STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No.: 2017009937 AVANTE AT ORLANDO, INC. Respondent. / ADMINISTRATIVE COMPLAINT The Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), files this Administrative Complaint against the Respondent, Avante at Orlando, Inc. (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges as follows: NATURE OF THE ACTION This is an action to impose administrative fines totaling $43,500.00 from the following: three $12,500.00 fines based upon three Class I violations; a $6,000 fine based upon a 6-month survey cycle; to affirm conditional licensure status commencing on April 7, 2017 and expiring on April 26, 2017; and to revoke the Respondent’s license to operate a skilled nursing facility. PARTIES 1. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities (also called nursing homes) and enforces the state statutes and rules governing such facilities. Ch. 408, Part II, Ch. 400, Part Il, Fla. Stat.; Ch. 59A-4, Fla. Admin. Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121, and 400.23, Fla. Stat, (2016), assign a conditional license pursuant to Subsection 400.23(7), Fla. Stat., (2016), and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Fla. Stat., (2016). 2. The Respondent was issued a license by the Agency to operate a nursing home located at 2000 North Semoran Boulevard, Orlando, Florida 32807, and was at all times material required to comply with the applicable statutes and rules governing nursing homes. COUNT I Right to Adequate and Appropriate Health Care 3. Under Florida statutes, in pertinent part: (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: * * * 6) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. (m) The right to have privacy in treatment and in caring for personal needs; to close room doors and to have facility personnel knock before entering the room, except in the case of an emergency or unless medically contraindicated; and to security in storing and using personal possessions. Privacy of the resident’s body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene, except as needed for resident safety or assistance. Residents’ personal and medical records shall be confidential and exempt from the provisions of s. 119.07(1). (n) The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis. § 400.022(1)(), (m), (n), Fla. Stat. (2016). Facts 4. On or about April 4, 2017 to April 7, 2017 the Agency conducted a complaint survey at Respondent’s Facility. 5! Based on interview, record review, and policy review, the Agency determined Respondent’s Facility failed to provide supervision and ensure that adequate care and services were provided for 8 residents. 6. During the survey, the Agency’s surveyors became aware of an activity outing to a supercenter that occurred on February 8, 2017. 7. During the outing an elderly resident (Resident #1) fell while attempting to use the toilet unsupervised and sustained a fracture to his/her right hip. 8. The activity director was to follow the buses in her own personal car, but she did not attend. At 9:15 AM, while she was still in the facility, she sent a text message on her personal cellular phone to the business office manager saying she had to go home and would not be attending the outing. She did not inform the administrator at that time. The business office manager informed the administrator that the activity director had to go home and would not be going to the outing at the supercenter, already in progress. 9. On or about April 4, 2017 the Agency reviewed care plans for the 9 residents who attended an outing to an area supercenter store on February 8, 2017. 10. 5 residents who attended the outing required wheelchairs for mobility (Residents #1, #2, #3, #4 & #8); 3 residents required walkers (Residents #5, #7 & #9); one resident was independent with ambulation (Resident #6); 3 residents required extensive assistance with toileting and were incontinent (Residents #1, #2 & #3); and 1 resident required supervision with toileting (Resident #8). 11. Resident #1’s care plan identified diagnoses including multiple sclerosis, weakness, dementia, seizures, suprapubic catheter and recurrent falls. 12. Resident #1’s care plan identified that could voice his/her needs, was a high risk for falls, had 9 falls in the past year, was wheelchair dependent, had chronic pain, and was dependent on staff for toileting and activities of daily living including transfers, eating and dressing. 13. Resident #1’s care plan also noted that he/she was at risk for decline in overall health status related to progression of his diseases. 14. _ Resident #1 had a suprapubic catheter and was incontinent of bowel at times, but was also able to tell staff when a restroom was needed. 15. On or about April 4, 2017 the Agency interviewed Resident #1. 16. Resident #1 stated he/she enjoyed going to the supercenter, it was his/her favorite outing. 17. Resident #1 stated that on the February 8, 2017 outing, he/she had an urgent need to use the restroom shortly after arriving at the supercenter. Resident #1 then said he/she could not find the activity assistant in the area at that time, but did not want to have an accident. 18. Resident #1 was aware that he/she needed assistance to use the toilet, but felt he/she had no choice. Resident #1 said he/she attempted to transfer him/herself from the wheelchair onto the toilet, but slipped and fell. 19. Resident #1 reported that he/she heard a cracking sound during the fall and started to yell for help. 20. Resident #1 stated when he/she was in the facility, he/she could use a call light to summon help, but there was no way to call for someone at the supercenter. 21. An unknown person in the restroom went to go get help for Resident #1, which resulted in Respondent’s Activity Assistant being paged by the store intercom. 22. Resident #1 then stated that the Activity Assistant arrived at the restroom after some time and cleaned Resident #1 up, dressed him/her and tried to transfer the resident into the wheelchair, but could not do it on his own and had to get help. 23. Resident #1 finally stated that he/she was embarrassed about the accident in the restroom, falling, and having the Activity Assistant and a stranger clean him/her up. 24. The Agency reviewed resident records for Resident #1 that revealed the resident was diagnosed with a fractured right hip as a result of the fall one day after the outing incident, on February 9, 2017. 25. The review also revealed Resident #1 was transferred to a hospital for surgical repair of the right fractured hip on February 10, 2017. 26. The Agency then reviewed Resident #1’s minimum data set (“MDS”) assessment, dated January 6, 2017. 27. The MDS Assessment noted Resident #1’s brief interview for mental status (“BIMS”) score was 13 out of possible score of 15 indicating that he/she was cognitively intact; It showed that Resident #1 required a wheelchair for mobility; and it showed Resident #1 required extensive assistance of one person for transfers, toileting, eating, dressing, and was incontinent of bowels. 28. The Agency also reviewed Resident #1’s care plan with target date of June 1, 2017. 29. On or about April 4, 2017, the agency reviewed Respondent’s activities care plan with a target date of June 1, 2017. 30. The interventions for Resident #1 contained in the activities care plan had not changed. The care plan read that the resident enjoyed attending facility outings, but there were no interventions as to how the facility would supervise and keep Resident #1 safe while on outings. 31. The date of the last review and intervention was noted as August 9, 2015. 32. On or about April 4, 2017. the Agency interviewed Respondent’s Activity Assistant. 33. The Activity Assistant stated that he had been an activity assistant for two years. 34. The Activity Assistant further stated that there were monthly outings to the supercenter because it was a favorite outing for residents. He said he had attended numerous outings to the supercenter with 5-8 residents. 35. The Activity Assistant then stated that on February 8, 2017, two buses were used for transporting 9 residents and himself. Because the Activity Assistant was the only facility staff attending the outing on that date, the residents on the other bus were without supervision. 36. The Activity Assistant stated that the group arrived at the supercenter at approximately 9:00 A.M. 7 residents, including Resident #1, went in different directions to shop while the Activity Assistant stayed with Residents #2 and #4. 37. The Activity Assistant explained that Resident #2 needed a staff member to move his/her wheelchair and Resident #4 was cognitively impaired, but was able to mobilize her wheelchair without assistance. 38. The Activity Assistant then stated that he was with these two residents when he heard his name being paged overhead requesting him to come to customer service. He stated that he headed to customer service with Residents #2 and #4 and was informed that someone from his group needed help in the restroom. 39. The Activity Assistant continued stating that he went into the restroom, leaving Residents #2 and #4 unsupervised near-by. 40. The Activity Assistant stated that when he went into the restroom, he observed Resident #1 hanging onto the safety rail trying to pull him/herself up from the floor, but let him/herself down when the assistant arrived. 41. The Activity Assistant described that Resident #1 had feces on his/her clothing, along with feces on the floor and toilet. 42. The Activity Assistant asked a supercenter employee to help, but she could not tolerate the odor in the restroom, so a supercenter housekeeping employee assisted the Activity Assistant. 43. The Activity Assistant stated that he did not have any supplies with him and the supercenter supervisor gave him latex gloves, paper towels and garbage bags. He said he cleaned Resident #1 up as much as he could, and the supercenter housekeeping staff assisted him to transfer Resident #1 into the wheelchair. 44. The Activity Assistant additionally stated he asked a supercenter employee to buy some clothing for Resident #1 so the resident could have clean clothes. The supercenter employee bought shorts, shirt, socks, and sandals so that Resident #1 could change clothes. 45. Finally, the Activity Assistant said they exited the restrooms, Resident #1 wanted to continue to shop, but the assistant did not want Resident #1 to do any shopping due to the resident’s odor. Resident #1 then finished shopping, while the Activity Assistant took Residents #4 and #2 to the nail salon located in front of the supercenter. 46. The Activity Assistant said Resident #1 did not complain of any pain during the outing on February 8, 2017. 47. On or about April 6, 2017 the Agency interviewed the Respondent’s Advanced Registered Nurse Practitioner (““ARNP”). 48. The ARNP stated that she had known Resident #1 since September 2016. 49. She said the resident had chronic constipation and chronic ileus, and his/her bowel movements were unpredictable. 50. The ARNP further stated that Resident #1 could have the need use the toilet anytime, as he/she received several laxatives in the morning of the activity outing on February 8, 2017. 51. | The ARNP then said Resident #1 had dementia and was a very high fall risk, additionally the resident had multiple sclerosis and his/her legs were very weak. 52. The ARNP stated that Resident #1 should never go anywhere on his/her own, especially a large supercenter. She continued to state that someone needed to have sight of Resident #1 at all times. 53. | The ARNP stated that in the Facility there are ways for residents to call for help, but not in an outside area like the supercenter. 54. The ARNP then stated that she was made aware of Resident #1’s fall on February 8, 2017. 55. The ARNP continued to state that she saw Resident #1 on February 9, 2017 and when she extended the resident’s right knee, he/she had severe pain. After that, the ARNP ordered x-rays and the results showed Resident #1 had a fractured right hip. 56. | The ARNP finally stated that Resident #1 was transferred to a hospital for surgical repair of the right hip on February 10, 2017. 57. On or about April 4, 2017, the Agency interviewed Respondent’s employee, a certified nursing assistant (“CNA G”). 58. CNA G stated that Resident #1 required one-person assistance for toileting, transfers, and dressing. 59. | CNA G then stated that Resident #1 always called for assistance when needing to use the toilet. She stated Resident #1 would either use the call light to call for help, or would tell staff that he/she needs to go. 60. CNA G additionally stated she had never seen Resident #1 attempting to toilet without supervision. 61. Prior to the February 8, 2017, outing, CNA G stated Resident #1 required one person to assist with toileting as the resident was able to hold on to the safety rail and pivot. Now, CNA G said as a result of the fall and fracture, Resident #1 required two people to assist with toileting. 62. On or about April 6, 2017, the Agency interviewed Respondent’s employee, an additional certified nursing assistant (“CNA H”). 63. | CNA H stated that she had known Resident #1 for the past two months. 64. CNAH then stated that Resident #1 had a suprapubic catheter, was incontinent of bowels, but could also inform staff when he/she needed to use a restroom. 65. CNA H confirmed Resident #1 always called for assistance with toileting and had never attempted to toilet unsupervised. 66. CNAH finally stated Resident #1 knows he/she cannot toilet alone, so the resident does not try to toilet alone. 67. | Onor about April 6, 2017, the Agency observed CNA H and an additional Facility employee enter Resident #1’s room to assist the resident with toileting. 68. | Onor about April 5, 2017 the Agency interviewed Respondent’s Activity Director. 69. The Activity Director stated that she had worked at the Facility for 10 years. 70. She confirmed that the monthly supercenter outing was a favorite for residents. The Activity Director continued to state that she had always sent one person on outings as that was their normal procedure. 71. The Activity Director did state that she would also attend the outings sometimes, but she did not provide assistance or supervision for the other residents; instead, she was there to shop for residents who could not attend the outing. 72. The Activity Director then stated that it is difficult to prevent falls at the supercenter because residents are on their own, it is tricky as it's a big area and hard to keep track of residents. 73. | Onor about April 4, 2017, the Agency interviewed Respondent’s Administrator. 74, The Administrator stated that the Activity Director managed the outings, but since February 8, 2017, the Administrator is more involved in directing the outings. 75. The Administrator then stated that he was aware that 9 residents were going on the outing with only one activity assistant on February 8, 2017, but he did not think anything of it because they usually only send one activity assistant on outings. 76. The Administrator stated he was familiar with the residents on the outing and their care needs. 77. The Administrator continued to state that the Facility had never had any issues on outings before and he didn't think anything of one staff being there at the supercenter with the 9 residents, 78. The Administrator finally stated, looking back, he would do things differently and would send more staff to supervise residents. 79. The Administrator reported that he, the Respondent’s regional consultant, and corporate risk manager had recently developed a form to use for outings, which would determine how many staff would accompany residents on outings. 80. On or about April 5, 2017, the Agency reviewed a document titled “Avante of Orlando Activity Outing Request”, dated February 15, 2017 with a revision date of February 20, 2017. 81. The document revealed resident information from March 14, 2017 for 2 residents, #5 and #6. It listed the assistive device used by resident, level of assist for toileting needed, the fall risk score, the elopement risk score, the cardiopulmonary resuscitation status, any food or fluid restriction/allergy, and the resident's brief interview for mental status (“BIMS”) score. The form showed that resident #5 had a score of 5 for fall risk and resident #6 had a score of 4 for fall risk 82. On or about April 5, 2017, the Agency again interviewed Respondent’s Administrator about the Activity Outing Request form. 83. The Administrator stated the Activity Director fills out the Activity Outing Request form 3 days before the scheduled activity outing, and then the director of nursing signs off on the form, from which the DON is responsible to determine the number of staff that go on the outing with the residents. 84. | The administrator was unable to explain how fall scores are used to determine the number of activity staff needed to provide supervision and care needs to residents on outings. 85. | The Administrator did not explain how he would determine the number of staff and how he would schedule the staff needed to go on the outing. The Administrator stated that it was unusual for only 2 residents attend an outing, so they could not evaluate the effectiveness of the form. 86. The Administrator finally stated that if he had 3 residents who required 2 persons to assist with toileting, he would need to send 7 staff persons on the outing. The Administrator stated that he would call extra staff to work to cover this needed staffing. 87. On or about April 7, 2017, the Agency interviewed Respondent’s Staffing 11 Coordinator. 88. The Staffing Coordinator stated the Facility did not have additional staff available to come in to participate in outings. 89. The Staffing Coordinator further stated their staffing pool was minimal and she would need at least a week to get even a few extra CNAs to come in for an extra half shift for outings. 90. On or about April 4, 2017 the Agency interviewed Resident #3. 91. Resident #3 stated that he/she went to the supercenter in her motorized wheelchair. 92. Resident #3 said that when they arrive at the store, everyone goes shopping in different directions. 93. Resident #3 stated he/she knew that the Activity Assistant had a personal phone, but did not know the number. Resident #3 further stated that if he/she needed assistance, he/she would have to find the activity assistant. 94. Resident #3 she had a fall or accident, she would have to scream for the Activity Assistant. 95. On or about April 4, 2017, the Agency reviewed Resident #3’s care plan with a target revision date of May 7, 2017. 96. Although Resident #3 stated that he/she enjoyed going to the monthly supercenter outings, there was no mention of the outings in the care plan and no interventions as to how to provide care and supervision when on outings. 97. The Agency also reviewed the MDS Assessment for Resident #3 dated February 3, 2017. 98. The MDS Assessment revealed Resident #3 required extensive assistance with transfers, was totally dependent on staff for toilet use, was always incontinent of bladder, and frequently incontinent of bowel. 99. Resident #3’s balance was not steady and he/she required staff assistance with moving from seated to standing position, and moving on and off the toilet. 100. Resident #3’s interventions included: anticipate and meet the resident's needs, provide gentle reminders not to get up unassisted, and keep personal items within reach. 101. On or about April 4, 2017, the Agency interviewed Resident #5. 102. Resident #5 stated that he/she used a walker in the facility, but used the supercenter's electric scooter while on shopping outings. Resident #5 stated she enjoyed the outings to the supercenter. 103. Resident #5 further stated he/she was not aware of how he/she would find or contact the Activity Assistant when in the supercenter. 104. On or about April 4, 2017, the Agency reviewed Resident #5’s care plan with a target date of April 19, 2017. 105. The care plan noted Resident #5 enjoyed the outings to the supercenter, but there were no interventions identifying the need for supervision or assistance during outings. 106. On or about April 4, 2017, the Agency interviewed Resident #7. 107. Resident #7 stated that he/she was independent with toileting in the facility, but it was different in a supercenter as it was not set up like the restroom in the facility. 108. Resident #7 stated he/she used a walker in the facility but required an electric scooter in the supercenter as he/she was unable to walk for long distances. Resident #7 continued to state that he/she parked the scooter outside the restroom and walked into the restroom slowly. 109. Resident #7 said that if he/she needed assistance in the supercenter, he/she did not 13 have any way of contacting the Activity Assistant except to look for the assistant. Resident #7 finally stated that it would take him/her at least 15 minutes to find the Activity Assistant using the scooter because it is a large store and the activity staff person could be anywhere. 110. On or about April 4, 2017, the Agency reviewed Resident #7’s care plan with a targeted date of May 1, 2017. 111. The care plan not have any documentation of any outings or supervision or assistance levels needed during outings. 112. On or about April 4, 2017, The Agency interviewed Resident #8. 113. Resident #8 stated he/she liked the outings to the supercenter. He/she is independent with ambulation in the facility, but used her wheelchair while shopping. 114. Resident #8 stated that an Activity Assistant is in the store, but he/she did not know how he/she would contact the assistant or where to find him. 115. The Agency reviewed Resident #8’s Care Plan with a target date of April 17, 2017. 116. The resident’s care plan showed no documentation of any outings except a note stating “staff will invite resident to scheduled activities of known interest such as bingo, social events, music entertainment, group games and outings.” 117. On or about April 4, 2017, the Agency interviewed Resident #9. 118. Resident #9 stated that he/she enjoyed the supercenter outings where the resident would shop on his/her own, and used his/her walker when in the store. 119. Resident #9 was not aware of how he/she would get in touch with the Activity Assistant while in the store. 120. Resident #9 stated that he/she knew the residents had to return to the eating area when finished shopping. 14 121. On or about April 4, 2017, the Agency reviewed Resident #9’s Care Plan with a target date of April 17, 2017. 122. Resident #9’s Care Plan showed no interventions regarding outings to the supercenter. There was no documentation of the Resident's participation in supercenter or any other outings. 123. On or about April 4, 2017, the Agency reviewed Resident #2’s MDS Assessment dated December 21, 2016. 124. The MDS Assessment stated Resident #2 was incontinent, required total assistance of 1 person for transfers, and required assistance of one person with mobilizing the wheelchair. Further, Resident #2 was at risk for falls related to impaired mobility and uncontrolled movements due to cerebral palsy, and impaired safety awareness. 125. Onor about April 4, 2017, the Agency reviewed the MDS Assessment for Resident #4 dated January 14, 2017. 126. The MDS Assessment stated that Resident #4 used a wheelchair but was at risk for wandering and elopement. 127. On or about April 4, 2017, the Agency also reviewed care plans for Resident’s #2, #4, and #6. None of the care plans contained any interventions for supervision and assistance needed during outings. 128. The Facility’s actions and inactions as cited constitute a Class I deficiency. Sanction 129. Under Section 400.23(8)(a), Florida Statutes, in pertinent part, “[a] class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correct.” § 400.23(8)(a), Fla. Stat. (2016). 130. Under Section 400.23(8)(a), Florida Statutes, in pertinent part, “A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency.” § 400.23(8)(a), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $12,500.00 on the Respondent. COUNT II Health and Safety of Residents 131. Under Florida law, in addition to the grounds listed in Part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) an intentional or negligent act materially affecting the health or safety of residents of the facility. § 400.102(1), Fla. Stat., (2016). Facts 132. The Agency re-alleges and incorporates by reference the allegations in Count I. 133. Based on interview and record review, the Agency determined that the Respondent failed to ensure residents were free from neglect, which materially affected the health and safety of residents due to not providing adequate supervision and not being available for care and services 16 during activity outings. 134. On or about April 4, 2017, the Agency interviewed the Respondent’s Activity Assistant about an outing that occurred on February 8, 2017 at a local supercenter store. 135. The Agency learned from the interview that the Activity Assistant took approximately 1 hour to provide care to Resident #1 in the supercenter restroom after a fall, leaving 8 other residents unsupervised and without any assistance in the supercenter store, which was approximately 150,000 square feet in size. 136. The Activity Assistant explained that he was aware the other residents were on their own while he was with Resident #1, but since he did not have any other options, the Activity Assistant told Residents #2 and #4 to remain near the restroom 137. The Activity Assistant stated that he was not concerned about going on an outing by himself with 9 residents as that was the normal practice for outings to the supercenter. 138. The Activity Assistant further stated that he did not call the Facility to report Resident #1’s fall in the restroom when it occurred. The Activity Assistant said he did not think of calling the facility to ask what steps he should take or to get assistance after he found the resident on the floor in the restroom. 139. The Activity Assistant stated that he was in a hurry to get Resident #1 off the floor and only asked the resident if he/she had any pain. 140. The Activity Assistant further stated that he did not think about calling for an ambulance. 141. Finally, the Activity Assistant stated that he had not been trained about emergency care during activity outings that occur outside the facility. 142. Onor about April 4, 2017, the Agency interviewed Respondent’s Activity Director. 17 143. The Activity Director stated the activity staff have never had any formal education regarding facility outings and emergency care while on outings, and there was no policy and procedure for activity outings. 144. On or about April 4, 2017, the Agency interviewed Respondent’s Administrator. 145. The Administrator stated that the Facility had not identified any of the events that occurred on February 8, 2017 as neglect, nor did it consider neglect even after Resident #1 fell, and sustained a fracture on the outing. 146. The Administrator stated the conclusion was that the Facility did not provide enough staff to attend the outing. 147. The Administrator continued to state that he was aware that 9 residents were going on the supercenter outing with only one activity assistant on February 8, 2017, but he was not concemed as they usually had one assistant going on outings. 148. The Administrator then stated he did not think of canceling the outing or sending extra staff. 149. The Administrator finally stated the Facility did not have a policy and procedure related to facility outings. 150. The Facility’s actions and inactions as cited constitute a Class I deficiency. Sanction 151. Under Section 400.23(8)(a), Florida Statutes, in pertinent part, “[a] class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correct.” § 400.23(8)(a), Fla. Stat. (2016). 152. Under Section 400.23(8)(a), Florida Statutes, in pertinent part, “A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency.” § 400.23(8)(a), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $12,500.00 on the Respondent. COUNT Ik Internal Risk Management and Quality Assurance Program 153. Under Florida law, in pertinent part: (1) Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (a) A designated person to serve as risk manager, who is responsible for implementation and oversight of the facility’s risk management and quality assurance program as required by this section. (b) A risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. The risk management and quality assurance committee shall meet at least monthly. (c) Policies and procedures to implement the internal risk management and quality assurance program, which must include the investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to residents. (d) The development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. (e) The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited to, education and training in risk management and risk prevention for all nonphysician personnel, as follows: 1. Such education and training of all nonphysician personnel must be part of their initial orientation; and 2. At least 1 hour of such education and training must be provided annually for all nonphysician personnel of the licensed facility working in clinical areas and providing resident care. (f) The analysis of resident grievances that relate to resident care and the quality of clinical services. § 400.147(1), Fla. Stat. (2016). Facts 154. The Agency re-alleges and incorporates by reference the allegations in Counts I and I. 155. Based on interview and record review, the Agency determined that Respondent failed to maintain an effective Quality Assessment and Assurance (QAA) program for failure to plan, supervise and be available for care and services during activity outings. 156. On or about April 4, 2017, the Agency interviewed Respondent’s Administrator. 157. The Administrator stated that the Facility did not have an emergency QAA meeting following the incident on February 8, 2017, where Resident #1 fell in a supercenter bathroom and fractured his hip while on an outing. 158. The Administrator further stated the incident was first discussed officially at the QAA meeting 36 days later on March 16, 2017. 159. The Administrator confirmed that that the facility did not have a policy or procedure 20 for activity outings, but they identified activity outings as an area for improvement. 160. The Administrator continued to state the Facility had provided in-service education to the activity staff as a part of their plan; he then showed an Agency surveyor a form signed by the Activity Director and Activity Assistant which read, "Never go on outings alone.” 161. The Administrator also stated that the Facility had reviewed the new activity outing request form, but was unable to provide education to show that two activity assistants were provided with this in-service. 162. The Administrator then stated after the incident on February 8, 2017, the activity staff were in-service trained to never to go on an outing alone. 163. The could not provide any documentation to show that staff were provided with training on what to do in case of emergencies, such as falls, illness, or accidents during activities. 164. On or about April 4, 2017, the Agency reviewed the Facility’s correction plan. 165. The correction plan included developing an outing form and educating their activity staff. 166. The outing form titled “Avante of Orlando Activity Outing Request” was dated February 15, 2017 with a revision date of February 20, 2017. 167. The Agency then interviewed the Administrator about the outing form. 168. The Administrator was unable to explain what the fall risk scores and elopement scores indicated on a form prepared for an outing on March 14, 2017. 169. The Administrator was also unable to determine the number of staff members needed for supervision of the residents on the March 14, 2017 outing. 170. The Administrator finally stated it was unusual for only 2 residents to attend an outing, so they could not determine effectiveness of the outing form with regards to the March 14, 21 2017 outing. 171. On or about April 5, 2017 the Agency interviewed the Activity Assistant. 172. The Activity Assistant stated that he alternated with another employee to attend outings; he went one month and she attended the outing the next month. 173. The Activity Assistant stated he did not have any training with outings, but he had “shadowed” the Activity Director once a few years ago, and she told him verbally what to do. 174. The Activity Assistant further stated he was not aware of what he would do if a resident became ill, had chest pain or seizures while on an outing. He said he would probably have to call emergency services. 175. The Activity Assistant also stated he would have to use his personal cellular phone to call EMS because they did not have work phones on resident outings. 176. The Respondent’s QAA committee failed to fully investigate this incident which occurred on February 8, 2017. 177. Respondent’s Facility concluded that they had insufficient number of staff to meet the residents’ needs on the outing, yet the Facility failed to recognize and develop a system for residents to be supervised during outings, and did not have a method for residents to call for assistance for care when needed during outings 178. The QAA committee focused on the number of staff for outings and not on the individual resident's needs and the process to ensure safe outings. 179. The QAA failed to implement a system for meeting the resident’s needs for supervision and for required care and services during facility outings; they failed to address the potential for harm. 180. Due to an incomplete investigation, the facility's action plan was inadequate to 22 address the process for activity outings. 181. The actions and inactions of the Respondent constitute a Class I deficiency. Sanction 182. Under Section 400.23(8)(a), Florida Statutes, in pertinent part, “[a] class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correct.” § 400.23(8)(a), Fla. Stat. (2016). 183. Under Section 400.23(a), Florida Statutes, in pertinent part, “A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency.” § 400.23(8)(a), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $12,500.00 on the Respondent COUNT IV 6 Month Survey Cycle 184. The Agency re-alleges and incorporates by reference the allegations in Counts I, II, and IIT. 185. Under Florida law: 23 The Agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class JI deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. § 400.19(3), Fla. Stat. (2016). 186. The Agency properly cited the Respondent for 3 class I deficiencies and therefore the Respondent is subject to a six-month survey cycle for a period of two years, commencing on April 7, 2017 through April 6, 2019, and a survey fine of $6,000.00 § 400.19(3) Fla. Stat. (2017). WHEREFORE, The Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose a six-month survey cycle for a period of two years and impose a survey fine of $6,000.00. COUNT V Conditional Licensure 187. The Agency re-alleges and incorporates by reference the allegations in Count I, II, and III. 188. Due to the citations of three Class I deficiencies, the Respondent was not in substantial compliance at the time of the survey with Part II of Florida Statute 400 and the rules adopted by the Agency. 189. Under Florida law, a conditional licensure status is assigned to a F acility due to the presence of one or more class J or class II deficiencies, or class III deficiencies not corrected within 24 the time established by the Agency, leaving the Facility not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the Facility has no class I, class II, or class III deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. § 400.23(7)(b), Fla. Stat. (2016). 190. The Agency assigned the Respondent conditional licensure status with an action effective date of April 7, 2017, ending date of April 26, 2017. The standard and conditional licenses are attached to this Administrative Compliant as Composite Exhibit A. WHEREFORE, the Agency requests the assignment of a conditional licensure status to Respondent, a nursing facility, in the State of Florida be confirmed pursuant to §400.23(7), Florida Statutes. COUNT VI License Revocation 191. Onor about January 5, 2017, the Agency cited Respondent with a Class I deficiency in the area of Resident’s Rights. 192. On or about April 7, 2017, the Agency cited Respondent with 3 Class I deficiencies in the areas of Resident’s Rights, Health and Safety of Residents, and Risk Management and Quality Assurance Programs. 193. Pursuant to Florida law, the Agency may revoke a license for the violation of any provision of this part, part II of chapter 408, or applicable rules, against any applicant or licensee for the following violations by the applicant, licensee, or other controlling interest: (a) A violation of any provision of this part, part II of chapter 408, or applicable rules. § 400.121(1)(a), Fla. Stat., (2016). 194. Under Florida law, in pertinent part, the Agency shall revoke or deny a nursing home license if the licensee or controlling interest operates a facility in this state that: ... (d) Is 25 cited for two class I deficiencies arising from separate surveys or investigations within a 30-month period. The licensee may present factors in mitigation of revocation, and the agency may make a determination not to revoke a license based upon a showing that revocation is inappropriate under the circumstances. § 400.121(3)(d), Fla. Stat., (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration seeks to revoke Respondent’s license to operate a skilled nursing facility. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to enter a final order that: 1. Renders findings of fact and conclusions of law as set forth above. 2. Grants the relief set forth above. Respectfully Submitted, iq ssistqnt General Counsel Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite #300 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 26 NOTICE OF RIGHTS Pursuant to Section 120.569, F.S., any party has the right to request an administrative hearing by filing a request with the Agency Clerk. In order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), F.S., however, a party must file a request for an administrative hearing that complies with the requirements of Rule 28- 106.2015, Florida Administrative Code. Specific options for administrative action are set out in the attached Election of Rights form. The Election of Rights form or request for hearing must be filed with the Agency Clerk for the Agency for Health Care Administration within 21 days of the day the Administrative Complaint was received. If the Election of Rights form or request for hearing is not timely received by the Agency Clerk by 5:00 p.m. Eastern Time on the 21st day, the right to a hearing will be waived. A copy of the Election of Rights form or request for hearing must also be sent to the attorney who issued the Administrative Complaint at his or her address. The Election of Rights form shall be addressed to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630, Facsimile (850) 921-0158. Any party who appears in any agency proceeding has the right, at his or her own expense, to be accompanied, represented, and advised by counsel or other qualified representative. Mediation under Section 120.573, F.S., is available if the Agency agrees, and if available, the pursuit of mediation will not adversely affect the right to administrative proceedings in the event mediation does not result in a settlement. CERTIFICATE OF SERVICE I 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 6th day of October, 2017. Andrew B. Thornquest,/Assistant General Counsel Florida Bar No. 0104832 Agency for Health Care Administration 525 Mirror Lake Drive N., Suite #300 St. Petersburg, Florida 33701 Telephone: 727-552-1942 Facsimile: 727-552-1440 andrew.thornquest@ahca.myflorida.com 27 Administrator Amy W. Schrader, Esq. Avante at Orlando, Inc. Baker, Donelson, Bearman, Cladwell & 4601 Sheridan Street, Suite #500 Berkowitz, PC Hollywood, Florida 33021 101 N. Monroe Street, Suite 925 (Certified Mail- 7016 2140 0001 1591 9748 ) | Tallahassee, Florida 32301 (Electronic Mail ) 28 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Avante at Orlando, INC ACHA No. 2017009937 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (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 form 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 fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a 29 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 (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: 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 form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: _ _ Title: 30 RICK SCOTT GOVERNOR JUSTIN M. SENIOR SECRETARY August 31, 2017 Jeanmarc Ulysse, Administrator File Number: 74809 Avante At Orlando Inc. License Number: 1393096 4601 Sheridan Street Provider Type: Nursing Home Hollywood, FL 33021 RE: 2000 North Semoran Boulevard, Orlando Dear Mr. Ulysse: The enclosed Nursing Home license with license number 1393096 and certificate number 20835 is issued for the above provider effective April 7, 2017 through May 31, 2018. The license is being issued for: approval of the Status Change to Conditional during licensure period application. Review your certificate thoroughly to ensure that all information is correct and consistent with your records. If errors are noted, please contact the Long Term Care Unit. Please take a short customer satisfaction survey on our website at ahca.myflorida.com/survey/ to let us know how we can serve you better. Additional licensure information can be found at http://ahca.myflorida.com/longtermcare. If we may be of further assistance, please contact me by phone at 850-412-4458 or by email at Flora. Austin@ahca.myflorida.com. Sincerely, Flora, reattin Health Services and Facilities Consultant Long Term Care Unit Agency for Health Care Administration Division of Health Quality Assurance ae Facebook.com/AHCAFlorida Youtube.com/AHCAFlorida Twitter.com/AHCA_FL SlideShare.net/AHCAFlorida 2727 Mahan Drive »=MS#33 Tallahassee, FL 32308 AUHCA.MyFlorida.com View current license information at: Floridahealthfinder.gov LICENSE #: SNF1393096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE NURSING HOME STANDARD This is to confirm that AVANTE AT ORLANDO INC. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: AVANTE AT ORLANDO INC. 2000 North Semoran Boulevard Orlando, FL 32807 TOTAL: 118 BEDS STATUS CHANGE EFFECTIVE DATE: 04/26/2017 ty, Division of Huulth ¢ ity Assurance EXPIRATION DATE: _05/31/2018 Deputy Seer View current license information at: Floridahealthfinder.gov LICENSE #: SNF1393096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE NURSING HOME CONDITIONAL This is to confirm that AVANTE AT ORLANDO INC. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: AVANTE AT ORLANDO INC, 2000 North Semoran Boulevard Orlando, FL 32807 TOTAL: 118 BEDS STATUS CHANGE EFFECTIVE DATE: 04/07/2017 Deputy Seorg{iny, Division of Menlth ¢ ty Assurnnoy EXPIRATION DATE: 05/31/2018 RICK SCOTT GOVERNOR JUSTIN M. SENIOR SECRETARY August 31, 2017 Jeanmarc Ulysse, Administrator File Number: 74809 Avante At Orlando Inc. License Number: 1393096 4601 Sheridan Street Provider Type: Nursing Home Hollywood, FL 33021 RE: 2000 North Semoran Boulevard, Orlando Dear Mr. Ulysse: The enclosed Nursing Home license with license number 1393096 and certificate number 20836 is issued for the above provider effective April 26, 2017 through May 31, 2018. The license is being issued for: approval of the Status Change to Standard during licensure period application. Review your certificate thoroughly to ensure that all information is correct and consistent with your records. If errors are noted, please contact the Long Term Care Unit. Please take a short customer satisfaction survey on our website at ahca.myflorida.com/survey/ to let us know how we can serve you better. Additional licensure information can be found at http://ahca.myflorida.com/longtermcare. If we may be of further assistance, please contact me by phone at 850-412-4458 or by email at Flora. Austin@ahca.myflorida.com. Sincerely, Flora UM. Austin Health Services and Facilities Consultant Long Term Care Unit Agency for Health Care Administration Division of Health Quality Assurance Facebook.com/AHCAFlorida Youtube.com/AHCAFlorida Twitter.com/AHCA_FL SlideShare.net/AHCAFlorida 2727 Mahan Drive »>MS#33 Tallahassee, FL 32308 AHCA.MyFlorida.com USPS Tracking’ Results FAQs (http://faq.usps.com/?articteld=220900) Track Another Package + Remove Tracking Number: 701621400001 15919748 > ) ) Delivered Product & Tracking information See Available Actions Postal Product: Features: Certified Mail™ DATE & TIME STATUS OF ITEM. LOCATION October 10, 2017, 2:21 pm Delivered, Front Desk/Reception HOLLYWOOD, FL 33021 ~ ‘Your item was delivered to the front desk or reception area at 2:21 pm on October 10, 2017 in HOLLYWOOD, FL 33021. October 10, 2017, 1:43 am Departed USPS Regional Facility OPA LOCKA FL DISTRIBUTION CENTER October 9, 2017, 9:48 am In Transit to Destination ON ITS WAY TO HOLLYWOOD, FL 33021 October 8, 2017, 9:11 am In Transit to Destination ON ITS WAY TO. HOLLYWOOD, FL 33021 See More Available Actions Text & Email Updates See Less Can’t find what you’re looking for? Go to our FAQs section to find answers to your tracking questions. FAQs (http://faq.usps.com/?articleld=220900) The easiest tracking number is the one you don't

Docket for Case No: 17-006159