) Resides in a standard licensed facility and contracts directly with a licensed home health agency or a nurse to provide care, or (ID) Resides in a limited nursing services licensed facility and services are provided pursuant to a plan of care issued bya health care provider, or the resident contracts directly with a licensed home health agency or a nurse to provide care; b. The condition is documented in the resident's record and admission and discharge log; and c. If the resident’ s condition fails to improve within 30 days as documented by a health care provider, the resident must be discharged from the facility. 11. Not require any of the following nursing services: a. Oral, nasopharyngeal, or tracheotomy suctioning; b. Assistance with tube feeding; c. Monitoring of blood gases; d. Intermittent positive pressure breathing therapy; or e. Treatment of surgical incisions or wounds, unless the surgical incision or wound and the condition that caused it, has been stabilized and a plan of care developed. 12. Not require 24-hour nursing supervision. 13. Not require skilled rehabilitative services as described in Rule 59G-4,290, F.A.C. 14. Have been determined by the facility administrator to be appropriate for admission to the facility. The administrator must base the decision on: a. An assessment of the strengths, needs, and preferences of the individual, and the medical examination report required by Section 429.26, F.S., and subsection (2) of this rule; b. The facility's admission policy and the services the facility is prepared to provide or arrange in order to meet resident needs. Such services may not exceed the scope of the facility’s license unless specified elsewhere in this tule; and c. The ability of the facility to meet the uniform fire safety standards for assisted living facilities established in Section 429.41, F.S., and Rule Chapter 69A-40, F.A.C. (b) A resident who otherwise meets the admission criteria for residency in a standard licensed facility, but who requires assistance with the administration and regulation of portable oxygen, assistance with routine colostomy care, or assistance and monitoring of the application of anti- embolism stockings or hosiery as prescribed by a health care provider in accordance with manufacturer's guidelines, may be admitted to a facility with a standard license as long as the following conditions are met: 1. The facility must have a nurse on staff or under contract to provide the assistance or to provide training to the resident to perform these functions. 2. Nursing staff may not provide training to unlicensed persons to perform skilled nursing services, and may not delegate the nursing services described in this section to certified nursing assistants or unlicensed persons as defined in Section 429.256(1)(b), F.S. Certified nursing assistants may not be delegated the nursing services described in this section, but may apply anti-embolism stockings or hosiery under the supervision of a nurse in accordance with paragraph 64B9-15.002(1)(e), F.A.C. This provision does not restrict a resident or a resident's representative from contracting with a licensed third party to provide the assistance if the facility is agreeable to such an arrangement and the resident otherwise meets the criteria for admission and continued residency in a facility with a standard license. (c) An individual enrolled in and receiving hospice services may be admitted to an assisted living facility as long as the individual otherwise meets resident admission criteria. 10. 11, (d) Resident admission criteria for facilities holding an extended congregate care license are described in Rule 58A- 5.030, F.A.C. Rule 58A-5.0181, Fla. Admin. Code. That on or about March 28, 2016, the Agency completed a complaint survey of Respondent’s facility. Based on interview and record review, the facility failed to meet the minimum criteria to admit one (1) out of one (1) resident (resident #1). On or about March 22, 2016, at approximately 10:45AM, interview with the administrator revealed that resident #1 was admitted to the facility’s Memory Care Unit (hereinafter MCU) on February 18, 2016, and suffered a fall within a few hours thereafter. On or about March 22, 2016, at approximately 12:30PM, interview with the administrator revealed that resident #1 suffered a "little cut" on his head after he fell. He stated that the resident was sent to the hospital on February 18, 2016 at approximately 1:00pm. The Administrator stated that he did not evaluate the resident prior to admittance and he relied on the facility's (previous) memory care director and the memory care nursing supervisor to determine whether to admit the resident. The Administrator admitted that he did not personally ensure that resident #1 met the facility's admission criteria prior to admittance, which included the ability of the facility to meet the resident's specific needs. He stated that the facility did not ensure they received and maintained the resident's current health assessment and was therefore not aware of the resident's clinical functional and behavioral status prior to admission. The Administrator stated that he was unsure whether the resident was an appropriate candidate for admittance. The Administrator 13. 14. further acknowledged that neither he nor the facility’s direct care staff were aware of the results of the resident’s most recent medical examination (conducted on February 18, 2016). On or about March 22, 2016, at approximately 3:15PM, interview with the memory care nursing supervisor revealed that she performed resident #1’s nursing evaluation on about a week before his admission at his private residence. She determined that the resident was a fall risk due to a left foot drop, to which he did not wear a prosthetic device. She stated that the resident's foot drop was due to a neurological disorder and not a cerebral vascular accident. She also determined that the resident habitually got up in the middle of the night and the resident presented to be cooperative at the time. During her initial nursing assessment, she did not inform the resident that he would be admitted to the facility because she anticipated that the resident might overreact. She stated that she told the memory care director that the resident did not meet the facility's admission requirements due to the resident's extreme fall risk, and therefore the facility would not be able to meet his needs. She stated that the facility administration must have overruled her decision, given that the resident was admitted on February 18, 2016. She stated that when resident hit the side of his head on the wall when he fell. As a result of the fall the resident’s head broke the drywall in the MCU hallway next to the dining. She stated that she did not witness the resident's fall and was not aware if any direct care staff member was supervising the resident at the time. On or about March 23, 2016 at approximately 10:35AM, interview with the previous memory care director revealed that she admitted resident #1, and relied on the memory 15. care nursing supervisor's evaluation and an unspecified health assessment to admit this resident. She stated that the administrator did not question her decision admit resident #1 into the facility at any time. She stated that she was not aware when the physician completed the resident's health assessment, but she remembered that the health assessment indicated that the resident needed supervision with ambulation and transfers. She stated that the facility did not inform the resident that he was being admitted, and he overreacted when the resident realized that his family left him at the facility. She stated that she was not aware of the resident's clinical behavioral status before admission. She stated that she did not witness the resident falling on February 18, 2016 and was not aware whether the resident was being supervised in the moments leading up to the fall. She stated that the resident suffered a head injury as a result of the fall and did not notice any other injuries. She stated before resident #1’s admittance, the memory care nursing supervisor told her that resident #1 had unsteady gait. She did not recall any further discussions with the memory care nursing supervisor regarding the resident's admission criteria or whether the facility was able to meet the resident's needs. On or about March 23, 2016, at approximately 11:10AM, interview with MCU nurse 2 revealed that she was concemed for resident #1 because he became combative after his wife left him at the facility. She stated that the memory care director or the nursing supervisor did not brief her or any other MCU direct care staff members on or before February 18, 2016 regarding resident #1’s admittance. She stated that she believed that resident #1 needed a wheelchair instcad of a walker for ambulation as a safety precaution, however she was unable to make this determination because the facility did not have the resident's health assessment on file. She stated that resident #1 needed supervision 16. 17. 18. during ambulation and transferring, and she was not aware whether any staff was supervising the resident when he fell. On or about March 23, 2016, at approximately12:00PM, interview with MCU caregiver 4 revealed she attempted to escort resident #1 inside the dining room so he could participate in another resident's birthday celebration. However, resident #1 refused and she proceeded to go inside the dining room without the resident. She stated that the resident fell immediately after their encounter and confirmed that she was not supervising resident #1 before he fell. Furthermore, she did not observe any other staff members supervising the resident while he was in the MCU hallway before he fell. She stated that resident #1 was extremely combative before and after he fell. She felt the resident was not appropriate candidate for admission due to his behavior. She stated that the resident was ambulating uncontrollably while using a rolling walker, which appeared unsafe for the resident’s use and posed a safety hazard to other residents. She stated that when the resident fell he hit his head on the wall and was bleeding profusely. On or about March 23, 2016, at approximately 12:55PM, interview with the administrator revealed that the administrator relied on both staff members, previous memory care director, and the memory care nursing supervisor to make resident #1's admission decision. However, the administrator admitted that he did not seek or consider the memory care nursing supervisor's recommendation before deciding whether to admit resident #1 to the facility. Review of the hospital records indicated that resident #1 was admitted to the emergency department on February 18, 2016 at approximately 3:04PM with injuries sustained to his head and left forearm. Further review of the hospital records indicated that the hospital discharged the resident to a hospice unit on February 18, 2016. 19. On or about March 30, 2016, at approximately 11:20AM, interview with resident #1's hospice physician revealed that he provided medical care to resident #1 while the resident was in the hospice unit for end of life care. The physician revealed that he examined the resident on February 19, 2016. During this examination, the resident was minimally responsive and agitated due to an acute subdural hematoma, and on February 21, 2016, the resident was unresponsive and had ineffective breathing. He stated that the resident passed away on February 22, 2016 from suspected complications of the resident's underlying dementia condition coupled with the acute subdural hematoma. 20. Under Florida law, in pertinent part, class II are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2016). 21. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. 22. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2014), and Respondent was cited with a Class II deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2016). 23. 24. 25. COUNT II The Agency re-alleges and incorporates paragraphs one (1) through five (5), and paragraphs thirteen (13) through nineteen (19) as if fully set forth herein. Pursuant to Section 429,26(7), Florida Statutes (2016), the facility must notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and services to treat the condition. That Florida law provides that: An assisted living facility must provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities must offer personal supervision as appropriate for each resident, including the following:(a) Monitoring of 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 resident. (c) Maintaining a 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. (€) Maintaining a written record, updated as needed, of any significant changes, any illnesses that resulted in medical attention, 26. 27. 28. 29. changes in the method of medication administration, or other changes that resulted in the provision of additional services, Rule 58A-5.0182 Fla. Admin. Code. That on or about March 28, 2016, the Agency completed a complaint survey of Respondent’s facility. Based on observation, interview and record review, the facility failed to provide assisted living services to identified at-risk residents by not properly supervising their care and by not promoting the safety and physical well-being for six (6) out of seven (7) sampled residents (residents #1,2,3,4, 5 and 6). On or about March 22, 2016, at approximately 10:45AM, interview with the administrator revealed that the facility admitted resident #1 to its Memory Care Unit (MCU) on February 18, 2016, and suffered a fall within a few hours thereafter. On or about March 22, 2016, at approximately 1:00PM, interview with the administrator revealed that it was common facility practice to document whether a resident is a fall risk in the charting log. The facility did not enter Resident #1 into this log until after the resident suffered a fall on February 18, 2016. The administrator stated that the resident had abnormal gait. He further stated that the facility did not have a specific resident fall tisk policies and procedures necessary to protect, prevent and reduce the risk for falls and accidents. Review of the charting log (dated February 18, 2016) indicated that resident #1 had unsteady gait, lost his balance and then fell. Emergency services subsequently transported the resident to the hospital. Review of the facility's policies and procedures on March 22, 2016 indicated that there were no specific procedures or interventions in place to address residents prone to falls or accidents. 30. 31. 32, 33. On or about March 23, 2016, at approximately 9:40AM, interview with the memory care nursing supervisor on revealed that resident #5 ate breakfast and thereafter proceeded to his room to rest. She was not aware whether the resident was supervised or needed direct care assistance when he went into his bedroom that morning. Observations revealed that the resident was resting and his shoes were placed on top of the nightstand next to his bed. On or about March 23, 2016, at approximately 12:10PM, observations revealed that resident #5 transferred and ambulated independently from bed to the bathroom without any direct care assistance. On or about March 23, 2016, at approximately 12:15PM, interview with caregiver 6 revealed that she was responsible for providing direct care assistance MCU residents, but did not assist resident #5 to go to the bathroom. She stated that she only assisted him with ambulating down the hallway until the resident reached the dining room entrance. Once the resident reached the dining room entrance, the care giver allowed the resident to walk unassisted to his table. She stated that she did not know the level of assistance the resident needed for toileting, ambulation or transfers, but she habitually allowed the resident to go to the bathroom, ambulate and transfer independently, without direct assistance. Review of resident #5's health assessment (dated Mach 16, 2016) revealed that he was diagnosed with diabetes, atrial fibrillation, dementia, and osteoarthritis. The health assessment also indicated that the resident had physical limitations, including difficulty with walking and muscle weakness. Further review of his health assessment indicated 12 34. 35. 36. 37. that the resident needed direct care assistance with all daily living activities, including toileting, ambulation and transferring. On or about March 23, 2016, at approximately 11:30AM, observation revealed that resident #6 was ambulating in the MCU hallway independently and without any assistive device. On or about March 23, 2016, at approximately 11:35AM, interview with MCU caregiver 5 revealed that the resident was supposed to use a walker to ambulate. Further interview with the MCU caregiver revealed that he was unaware of resident #6's ambulation requirements and was informed by another caregiver that the resident did not use a walker to ambulate. Review of resident #6's health assessment (dated March 8, 2016) revealed that she was diagnosed with hypertension, muscle weakness, dementia, unspecified psychosis and anxiety disorder. Further review of the health assessment indicated that the resident's physician ordered physical and occupational therapy evaluations for the resident. Review of the resident's record indicated that the resident was found lying on her bedroom floor on March 20, 2016 at approximately 11:00PM. The resident suffered a closed head injury, scalp laceration, and injury to her tight elbow. The resident was treated for injuries at the hospital on March 20, 2016. The resident was readmitted to the facility on March 21, 2016. On or about March 23, 2016, at approximately 12:05PM, interview with the memory care supervising nurse revealed that she was unaware of resident #6's actual physical and functional activities of daily living status because the facility did not ensure the resident received the physician ordered physical and occupational therapy evaluations. She stated 13 38. 39. 40. that she felt that resident #6 needed supervision with all of her activities of daily living, including ambulation and transfers. She stated that she did not complete the facility's incident investigation after the resident returned to the facility on March 21, 2016. She stated that a resident incident investigation must be performed immediately after an incident to help determine contributors to the resident's accident/injury and interventions to prevent further accidents/injuries. Review of resident #4's medical record indicated that he was admitted to the MCU on July 22, 2015. The resident’s diagnoses included dementia, depression, syncope, status/post (S/P) fall and right hip fracture, hypertension, anemia and chronic renal insufficiency. Review of the resident's admission health assessment (dated July 28, 2015) indicated that he required extensive assistance with all activities of daily living. Further review indicated the resident was alert but forgetful and required physical therapy /occupational therapy (PT/OT) services. Review of the facility internal "Resident Service Sheet" (dated July 16, 2015) indicated that the resident #4 required supervision with ambulation and transfers and utilized a walker and wheelchair. Review of the physical therapy discharge summary (dated September 22, 2015) indicated that resident #4 could move independently for bed mobility but required supervision for ambulation with a rolling walker and transfers. Resident #4 was assessed as a fall risk due to his unsteadiness and cognitive deficits. The summary indicated that the caregivers were advised to always supervise the resident when standing or walking. Review of the resident #4’s health assessment (dated on March 8, 2016) indicated that the resident was independent with ambulation with an assistive device, but required PT/OT 14 41. 42. services. Further review of the record indicated that the resident was independent for self care, toileting and transfers. Review of the facility Resident Service Sheet (dated March 8, 2016) indicated that resident #4 was independent for ambulation, eating, grooming, toileting and transfers. Resident #4 required supervision during showers and dressing, and ambulated with a walker. Review of resident #4's facility incident report (dated March 19, 2016) indicated that a care giver found the resident on the floor in his room at approximately 3:15AM. The report referenced observation of skin tears on the resident’s ri ght arm and lower leg. The tesident also complained of right hip pain. The report indicated that the care giver notified the physician and family, in addition to reporting the incident to the nursing supervisor. There was no additional documentation contained in the report concerning any investigation of the incident. Review of the facility electronic progress notes (dated March 19, 2016 at 10:30AM) indicated that resident #4 complained of right hip pain and was unable to bear weight on his right leg. Staff notified the physician and an x-ray of the right hip area was ordered, Further review indicated that the X-ray was completed at 10:45AM and the physician was notified of the test results at 2:30PM. Resident #4 was transferred to the hospital for evaluation of a tight hip fracture at 3:30PM on March 19, 2016. Review of the facility incident report log sheet for March 2016 indicated no documentation of resident #4 's fall or hospitalization. Review of resident #4's hospital emergency department record (dated March 19, 2016) indicated that he arrived to the hospital by emergency transportation due to injuries from an unwitnessed fall while he was attempting to ambulate to the toilet at the facility. The records also indicated that resident #4 had sustained a right periprosthetic femur fracture. 15 43. 44, The resident had moderate pain upon admission and had no recollection of the fall. The hospital record indicated that resident #4 was assessed to be a fall risk and he was placed on the hospital's fall prevention program. On or about March 23, 2016, at approximately 10:45AM, interview with the caregiver on revealed that resident #4 was independent with ambulation with a rolling walker. She stated that the resident ambulated on his own throughout the MCU and he required no physical support or direction while ambulating. On or about March 23, 2016, at approximately 11 :50AM, interview with the memory care nursing supervisor revealed that she understood that resident #4 was independent with ambulation, transfers, toileting and grooming and he required supervision with bathing and dressing. She stated that resident #4 received PT services briefly after his admission but she was unable to provide any documentation of the PT evaluation or services which had been provided. She stated that the resident had experienced a prior fall and suffered a right hip fracture. After that incident, the resident was not assessed as a fall risk and the facility did not implement any interventions to reduce or prevent future accidents or falls. The nurse reviewed the resident's current 1823 Health Assessment form (dated on March 8, 2016) which indicated that the resident needed "PT/OT service.” However, the nurse had failed to communicate with the health care provider/ physician to discuss PT services for the resident. She stated that based on her nursing judgement, the resident should have been considered a fall risk and had ADL care levels reevaluated. The nurse stated that she had not communicated with the hospital to determine resident #4's condition and the potential readmission timeframe. She stated that she had not 45. 46. 47 completed the incident investigation and had not made any determination of potential interventions to reduce resident #4's fall risk upon his readmission. On or about March 24, 2016, at approximately 1:50PM, interview with resident #4's physician revealed that the resident may have been assessed to be independent with ambulation and transfers but should have been monitored within the unit. He stated that the healthcare provider who had completed resident #4's assessment on March 8, 2016 was employed by his office. The physician stated that if the health care provider had documented the requirement for PT/OT services then the facility should have notified him and obtained the PT evaluation orders. He stated that he relied on the PT evaluation to further assess the resident #4's current functional status and felt the PT services would benefit the resident. He stated that he reviewed his electronic medical records and did not locate any documentation that the facility had contacted him for orders and he was not aware of any safety precautions the facility had established for the resident. He stated that resident #4 was admitted to the MCU based on his medical diagnoses and requirement for supervision and oversight. In multiple observations conducted on March 22, 2016 through March 23, 2016, revealed that resident #2 was observed ambulating with the assistance of a rolling walker throughout the MCU without staff supervision. Observations further revealed that the resident had an area of greenish/ purple bruising on her right forehead and under her right eye. The resident was only responsive when called by name, and when questioned about her injury the resident replied that she had fallen. Review of resident #2’s record indicated that the facility’s MCU admitted the resident during April 2013, with diagnoses including dementia and depression. Review of the 17 48. 49. 50. resident #2's current health assessment (dated April 2, 2015) indicated that she was independent for ambulation and transfers, and she needed standby assistance with bathing, dressing, grooming, and toileting. Review of the facility internal Resident Service Sheet (dated on April 2, 2015) indicated that resident #2 was stable using the walker but required verbal reminders to use her walker. Review of resident #2 's facility incident report (dated on March 10, 2016) indicated that the resident screamed for help and was found on the floor in an activity area at 1:15 AM, with a hematoma on her right forehead. Resident #2 was transported to the hospital for further evaluation and the medical physician and family were notified of the incident. Review of the facility electronic record indicated the resident returned to the facility that same day. Further review of the facility incident report indicated that an investigation was conducted on March 10, 2016, which included documented interventions to be implemented for the resident as "Resident on PT", and staff interventions which included monitoring. Further review of the electronic record notes indicated the resident #2 continued to ambulate with the rolling walker throughout the unit with no difficulty and staff reminded the resident to utilize her walker. Further review of resident #2's medical record indicated no additional contact with the physician after the initial notification and no request for reassessment of the resident as a fall risk, no orders for physical therapy evaluation or reevaluation by the nursing staff to update the resident's service sheet. Review of resident #2's hospital emergency department (ED) record (dated on March 10, 2016) indicated that she arrived to the ho spital by emergency transportation due to 51. 52. 53. injuries from a fall while ambulating in the facility. This record indicated that she sustained a right forehead hematoma. On or about March 23, 2016, at approximately 11 :45AM, interview with the memory care nursing supervisor revealed that she understood that resident #2 was mostly independent with ambulation and transfers and required supervision with bathing, dressing and toileting. She stated that the facility did not implement any demonstrable interventions to reduce or prevent future accidents or falls for the resident after her hospitalization. She stated that she thought resident #2 had been on PT services but was unable to provide any documentation of such services. She stated that she had not been in communication with the health care provider to discuss physical therapy (PT) for the resident. She stated that resident #2 should have been considered a fall risk and reevaluated for her ADL care. She stated that the facility’s policy included that after each fall, the resident should be reevaluated and the facility should complete a new Resident Service form. She stated that she had not completed the form. On or about March 23, 2016, at approximately 10:45AM, interview with the caregiver revealed that resident #2 was independent with ambulation with a rolling walker. She stated that the resident had recently fallen and the staff should have monitored the resident more frequently. She stated that the resident was known to wander throughout the unit unsupervised. She stated that unit did not utilize any personalized call bell system due to the resident's cognitive limitations, therefore the staff was responsible for monitoring the residents for falls. On or about March 24, 2016, at approximately 1:50PM, interview with resident #2's physician revealed that the staff may have assessed the resident as independent with 54. 55. ambulation and transfers, but should be monitored more closely within the unit and be reevaluated with PT services provided as a result of the fall. He stated that he relied on the PT evaluation to further assess the resident #2's functional status and felt the PT services would benefit the resident. He stated that he reviewed his electronic medical records and could not locate have any documentation that the facility had contacted him for orders and he was not aware of any safety precautions the facility had established for the resident after her fall. Review of resident #3's record indicated that the facility’s MCU admitted the resident on March 14, 2016 with Alzheimer's, heart disease, dysphagia, chronic kidney disease and benign prostatic hyperplasia. Review of resident #3's admission health assessment (dated February 23, 2016) indicated that he required extensive assistance with all activities of daily living, including two-person assistance with transfer, bathing, dressing and toileting. Further review indicated resident #3 was oriented to person only and could follow simple commands. The assessment indicated the resident had progressive Cognitive loss and muscle strength becoming weaker in gait performance. Review of the facility internal "Pre move-in" Resident Service sheet (dated on February 26, 2016) indicated resident #3 required supervision with ambulation and transfers and utilized a walker. Further review of the facility internal Resident Service sheet indicated that resident #3 required assistance for showers, dressing, grooming and toileting. The form indicated the resident needed PT/OT evaluation for admission. Multiple observations conducted on March 22, 2016 through March 23, 2016 revealed that resident #3 was observed sitting in his wheelchair participating in activity programs and in the dining room for his meals. Resident #3 was observed making attempts to move 20 56. 37. 58. his wheelchair and attempting to stand without any assistance. The staff was observed and heard providing verbal cueing for the resident to remain seated in his wheelchair. Review of resident #3's facility incident report (dated on March 22, 2016) indicated that a care giver found the resident on the floor in his room at 6:00AM. Observations revealed bruising on both arms and no other observed injuries. The care giver who notified the day shift nursing supervisor completed the incident report. Further review of the report indicated no additional documentation concerning the investigation of the incident. On or about March 22, 2016, at approximately 14:45AM, interview with the caregiver revealed that resident #3 required staff assistance for his activities of daily living (ADL). She stated resident #3 was unable to ambulate and was only able to take one-to-two (1-2) steps for transfers. She stated that the resident used a wheelchair for mobility and staff were required to monitor the resident at all times because he had attempted to stand unassisted. She stated that she was not sure if he had sustained any falls since his admission or if he was considered a fall risk. She stated that the nursing supervisor would provide her with a verbal notification when a resident was considered a fall risk. She stated that she was not sure what other specific interventions would be implemented if a resident were identified as a fall risk, except only to monitor the resident. On or about March 23, 2016, at approximately 1 1:50PM, interview with the memory care nursing supervisor revealed that she understood that resident #3 required extensive assistance for his ADL care. She stated that he was unsteady while standing and required one-to-two (1-2) staff for transfers and he was utilized a wheelchair for mobility. She stated that she had reviewed the Resident Service sheet prior to resident #3's admission and felt the resident had a very high potential as a fall risk and would require additional 21 59, 60. 61. staff supervision. The nurse reviewed the resident's current 1823 Health Assessment form (dated February 23, 2016) which indicated the resident was not a fall risk, and no requirement of nursing or PT therapy. She stated that she had not been in communication with the health care provider/ physician to discuss a PT evaluation/services for the resident. She stated that resident #3 was found on the floor in his room on March 22, 2016 at 6:00AM. Under Florida law, in pertinent part, class II are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2016). The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of the provider or to the care of clients which directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. That the same constitutes a Class II offense as defined in Florida Statute 429.1 9(2)(b) (2014), and Respondent was cited with a Class II deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(b), Florida Statutes (2016). 62. COUNT Ii The Agency re-alleges and incorporates paragraphs (1) through (5) and Counts J and II as 22 if fully set forth herein. 63. 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 haif 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 (2014), to verify the correction of the violations. 64. That Respondent was subject to the citation of one or more Class II deficient practices or the citation of a violation that was subject of the complaint which requires the imposition of a survey pursuant to law. See, Section 429.28(3)(c), Florida Statues (2016). 65. That Respondent is therefore subject to a survey fee of five hundred ($500.00) dollars), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes (2016). Respectfully submitted this __ day of May, 2017. Raphael M. Ortega, Esquire Fla. Bar. No. (PENDING) Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1945 (office) Raphael.Ortega@ahca.myflorida.com 23 DISPLAY OF LICENSE Respondent is notified that it has a tight 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 4926 Rene Buck, Administrator, and Timothy R. Barns, Registered Agent, 13770 58" Street N., Ste 3 12, Clearwater, FL 33760, . on this day of May, 2017. Zegle Raphael M. Ortega, Esquire Fla. Bar. No. (PENDING) Agency for Health Care Admin. 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1945 (office) Copy furnished to: Arlene Mayo-Davis Field Office Manager, Delray Agency for Healthcare Admin. 24 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: GV Delray West LLC d/b/a AHCA No. 2016006846 Grand Villa of Delray West 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 Se RRR NY 1 OF EHESE 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. 25 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 Gf 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: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) Thereby certify that I am duly authorized to submit this Election of Ri ghts to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: 26 Tracking Number: 70132250000149504926 Delivered Product & Tracking Information See Available Actions Postal Features: Product: Certified Mail™ Your item was delivered to the front desk or reception area at 11:31 am on May 15, 2017 in CLEARWATER, FL 33760. DATE & TIME STATUS OF ITEM LOCATION May 15, 2017, 11:31 am Delivered, Front CLEARWATER, FL 33760 Desk/Reception 'Y our item was delivered to the front desk or reception area at 11:31 am on May 15, 2017 in| CLEARWATER, FL 33760 May 15, 2017, 3:21 am Departed USPS Facility SARASOTA, FL 34260 May 14, 2017, 11:17 am Arrived at USPS Facility SARASOTA, FL 34260 May 12, 2017, 3:32 am Arrived at USPS Facility TAMPA, FL 33605

Docket for Case No: 17-005412

Orders for Case No: 17-005412