STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Case Nos. 2017005735 Petitioner, 2017005736 2017005746 AM GRAND COURT LAKES LLC, 2017005744 2017005740 Respondent. 2017005741 ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, AM Grand Court Lakes, LLC (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2017), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of twenty-five thousand five hundred dollars ($25,500.00) and survey fees of one thousand dollars ($1,000.00), for a total sum of twenty-six thousand five hundred dollars ($26,500.00) based upon three (3) Class II deficiencies, ten (10) uncorrected Class III deficiencies, and one (1) unclassified deficient practice. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2017). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES Sy The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent operates a one hundred forty (140) bed assisted living facility located at 280 Sierra Drive, North Miami Beach, Florida 33179, and is licensed as an assisted living facility, license number 8390. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT 1(A30) 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That Florida law provides: (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. Section 429.28(1), Florida Statutes (2017). 8. That Florida law provides: (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Program must be posted in full view in a freely accessible resident area, and included in the admission package provided pursuant to Rule 58A-5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility must have a written grievance procedure for receiving and responding to resident complaints, and for residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The telephone number for lodging complaints against a facility or facility staff must be posted in full view in a common area accessible to all residents. The telephone numbers are: the Long-Term Care Ombudsman Program, 1(888) 831- 0404; Disability Rights Florida, 1(800) 342-0823; the Agency Consumer Hotline 1(888) 419-3456, and the statewide toll-free telephone number of the Florida Abuse Hotline, 1(800) 96-ABUSE or 1(800) 962-2873. The telephone numbers must be posted in close proximity to a telephone accessible by residents and must be a minimum of 14-point font. (d) The facility must have a written statement of its house rules and procedures that must be included in the admission package provided pursuant to Rule 58A- 5.0181, F.A.C. The rules and procedures must at a minimum address the facility’s policies regarding: 1. Resident responsibilities; 2. Alcohol and tobacco; 3. Medication storage; 4. Resident elopement; 5. Reporting resident abuse, neglect, and exploitation; 6. Administrative and housekeeping schedules and requirements; 7. Infection control, sanitation, and universal precautions; and 8. The requirements for coordinating the delivery of services to residents by third party providers. (e) Residents may not be required to perform any work in the facility without compensation, unless the facility rules or the facility contract includes a requirement that residents be responsible for cleaning their own sleeping areas or apartments. If a resident is employed by the facility, the resident must be compensated in compliance with state and federal wage laws. (f) The facility must provide residents with convenient access to a telephone to facilitate the resident’s right to unrestricted and private communication, pursuant to Section 429.28(1)(d), F.S. The facility must not prohibit unidentified telephone calls to residents. For facilities with a licensed capacity of 17 or more residents in which residents do not have private telephones, there must be, at a minimum, a readily accessible telephone on each floor of each building where residents reside. (g) In addition to the requirements of Section 429.41(1)(k), F.S., the use of physical restraints by a facility must be reviewed by the resident’s physician annually. Any device, including half-bed rails, which the resident chooses to use and can remove or avoid without assistance, is not considered a physical restraint. Rule 58A-5.0182(6), Florida Administrative Code. 9. That on June 2, 2016, the Agency completed a complaint survey of Respondent’s facility. 10. That based upon observation, interview, and the review of records, Respondent failed to honor resident rights to treat residents with consideration and respect, and with due recognition of personal dignity, individuality, and the need for privacy where staff were managing residents’ personal spending allowance funds by subtracting money from resident accounts to make purchases for those residents without obtaining prior written consent from the residents, the same being contrary to the mandates of law. 11. That Petitioner’s representative reviewed Respondent’s resident trust account ledgers for residents number three (3), four (4), twenty-five (25), and twenty-six (26), which reflected withdrawals were made from the residents accounts without their signatures and expenses listed 99 &6, as “beauty salon,” “cash out,” “grocery store” and “miscellaneous.” 12.‘ That Petitioner’s representative interviewed on May 13, 2016, resident number twenty (20) who indicated that because of the resident’s poor sight, staff kept the resident’s checks, paid the resident’s bills, the resident did not remember signing the checks, and staff withdrew the money from the bank. 13. That Petitioner’s representative interviewed on May 13, 2016, Respondent’s business manager and administrator who admitted that the facility did not have financial consent or Power of Attorney from resident number twenty (20) to handle the resident’s financial affairs. 14. That Petitioner’s representative interviewed on May 19, 2016, resident number twenty- one (21) who indicated: a. While the resident was hospitalized, the facility withdrew money from the resident’ s/her account without the resident’s authorization. b. When asked about what the resident used to make rent payments, the resident said the facility had possession of the resident’s debit card and withdrew the money. 15. That the above-stated facts reflect a failure of the Respondent to treat its residents with consideration and respect, and with due recognition of personal dignity, individuality, and the need for privacy. 16. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 17. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 18. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 19. That on August 4, 2016, the Agency completed a re-visit survey of the Agency’s June 2, 2016 complaint survey of Respondent’s facility. 20. That based upon observation, interview, and the review of records, Respondent failed to honor resident rights to treat residents with consideration and respect, and with due recognition of personal dignity, individuality, and the need for privacy where staff were resident’s requiring assistance with adult undergarments are unable to obtain assistance during the night and the use of side rails without required resident consent, the same being contrary to the mandates of law. 21. That Petitioner’s representative interviewed on August 2, 2016, resident number eight (8) who indicated as follows: a. The resident was dissatisfied with the treatment the resident received during the short time the resident lived at Respondent’s facility. b. The resident was discharged to the hospital on March 3, 2016, with false information that the resident was having some issues going to the bathroom, with blood in the stool, and that the resident waited a long time to ask caregivers for assistance. c. When the resident was discharged from the hospital back to the facility on March 4, 2016, the facility would not accept the resident and the resident had to find another place to stay. d. The facility never gave the resident a refund. 22. That Petitioner’s representative interviewed on August 3, 2016, Respondent’s staff member “B” resident number eight (8) who indicated that residents do not have a way to call for staff assistance at night, but that staff usually performed rounds at least once every two (2) hours. 23. That Petitioner’s representative interviewed on August 3, 2016, resident number one (1) who indicated that caregivers did not assist the resident’s roommate regularly with changing soiled undergarments. 24. That Petitioner’s representative interviewed on August 3, 2016, resident number ten (10) who indicated as follows: a. The resident had to get up and go to staff for assistance. b. The phones in the rooms were turned off. CG If the resident wet the bed at night, the soiled undergarment or bedding was not changed. 25. That Petitioner’s representative interviewed on August 3, 2016, resident number three (3) who indicated that it was difficult to get assistance with changing soiled undergarments at night because the facility did not have a system in place for residents to call the caregivers. 26. That Petitioner’s representative interviewed on August 3, 2016, resident number nine (9) who indicated as that although the resident received assistance on some occasions with falling, the response time was slow, and the resident received no assistance at night. 27. That Petitioner’s representative interviewed on August 3, 2016, resident number five (5) who indicated that it was very difficult to get assistance at night from the certified nursing assistant. 28. That Petitioner’s representative interviewed on August 3, 2016, resident number eleven (11) who indicated that the resident received no assistance at night with changing undergarments. 29. That Petitioner’s representative toured the Respondent facility on August 3, 2016, and noted half bed rails attached to the beds in the rooms of residents numbered thirteen (13) and fourteen (14), yet when the Respondent’s files for the residents were reviewed there was no documentation of a signed consent for the half bed rails. 30. That Petitioner’s representative interviewed, on August 4, 2016 at 10:20 am., Respondent’s administrator regarding bed rails for residents numbered thirteen (13) and fourteen (14) and the administrator admitted that there were no consents for the half bed rails. 31. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 32. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 33. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 34. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT II (A30) 35. | The Agency re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein, 36. The Agency re-alleges and incorporates Count I as if fully set forth herein. 37. That on November 29, 2016, the Agency completed a re-visit to the August 4, 2016 re- visit survey of Respondent's facility, 38. That based on observations, record reviews, and interviews, the facility failed to honor resident rights to a safe and decent living environment free from abuse and neglect and to be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy as the same relates to communication, bed rails, and property storage, the same being contrary to the mandates of law. 39, That Petitioners representative toured Respondent’s facility commencing on October 28, 2016 and noted the bed of resident number forty-four (44) had full bed rail ut both sides. 40. That Petitioner’s representative reviewed Respondent’s records related to resident number forty-four (44) during the survey and noted as follows: b. The resident was not receiving hospice care. There was no prescription for or consent from the resident for the use of bed rails. The resident needed supervision with toileting and grooming. The resident lost twelve (12) lbs. since May 16, 2016 The medication observation sheet documented that the resident sclf-administered medications during November and October 2016. The resident’s Health Assessment (AHCA Form 1823) indicated that the resident needed assistance with self-administration of medication. 41. That Petitioner's representative interviewed resident number forty-four (44), an alert and oriented individual, on October 28, 2016, who indicated as follows: a, The resident indicated that the resident could not remove the full bed rails by self b. and would have to call a staff member for assistance to get out of bed. It takes staff fifteen to twenty minutes to respond to the resident because sometimes staff are helping other residents. 42. That Petitioner’s representative observed on October 28, 2016 at 6:06 a.m. in the room of resident number forty-seven (47) adult briefs, women’s deodorant, and some bags in the common area of the unit, and Respondent's staff member “V23” indicated, “This is staff stuff, These items are used by the other staff person. She stores them there to change and bathe residents on the floor.” 43. That Petitioner’s representative observed resident number forty-two (42) and interacted with staff on Gctober 29, 2016, at 2:34 p.m., and noted as follows: b. The resident was hearing impaired. Staff member “L12" was attempting to communicate with the resident and was observed yelling at the resident in an attempt to communicate with the resident. The resident did not initially respond. During the second attempt of staff member “L12” to communicate with the resident, the staff member touched the resident on the shoulder and the resident opened eyes waving and smiling and motioned that the resident was hearing impaired. Staff member “R18” was then observed trying to communicate with the resident, but the resident did not appear to understand the staffs gestures of communication. Staff member “R18” appeared to be gesturing to ask if the resident wanted a snack, but the resident responded that the resident had already taken a shower. Staff member “R18” claimed to know a small bit of sign language. is When Petitioner’s representative asked staff member “R18” to interpret during an interview with the resident, staff member “R18” stated that he did not speak sign language officially and could not interpret. fe When asked how staff communicate with the resident, staff member “R18” responded they do the best they could. k. Staff member “V22” explained to Petitioner’s representative that communication with the resident is done by use of gestures or speaking loudly and that she was not aware of any facility staff who communicated through sign language. 44. That Petitioner’s representative interviewed Respondent’s staff member “V22” and “R” on October 29, 2016 at 3:25 p.m. regarding medications and the staff responded as follows: a. There is no policy or procedure regarding how controlled substances are handled. b. The pharmacist told the facility administrator that an assisted living facility does not need a controlled substance policy. c. When the pharmacy delivered the controlled substance, medication technicians received the medications, and, for independent residents, gave the medications directly to the residents. d. When asked how the facility tracks medications to assure that residents receive the medications, staff member “V22” responded that residents tell her if they need anything or if medications are missing, adding that resident number forty-four (44) had not reported missing medications. 45. That the above reflects Respondent’s failure to ensure that its residents are provided a safe and decent living environment free from abuse and neglect including but not limited to Respondent’s failure to assure the availability of special communication needs of a hearing impaired resident and use of full bed rails as a physical restraint. 10 46. The Agency determined that these deficient practices were conditions or occurrences related to the operation and maintenance of the provider or to the care of clients which indirectly or potentially threatened the physical or emotional health, safety, or security of clients. 47. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 48. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT Iil (A25) 49. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 50. That Florida law provides: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the 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. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. Rule 58A-5.0182(1), Florida Administrative Code. 11 51. That on June 2, 2016, the Agency completed a complaint survey of Respondent's facility. 52. That based upon observation, the review of records, and interview, Respondent facility failed to provide care and services appropriate to resident needs, including supervision, where Respondent failed to maintain a general awareness of a resident whereabouts, the failure to maintain an accurate written record, updated as needed, of any significant changes or illnesses that resulted in hospitalization, and failed to document a theft incident, the same being contrary to the mandates of law. 53. That Petitioner’s representative interviewed on May 10, 2016, Respondent’s staff member “E” who indicated that resident number two (2) had been in the hospital for about one week. 54. That Petitioner’s representative reviewed during the survey the resident’s health assessment for resident number two (2), AHCA 1823 Form, dated on January 18, 2016, which reflected that the resident was hospitalized at that time for seizure disorder, heart failure, COPD, and SOB. 55. That Petitioner’s representative interviewed on May 10, 2016, Respondent’s administrator who confirmed that resident number two (2) was again hospitalized for wound care. 56. That absent from Respondent’s records related to resident number two (2) was any indication that the resident had been recently hospitalized. 57. That Petitioner’s representative interviewed on May 10, 2016, Respondent’s staff member “C” who confirmed that there was no documentation in the record of resident number two (2) regarding the resident’s most recent hospitalization. 58. That Petitioner’s representative interviewed on May 10, 2016, a family member of resident number five (5) who indicated that there was an incident two months previously 12 regarding a theft of the resident’s IPAD-M from the resident’s room and the facility did not notify the resident’s family of the incident. 59. That Petitioner’s representative reviewed Respondent’s records related to resident number five (5) and noted there was no written documentation regarding the theft of the resident’s IPAD-M. 60. That Petitioner’s representative interviewed on May 10, 2016, Respondent’s staff member “A” who confirmed that there was no written documentation regarding the theft of the IPAD-M of resident number five (5). 61. That the above reflects Respondent’s failure to maintain general awareness of residents’ whereabouts, as well as maintaining accurate written record, updated as needed, of any significant changes or illnesses that resulted in medical attention, as well as other major incidents. 62. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 63. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 64. — That Florida law requires that cited deficient practices be corrected within thirty (30) days. 65. That on August 4, 2016, the Agency completed a re-visit to the June 2, 2016 survey of Respondent’s facility. 66. That based upon observation, the review of records, and interview, Respondent facility failed to provide care and services appropriate to resident needs, including supervision, where Respondent failed to ensure that care and services related to resident personal care was timely provided, the same being contrary to the mandates of law. 13 67. That on August 3, 2016, Petitioner’s representative spoke to Respondent’s security guard who stated that there were one hundred thirty-one (131) residents in the facility and six (6) night staff working the 11:00 PM — 7:00 AM shift. 68. That Petitioner’s representative reviewed Respondent’s staff schedule and noted seven (7) staff members scheduled for the 11:00 PM - 7:00 AM shift. 69. That on August 3, 2016, Petitioner’s representative smelled an odious odor emanating from the room of resident number seven (7) and noted the resident sitting naked in a soiled bed. 70. That Petitioner’s representative interviewed Respondent’s staff member “B” regarding resident number seven (7) whose explanation of the situation was that the resident repeatedly removed the resident’s clothing and diaper and the resident would receive assistance when the resident completed the interview with Petitioner’s representative. 71. That Petitioner’s representative interviewed on August 3, 2016, resident number two (2) who indicated that the resident had to get up and go to staff for assistance and the phones in the rooms were turned off so, if the resident wet the bed at night, the resident’s soiled undergarment or bedding was not changed. 72. That Petitioner’s representative interviewed on August 3, 2016, resident number one 91) who indicated that if the resident fell at night, the only way to get assistance would be calling from the resident’s personal cell phone and even in those circumstances, the staff response time was slow. 73. That Petitioner’s representative interviewed on August 3, 2016, resident number three 93) who indicated that the resident did not have a phone in the bedroom, and that the resident notified staff of the need for a phone in the bedroom to call for assistance, if needed. 14 74. That Petitioner’s representative interviewed on August 3, 2016, resident number four (4) who indicated the facility was understaffed and that there was no one to help from 8:00 a.m. to 8:00 p.m. and the resident did not have access to a phone in the room to call for staff assistance. 75. That the above reflects Respondent’s failure to provide adequate supervision to the meet the needs of its residents. 76. | 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 77. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 78. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT IV (25) 79. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 80. The Agency re-alleges and incorporates Count III as if fully set forth herein. 81. That on January 9, 2017, the Agency completed a complaint survey of Respondent’s facility. 84. That based on record reviews and interviews, the facility failed to provide care and services appropriate to meet the needs residents, including supervision related to resident falls and elopement from the secure unit, the same being contrary to the mandates of law. 85. That Petitioner’s representative reviewed Respondent’s internal report completed on 15 November 18, 2016, and noted: a. Resident number one (1) was found on the floor in the resident’s room. b. The resident fell while climbing over the bed rail. C The resident was sent to the hospital. 86. That Petitioner’s representative reviewed progress notes for resident number one (1) that documented on November 18, 2016 at 8:00 a.m., the resident was found on the floor while staff conducted rounds 87. That Petitioner’s representative reviewed the health assessment, AHCA form 1823, completed on June 7, 2016, and noted: a. The resident was one hundred two (102) years old. b. The resident's medical history and diagnoses were senile dementia, COPD (Chronic Obstructive Pulmonary Disease), Dyslipidemia. Physical or sensory limitations: unsteady gait. C: The resident was identified as needing fall precautions. d. The resident needed total care for bathing and dressing, assistance for toileting, supervision for transferring and self-care (grooming) and ambulation and eating. 88. That Petitioner’s representative reviewed the hospice record for resident number one (1) that contained a doctor’s order for bed rails in place since November 16, 2016. 89. That Petitioner’s representative reviewed hospital records of resident number one (1) that documented the resident was admitted to the hospital on November 18, 2016, with the hospital x- ray revealing an impression of right sided rib fracture, fracture of seventh and eighth ribs, in addition to the bilateral hip fractures. 16 90. That Petitioner’s representative reviewed the hospice record of resident number one (1) that documented the resident was admitted to hospice on November 8, 2016, and on that same date, was placed on continuous care due to shortness of breath and for observation and safety. 91. That Petitioner’s representative reviewed a nursing assessment completed on November 9, 2016 that documented that resident number one (1) required assistance with all activities of daily living, had unstable mobility, weakness and motor changes, and the resident had limitations with dressing, bathing, positioning, grooming, toileting, transferring, eating and ambulating. 92. That Petitioner’s representative reviewed a nursing assessment completed on November 10, 2016 that documented that resident number one (1) had multi-ecchymotic area to upper extremities and needed total care. 93. That when Continuous Care was discontinued on November 10, 2016, hospice identified resident number one (1) as requiring fall precautions. 94. That Petitioner’s representative reviewed progress notes dated November 18, 2016 related to resident number one (1) and noted a statement from the resident’s adult child who indicated that the adult child received a call from the facility stating the resident was found on the floor with an apparent fracture of her hip. 95. That Petitioner’s representative interviewed on January 3, 2017, Respondent’s director of nursing who confirmed resident number one (1) was at the hospital because he/she fell out of bed. 96. That Petitioner’s representative telephonically interviewed Respondent’s administrator on January 6, 2017, who indicated: a. Resident number one (1) should have been seen by staff last on the date of the fall within a one (1) hour window because staff did hourly checks. b. The facility could not provide hourly rounds sheets showing when the resident was last seen, because they had problems with documentation. 97. That Petitioner’s representative reviewed the one-day incident report, completed on November 23, 2016, and the 15-day incident report, completed on December 5, 2016, regarding resident number two (2) and noted: a. On November 23, 2016, while being transported in the facility's van, the resident fell out of the wheelchair onto the floor of the van. b. Paramedics were contacted, and the resident was taken to the hospital for evaluation. Cc. The resident's hospital emergency discharge documents showed diagnoses of contusion of chest wall, right, initial encounter. 98. That Petitioner’s representative further reviewed Respondent’s one-day incident report for resident number two (2) and noted the resident arranged to see an orthopedic specialist due to continued pain after the van incident, and returned from the specialist's office with a diagnosis of "Sustained several right sided rib fracture.” 99. That Petitioner’s representative reviewed the orthopedic report dated December 13, 2016 for resident number two (2) which documented that X-rays of the rib cage showed multiple right- sided rib fractures. 100. That Petitioner’s representative noted in the records of resident number two (2) a prescription from a doctor dated December 13, 2016 which noted the resident sustained several right-sided rib fractures from being involved in a MVA (Motor Vehicle Accident) on November 23, 2016. 101. That Petitioner’s representative reviewed the personnel record of Respondent’s driver “A” that showed that he was terminated on November 29, 2016, due to his failure to secure 18 resident number two (2) during transportation, which caused the resident’s fall on November 23, 2016. 102. That Petitioner’s representative interviewed Respondent’s driver “B” on January 4, 2017, who indicated: a. He trained other drivers and taught them the basics, including how to secure residents in their wheelchairs. b. The last training done by driver “B” was approximately six (6) months ago. C Another incident occurred two (2) months prior to the incident involving resident number two (2) and there was no documentation of that incident. 103. That Petitioner’s representative interviewed Respondent’s administrator regarding resident number two (2) on January 4, 2017, and the administrator indicated: a. The resident was involved in a motor vehicle event, not an accident. b. The resident’s wheelchair was not secured and it toppied over. (ca The resident had bruises, not fractures. d. The Administrator did not know why the resident went to the orthopedic doctor. € Drivers “B” and “C” knew the policies and knew they could not operate the vehicle without residents being secured. f There was no training for the drivers. 104. That Petitioner’s representative interviewed resident number two (2) on January 4, 2017, who indicated as follows: a. On the way back to the facility from a cardiologist appointment on November 23, 2016, the driver made a fast left turn. b. The resident believed that the driver was driving too fast. 19 C As a result, the resident’s electric wheelchair toppled over, leaving the resident crunched between the wheelchair chair and the lift. d. The driver apologized for what happened. e. The resident’s orthopedic doctor advised the resident that the resident sustained five broken ribs. 105. That Petitioner’s representative reviewed Respondent’s records related to resident number two (2) and noted: a. The resident was admitted to the facility on April 5, 2016. b. The resident’s Health Assessment, AHCA form 1823, dated September 9, 2016, documented: i. Medical history and diagnoses of Rheumatoid arthritis, hypertension, Diabetes type II, Chronic kidney Disease stage 3, Morbid Obesity, Anemia, Cellulitis, Chronic Obstructive Pulmonary Disease, Gout, and anxiety. ii. The resident was wheelchair and oxygen dependent. iii. The resident needed assistance with ambulation. iv. The resident was independent with bathing, dressing, eating, self-care (grooming), toileting and transferring. v. The resident needed assistance with self-administering medication. 106. That during a telephonic interview on January 6, 2017, Respondent’s administrator revealed that facility transported around fifty-one (51) residents and all of them needed to be secured during transportation. 20 107. That Petitioner’s representative reviewed That a review of the one-day incident report for Resident #3 completed on 12/23/16, and the 15-day incident report completed on 12/28/16, revealed that Caregiver B found Resident #3 in the facility's lobby wanting to leave. 108. That Petitioner’s representative reviewed a Memory Care Unit’s rounds log that documented resident number three (3) was last seen on December 22, 2016 at 2:00 p.m. and, per the log, was not seen again until December 23, 2016 at 6:30 a.m. 109. That Petitioner’s representative reviewed the one-day incident report for resident number three (3) completed on January 1, 2017, that documented: a. Caregiver “A” informed medical technician “B’ that the resident was not in the resident’s room. b. The resident called the facility informing staff that the resident was lost. (a The administrator and director of nursing returned the resident back to the facility. 110. That Petitioner’s representative interviewed Respondent’s administrator on January 4, 2017, regarding resident number three (3) and the administrator indicated: a The resident left the facility, went for a walk, and could not find the way back. b. The facility called the police and the resident called the facility. C: The resident was found about four blocks away. d. The resident was a resident in the memory care unit, which is a locked unit. 6 The resident did not notify the facility before leaving. 111. That Petitioner’s representative reviewed the Memory Care Unit’s rounds log that documented resident number three (3) was last seen on December 31, 2016 at 10:00 p.m. and was not seen on December 31, 2016 at 11:00 p.m. or on January 1, 2017, between midnight and 7:00 a.m. 21 112. That Petitioner’s representative reviewed the only staff schedule available for review November 2016 and the facility did not have December’s staffing schedule available for review. 113. That on January 3, 2017, neither Respondent’s administrator or assistant business manager could identify what staff was on duty at the time of the elopement of resident number three (3) and neither the administrator nor the assistant business manager had the staff schedules, Respondent’s assistant business manager explaining that the written staff schedules were in a drawer on a flash drive in the office, but could no longer be found. 114. That Petitioner’s representative telephonically interviewed on January 6, 2017. Respondent’s administrator who indicated: a. Resident number three (3) was very bright, and may have known the code to get out of the Memory Care Unit by observing others. b. The administrator did not know if the facility had policies and procedures for the Memory Care Unit. c. The only precaution the facility took was to have regular meetings with staff to remind them to be cautious when putting in the Unit code. d. After the second elopement, the facility changed the unit code and re-secured the gate for that Unit. e. The administrator did not know why resident number three (3) was in the Memory Care Unit. 115. That Petitioner's representative interviewed on January 6, 2017, Respondent’s administrator who indicated: a. The facility had problems with documentation. b. There was no documentation about the last time staff saw resident number three (3). 22 C. She assumed that resident number three (3) was on the Memory Care Unit because the resident needed more supervision and had a history of elopement. 116. That Petitioner’s representative reviewed Respondent’s records related to resident number three (3} during the survey and noted: a. The resident was admitted to the facility on September 30, 2015. b. The resident’s Health assessment, AHCA form 1823, dated January 14, 2016, documented: a Diagnoses of hypertension, dyslipidemia and acute psychosis, ii. At the time of the assessment, the resident was alert and oriented times three (3), with limited concentration and attention. iii, The resident was independent with ambulation, bathing, dressing, eating, self-care (grooming), toileting, and transferring. iv. The resident needed assistance with sclf-administration of medications, ici That the updated Health Assessment did not identify the resident as an elapement risk. d. Progress notes showed that the resident eloped on January 1, 2016, the facility searched for the resident but could not locate the resident in the resident's apartment, and the resident called the facility to be picked up at a local address several hours later. 117. That the facility failed to ensure that resident number three (3) was properly assessed for clopement after the resident attempted to leave the facility twice, and successfully left the facility on January 1, 2017. 23 118. Thai Petitioner’s representative telephonically interviewed on January 6, 2017, Respondent's director of nursing regarding resident number three (3) who indicated that the resident wore a bright yellow bracelet but it did not have the resident's name nor the facility's address. 119, That That Petitioner’s representative interviewed on January 6, 2017learned through additional interviews on January 6, 2017, that Respondent had not completed an elopement assessment before or after the elopements of resident number three (3). 120. That Petitioner’s representative telephonically interviewed on January 9, 2017 Respondent's director of nursing who explained that she asked the administrator on December 23, 2016 to change the code to the Memory Care unit after the resident eloped the first time, however the code was not changed at that time. 121. That Respondent’s director of nursing further indicated: a. When she interviewed resident number three (3), the resident stated that the resident left the unit via a two-foot gap between the gate and the wall on the unit, or over the top of the gate, where there was another gap. b. After the resident's s second elopement, the maintenance director closed the gaps and changed the unit code. 122. That Petitioner’s representative interviewed Respondent’s director of nursing who indicated that she scheduled a doctor’s appointment for reevaluation of resident number three (3) for the doctor to evaluate the resident on December 23 and 30, but the doctor canceled both times, saying that he would be back on January 12, 2017. 123. That the above reflects Respondent’s failure to ensure the provision of care, serviccs, and supervision appropriate to the needs of residents, including a failure to maintain a general awareness of the resident whereabouts. 24 124. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatened the physical or emotional health, safety, or security of the clients, other than class I violations. 125. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2017). 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 (2017). COUNT V (Survey) 126. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count I as if fully set forth herein. 127. That pursuant to Section 429.19(7), Florida Statutes (2016), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2016), to verify the correction of the violations. 128. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2016). 25 COUNT V1 (152 129, The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 130, That Florida law provides: (3) OTHER REQUIREMENTS. (a) All facilities must: 1. Provide a safe living environment pursuant to Section 429.28(1)(a), F.S.; 2. Be maintained free of hazards; and 3. Ensure that all existing architectural, mechanical, electrical and structural systems, and appurtenances are maintained in good working order. (b) Pursuant to Section 429.27, F.S., residents must be given the option of using their own belongings as space permits. When the facility supplies the furnishings, each resident bedroom or sleeping area must have at least the following furnishings: 1. A clean, comfortable bed with a mattress no less than 36 inches wide and 72 inches long, with the top surface of the mattress at a comfortable height to ensure easy access by the resident; 2. A closet or wardrobe space for hanging clothes; 3. A dresser, chest or other furniture designed for storage of clothing or personal effects; 4. A table or nightstand, bedside lamp or floor lamp, and waste basket; and 5. A comfortable chair, if requested. Rule 58A-5.023(3), Florida Administrative Code. 131. That on June 2, 2016, the Agency completed a complaint survey of Respondent’s facility. 132. That based upon the review of records, observation, and interview, Respondent failed to maintain a safe and decent living environment, free of hazards and with all structural systems in good working order, the same being contrary to the mandates of law. 133. That Petitioner’s representative toured the Respondent’s second floor dementia unit in building A on May 10, 2016. Commencing at 9:05 a.m., and noted as follows; a. A entrance that leads to the stairs had a big, heavy iron door which appeared to be attached to the wall but was in fact loose and unsecured to the building. b. The dementia unit was populated with residents. 26 134. That Petitioner’s representative interviewed Respondent’s staff member “A” on May 10, 2016, at 9:09 a.m. who indicated, “I did not know that this door was not secured. The building has been under remodeling. I will call maintenance to fix it.” 135. That Florida’s Department of Health conducted an inspection of Respondent’s kitchen area on May 10, 2016, at 12:30 p.m. which Petitioner’s representative observed and it was noted that roaches were identified behind surfaces and in food serving areas. 136, That the above reflects Respondent’s failure to maintain a safe and-decent living environment, free of hazards and with all structural systems in good working order. 137. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 138. That the same constitutes a Class II] offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 139, That Florida law requires that cited deficient practices be corrected within thirty (30) days. 140. That, the Agency completed a survey of Respondent’s facility by survey dated on August 4, 2016. 141. That based upon the review of records, observation, and interview, Respondent failed to maintain a safe and decent living environment, free of hazards and with all structural systems in good working order, the same being contrary to the mandates of law. 142. That Petitioner’s representative toured the Respondent’s building D on August 13, 2016, commencing at 8:30 a.m., and noted as follows: a. The census of the Facility was one hundred thirty-one (131) residents. b. The female resident bathroom in the lower section of the building contained a single ceiling tile that was wet and buckling. 27 c. The male restroom on the first floor had s mets! door with the left end of the metal peeling away and presenting a danger to users should they be ambulating or in a wheel chair. d. A resident room on the upper floor had, in the upper left hand corner, peeling plaster and paint, with paint chips on the floor below while the same room had a crack in the wall with peeling paint and plaster around the crack. 143. That Petitioner’s representative toured the Respondent’s facility on August 13, 2016, commencing at 8:33 p.m., and noted in a resident room peeling and cracked paint and plaster between the window and the air conditioning unit while the same room, in the bathroom, contained two (20 areas under the sink where plaster was bubbling up on both sides of the wall. 144. That Petitioner’s representative interviewed Respondent’s administrator on August 4, 2016 at 2:00 p.m. who confirmed that the Facility was undergoing renovation and many things remain unfinished. 145. That the above reflects Respondent’s failure to maintain a safe and decent living environment, free of hazards and with all structural systems in good working order. 146. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 147. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 148. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 149. That the same constitutes an uncorrected Class III deficiency as defined by law. 28 WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2){c), Florida Statutes (2017). COUNT VII (152) 150. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count VI above as if fully set forth herein. 151. That the Agency conducted a second revisit to the June 2016 survey on October 28, 2016. 152. That based upon the review of records, observation, and interview, Respondent failed to maintain a safe and decent living environment, free of hazards and with all structural systems in good working order, the same being contrary to the mandates of law. 153. That Petitioner’s representative toured the Respondent’s Facility commencing on October 28, 2016, at 6:15 a.m. and noted as follows: a. In Building D, the elevator was inoperable, and residents of Building D who had difficulty utilizing stairs had to use the elevator in Building C. b. In Building C, three (3) floor tiles were broken. c. On the first floor, South Wing of Building D. on a lower wall was green, blue, and red electrical wires hanging from the wall with yellow safety caps thereon. d. In Building D, an electrical cover and box was detached from the wall and in the front reception area, a ceiling tile was missing and all of the piping, wiring, and air conditioning ducts were visible. e. In Building D on the opposite side of the hall, a ceiling panel was missing and piping and cement structure beams were visible. f. In the cafeteria area, nine (9) lighting fixtures were without light covers and the bare light bulbs were visible. 29 oO. The automatic rear door to the cafeteria was stuck half way open and would not close further, remaining open for the remainder of the day. On the walls of the cafeteria were three electrical outlets without covers. In the kitchen over rear stove panels and pots and trays were metal air vents that were covered with grease and dust. A kitchen worker observed that the vents required cleaning In the dishwashing area, a faucet to a sink had running water that continued to leak despite efforts to shut the valve. In the front hallway near the two (2) elevators, the panel over the elevator was missing and electrical wires could be seen. . In room 505, the carpet was snagged and stained; in room 504, a bathroom tile was cracked; and in room 503, there was an odor of urine and the paint on the wall was patched. At 6:14 a.m., the floor of the activities room had dark liquid substances with an empty yogurt container in front of a reclining chair and the kitchen manager immediately directed staff to clean the room. In room C-3-4, there was a strong odor of urine. 154. That on October 28, 2016, both Respondent’s business manager and director of nursing repeated several times that the building was being renovated. 155. That the above reflects Respondent's failure to maintain a safe and decent living environment, free of hazards and with all structural systems in good working order. 156. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 30 157. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 158. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 159. That the same constitutes a twice uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT VIII (165) 160. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 161. That Florida law provides: (1) Every facility licensed under this part may, as part of its administrative functions, voluntarily establish a risk management and quality assurance program, the purpose of which is to assess resident care practices, facility incident reports, deficiencies cited by the agency, adverse incident reports, and resident grievances and develop plans of action to correct and respond quickly to identify quality differences. (2) Every facility licensed under this part is required to maintain adverse incident reports. For purposes of this section, the term, “adverse incident” means: (a) An event over which facility personnel could exercise control rather than as a result of the resident’s condition and results in: 1. Death; 2. Brain or spinal damage; 3. Permanent disfigurement; 4. Fracture or dislocation of bones or joints; 5. Any condition that required medical attention to which the resident has not given his or her consent, including failure to honor advanced directives; 6. Any condition that requires the transfer of the resident from the facility to a unit providing more acute care due to the incident rather than the resident’s condition before the incident; or 7. Anevent that is reported to law enforcement or its personnel for investigation; or (b) Resident elopement, if the elopement places the resident at risk of harm or injury. (3) Licensed facilities shall provide within 1 business day after the occurrence of an adverse incident, by electronic mail, facsimile, or United States mail, a preliminary report to the agency on all adverse incidents specified under this section. The report must 31 include information regarding the identity of the affected resident, the type of adverse incident, and the status of the facility’s investigation of the incident. (4) Licensed facilities shall provide within 15 days, by electronic mail, facsimile, or United States mail, a full report to the agency on all adverse incidents specified in this section. The report must include the results of the facility’s investigation into the adverse incident. (5) Each facility shall report monthly to the agency any liability claim filed against it. The report must include the name of the resident, the dates of the incident leading to the claim, if applicable, and the type of injury or violation of rights alleged to have occurred. This report is not discoverable in any civil or administrative action, except in such actions brought by the agency to enforce the provisions of this part. (6) Abuse, neglect, or exploitation must be reported to the Department of Children and Families as required under chapter 415. (7) The information reported to the agency pursuant to subsection (3) which relates to persons licensed under chapter 458, chapter 459, chapter 461, chapter 464, or chapter 465 shall be reviewed by the agency. The agency shall determine whether any of the incidents potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of s. 456.073 apply. The agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken in response to the incident. The agency shall review each incident and determine whether it potentially involved conduct by a health care professional who is subject to disciplinary action, in which case the provisions of s. 456.073 apply. (8) Ifthe agency, through its receipt of the adverse incident reports prescribed in this part or through any investigation, has reasonable belief that conduct by a staff member or employee of a licensed facility is grounds for disciplinary action by the appropriate board, the agency shall report this fact to such regulatory board. (9) The adverse incident reports and preliminary adverse incident reports required under this section are confidential as provided by law and are not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or appropriate regulatory board. (10) The Department of Elderly Affairs may adopt rules necessary to administer this section. § 429.23, Florida Statutes (2016). 162. That Florida law provides: (1) INITIAL ADVERSE INCIDENT REPORT. The preliminary adverse incident report required by Section 429.23(3), F.S., must be submitted within 1 business day after the incident pursuant to Rule 59A-35.110, F.A.C., which requires online reporting. (2) FULL ADVERSE INCIDENT REPORT. For each adverse incident reported in subsection (1) above, the facility must submit a full report within 15 days of the incident. The full report must be submitted pursuant to Rule 59A-35.110, F.A.C., which requires online reporting. Rule 58A-5.0241, Florida Administrative Code. 32 163. That based upon observation, interview, and review of records, theRespondent failed to timely complete and file one day and fifteen day adverse incident reports, the same being contrary to the mandates of law. 164. That on June 2, 2016, the Agency completed a complaint survey of Respondent’s facility. 165. That Petitioner’s representative reviewed Respondent’s records related to resident number fourteen (14) during the survey and noted as follows: a. The health assessment, form 1823, dated May 26, 2016, listed diagnoses as including Alzheimer’s, hypertension, diabetic mellitus, and CKD. Cognitive and behavioral status was documented as progressive memory loss due to Alzheimer’s dementia. An entry in the resident’s observation log dated April 16, 2016 read, “Received a call from MT resident was seen by 199 and 2™ Ave. by night staff. This writer along with staff members and exec. Direct. Initiated a search for resident which included MDPD. Resident was found on 441 and 186stopping a bus. 0 Injury, distress or complaints. Resident brought back safely to facility, being monitored closely. Resident [adult child] notified by exec. Dir.” 166. That Petitioner’s representative reviewed Respondent’s records related to resident number fifteen (15) during the survey and noted as follows: a. The health assessment, form 1823, dated May 12, 2016, listed diagnoses as including Parkinson’s, dementia, and HTN. Documented was the resident ambulates with a walker, is alert to name, forgetful, and poor memory. The resident required assistance with medication administration and Hospice services. 33 d. Special precautions included falls, but no elopement risk was documented. e. An entry in the resident’s observation log dated April 2, 2016 read, “Resident observed wandering around community with unsafe gait, walker removed, resident placed in wheelchair, fall precaution bracelet applied to wrist. Staff made aware family. Exec. Dir. Advice [sic]. 0 distress 0 complaints. Dr. notified.” 167. That Petitioner’s representative observed on May 19, 2016, at 11:00 a.m. resident number fourteen (14) and noted the resident was not wearing an identification bracelet. 168. That Petitioner’s representative was unable to locate a photograph of the resident maintained by Respondent. 169. That Petitioner’s representative reviewed Agency records and could identify no adverse incident report, either one day or fifteen day reports, related to the incidents described for residents numbered fourteen (14) and fifteen (15). 170. That Petitioner’s representative interviewed Respondent’s staff member “A” on May 27, 2016, at 1:00 p.m. who indicated; a. Resident number fifteen (15) was not reflected as an elopement risk because the resident cannot walk and is under Hospice care. b. The staff member did not consider the events elopements. c. The facility has no elopement assessment or evaluation for facility residents. 171. That the above reflects Respondent’s failure to timely complete and file one day and fifteen day adverse incident reports where a resident elopes and or law enforcement is contacted. 172. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 34 173. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 174. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 175. That the Agency completed a re-visit to the June 2, 2016 survey of Respondent’s facility by survey dated on August 4, 2016. 176. That based upon observation, interview, and review of records, theRespondent failed to timely complete and file one day and fifteen day adverse incident reports, the same being contrary to the mandates of law. 177. That Petitioner’s representative reviewed Respondent’s incident log and the Agency’s incident reporting data base during the survey. 178. That Respondent had still not filed either a one day or fifteen day incident report for the events above-described involving residents numbered fourteen (14) and fifteen (15). 179. That the above reflects Respondent’s failure to timely complete and file one day and fifteen day adverse incident reports where a resident elopes and or law enforcement is contacted. 180. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 181. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 182. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 183. That the same constitutes an uncorrected Class III deficiency as defined by law. 35 WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT 1X (165) 184. The Agency re-alleges and incorporates paragraphs {1) through (5) as if fully set forth herein. 185. The Agency re-alleges and incorporates Count VIL above as if fully set forth herein, 186. That the Agency completed a re-visit to the Junc 2, 2016 survey of Respondent’s facility by sutvey dated November 29, 2016. 187. That based upon observation, interview, and review of records, theRespondent failed to timely complete and file one day and fifteen day adverse incident reports, the same being contrary to the mandates of law. 188. Thal Petitioner’s representative reviewed the Agency's incident reporting data base during the survey and noted no adverse incident report was filed related to a fall resulting in hospitalization on September 28, 2016, involving resident number forty-four (44). 189. That Petitioner’s representative reviewed hospital records and noted on September 28, 2016 at 12:29 p.m. the resident was tranfered from Respondent’s facility after a fall with comments reading, “Fell while trying to get into bed at 4 a.m. complaint of pain to right hip/ buttocks since the fall. [Patient] is concerned about prior right hip surgery that [patient] had in 7/16.” 190. That Petitioner’s representative interviewed Respondent’s administrator on November 29, 2016 at 8:20 a.m. who indicated that she was not sure if the facility’s previous administrator had filed an adverse incident report regarding the incident involving resident number forty-four (44). 36 191. That the above reflects Respondent’s failure to timely complete and file one day and fifteen day adverse incident reports where a resident is transferred to a higher level of care. 192. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 193. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 194. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 195. That the same constitutes a twice uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2){c), Florida Statutes (2017). COUNT X (79 196. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 197. That Florida law provides: (b) Notwithstanding the minimum staffing requirements specified in paragraph (a), all facilities, including those composed of apartments, must have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents’ scheduled and unscheduled service needs, resident contracts, and resident care standards as described in Rule 58A-5.0182, F.A.C. (c) The facility must maintain a written work schedule that reflects its 24-hour staffing pattern for a given time period. Upon request, the facility must make the daily work schedules of direct care staff available to residents or representatives, for that resident’s care. Rule 58A-5.019(3)(b and c), Florida Administrative Code. 198. That the Agency completed a biennial survey on June 2, 2016 of Respondent’s facility. 37 199. That based upon observation, interview, and review of records, Respondent failed to ensure it provided sufficient qualified staff to meet resident scheduled and unscheduled service needs, the same being contrary to the mandated of law. 200. That Petitioner’s representatives arrived at the Respondent facility at 6:00 a.m. on August 3, 2016, and the security guard indicated that the facility had a census of one hundred thirty-one (131) residents and six (6) staff members performing services for the 11:00 p.m. to 7:00 a.m. shift. 201. That Petitioner’s representative reviewed Respondent’s staffing schedules and noted that there were a total ov seven (7) staff members scheduled for the 11:00 p.m. to 7:00 a.m. shift. 202. That Petitioner’s representatives interviewed residents numbered one (1), three (3), four (4), five (5), seven (7), eight (8), nine (9), ten (10), and eleven (11) between 6:00 a.m. and 3:00 p.m. on August 3, 2016, and these alert and aware individuals indicated that they get no staff assistance during overnight hours including needed assitance with adult briefs or other toileting needs, and that the residents have no way to contact staff during an emergent condition. 203. That the above reflects Respondent’s failure to ensure it provided sufficient qualified staff to meet resident scheduled and unscheduled service needs. 204. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 205. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 206. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 38 207, That the Agency completed a revisit to the June 2, 2016 survey of Respondent's facility by survey dated October 28, 2016. 208. That based upon observation, interview, and review of records, Respondent failed to ensure it provided sufficient qualified staff te meet resident scheduled and unscheduled service needs, the same being contrary to the mandated of law. 209. That Petitioncr’s representatives arrived al the Respondent facility at 6:00 a.m. on October 28, 2016, and the security guard indicated he did not know the current census of the facility but displayed a census form dated October 23, 2016, which reflect a resident census of one hundred twenty-six (126) residens. 210. That Petitioner’s representative interviewed Respondent's staff member “V-25” on October 28, 2016 at 6:12 a.m. who indicated as follows: a. She has been working at the facility about four (4} months. b. She does not know the resident census. c. She opened the memory care unit and indicated there are residents living on ficors two 92) and three (3). 211. That Petitioner’s representative interviewed Respondent’s staff member “H” in room A204 on October 28, 2016 at 6:19 am. who indicated as follows: a. She was on duty with staff member “Y-23” b. Only six (6) residents are on the floor and only floors two {2) and five (5) are in use. c. There are about seventeen (17} people on the fifth floor and she is providing care to seven {7) of them, 212. That Petilioner’s representative toured building C of the facility on October 28, 2016 and al 7:45 a.m, with Respondent’s kitchen manager. staff member “L-12,” and no facility staff were 39 observed in the hallways and staff member “L-12” remarked, “We have one staff in this building but at this time she is assisting residents in their rooms. We have one elevator out of order. I don’t know where she is. She has a phone that she can be called on.” 213. That Petitioner’s representative interviewed Respondent’s admission and discharge log which showed that the census of building C was nineteen (19) residents. 214. That Petitioner’s representative interviewed resident number thirty-seven (37) on October 28, 2016 at 11:40 a.m. who indicated, “I don’t remember how long I have been here. I can stand up, but I can only walk little steps because I am not strong enough. Yes, I wear adult briefs. If need to have my brief changed I will call them and I will let them know. I have my own phone. At night they will come to change me maybe once. Occasionally, once in a while, they will leave me with my diaper without a change until the point it becomes uncomfortable.” 215. That Petitioner’s representative observed and interviewed resident number forty-four (44) on October 28, 2016 at 1:20 p.m. and noted as follows: a. Inroom C-201, the resident sat in a wheel chair and the bed had attached full bed rails on both sides. b. Medication was visible throughout the room. c. The resident indicated the resident cannot remove the bed rail by self and calls staff to assist in getting out of bed. d. The resident indicated the resident had to wait for fifteen (15) to twenty (20) minutes for staff to arrive because they may be helping other residents, which the residnt understood. e. The resident also indicated the resident sometimes calls and no one responds. 40 216. That Petitioner’s representative observed room C-304, the room of resident number forty- nine (49) and noted a half bedrail on the left side with urine disposal equipment hanging and a strong smell of urine in the room. 217. That Petitioner’s representative observed memory unit two (2) on October 29, 2016 at 2:18 p.m. and noted thirteen (13) residents and only a single staff member. 218. That Petitioner’s representative observed and interviewed resident number fifty (50) on October 28, 2016 at 2:34 p.m. and noted as follows: a. The resident was in a wheelchair at a table. b. The resident explained,” usually we had two staff, but today we have only one ... They change my briefs two (2) times a day only.” 219. That Petitioner’s representative reviewed the records of resident number two (2), resideng in room C-303, during the survey and noted as from the resident’s health assesment, form 1823, dated April 7, 2016, as follows: a. Diagnoses included diabetes mellitus, type II, depession, hypertension, coronary heart disease, cerebrovascular accident with residual deficits, and OA of knees. b. Ambulates with wheel chair. c. Required assitance with activities of daily living; supervision with self-care; assistance with ambulation, bathing, dressing, toileting, and transferring. 220. That Petitioner’s representative reviewed the records of resident number forty-four (44), residing in room C-201, during the survey and noted as follows: a. Health Assessment, form 1823, dated July 13, 2016: i. Diagnoses included Hx, right hip fracture, orif right hip, hypertension, prostatic hyperplasia, arteriosclerotic heart disease, anxiety, irritabkle bowel syndrome, depression, and history of falls. 41 ii. Special precautions were required for falls risk. iii. The resident required assistance with activities of daily living, ambulation, bathing, dressing, and transferring, and supervision with self-care and toileting. iv. The resident required assistance with administration of medication. b. Health Assessment, form 1823, dated October 26, 2016: i. Diagnoses included Hx, right hip fracture, prostatic hyperplasia, insomnia, history of falls, abnormality of gsit, hypertension, depression, and GERD. ii. The resident required assistance with activities of daily living and ambulation and supervision with eating, self-care, assistance with bathing and dressing, and total care with ambulation, toileting, and transfer. 221. That the above reflects Respondent’s failure to ensure it provided sufficient qualified staff to meet resident scheduled and unscheduled service needs. 222. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 223. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 224. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 225. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). 42 COUNT XI (161 226. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 227. That Florida law provides: (a) Personnel records for each staff member must contain, at a minimum, a copy of the employment application, with references furnished, and documentation verifying freedom from signs or symptoms of communicable disease. In addition, records must contain the following, as applicable: 1. Documentation of compliance with all staff training and continuing education required by Rule 58A-5.0191, F.A.C.; 2. Copies of all licenses or certifications for all staff providing services that require licensing or certification; 3. Documentation of compliance with level 2 background screening for all staff subject to screening requirements as specified in Section 429.174, F.S. and Rule 58A-5.019, F.A.C.; 4. For facilities with a licensed capacity of 17 or more residents, a copy of the job description given to each staff member pursuant to Rule 58A-5.019, F.A.C.; 5. Documentation verifying direct care staff and administrator participation in resident elopement drills pursuant to paragraph 58A-5.0182(8)(c), F.A.C. Rule 58A-5.024(2), Florida Administrative Code. 228. That Florida law provides: The administrator or owner of a facility shall maintain personnel records for each staff member which contain, at a minimum, documentation of background screening, if applicable, documentation of compliance with all training requirements of this part or applicable rule, and a copy of all licenses or certification held by each staff who performs services for which licensure or certification is required under this part or rule. § 429.275(2), Florida Statutes (2016). 229. That the Agency completed a revisit to the June 2, 2016 survey of Respondent’s facility on August 4, 2016. 230. That based upon observation, interview, and review of records, Respondent failed to ensure it obtained and maintained required documentation for employee personnel records, the same being contrary to the mandated of law. 231. That Petitioner’s representatievs reviewed Respondent’s personnel records during the survey and noted the following employee records lacked the following required documentation: 43 a. Employee “A” — No employment application was maintained. b. Employee “B” — No references were maintained. c. Employee “C” — No employment application was maitntianed and no job description was maintained. d. Employee “D” — No references were maintained and no job description was maintained. e. Employee “E” — No references were maintained and no job description was maintained. f. Employee “F” — No employment application was maitntianed, no references were maintained, and no job description was maintained. g. Emplyee “G” — No references were maintained. h. Employee “H” — no employment application was maintained. 232. That Petitioner’s representative interviewed Respondent’s administrator on August 4, 2016 at 3:15 p.m. who confirmed the omissions from personnel records identified above and announced an intention to correct the records. 233. That the above reflects Respondent’s failure to ensure it obtained and maintained required documentation for employee personnel records. 234, 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 235. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 236. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 44 237. That the Agency completed a second re-visit to the June 2, 2016 survey of Respondent’s facility by survey dated October 28, 2016. 238. That based upon observation, interview, and review of records, Respondent failed to ensure it obtained and maintained required documentation for employee personnel records, the same being contrary to the mandated of law. 239. That Petitioner’s representatievs reviewed Respondent’s personnel records during the survey and noted that the personnel record for staff member “A”, a medication technician, the record lacked an employment application. 240. That Petitioner’s representative interviewed Respondent’s staff member “V-26,” the human resources director, on November 28, 2016 at 8:26 a.m. who confirmed the omission from the personnel record of employee “A.” 241. That the above reflects Respondent’s failure to ensure it o btained and maintained required documentation for employee personnel records. 242. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 243. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 244. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 245. That the same constitutes an uncorrected Class III deficiency as defined by law. WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). 45 COUNT XII (Z213) 246. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 247. Under Florida law, level 2 background screening pursuant to Chapter 435 must be conducted through the Agency on each of the following persons, who are considered employees for the purposes of conducting screening under Chapter 435: (a) The licensee, if an individual. (b) The administrator or a similarly titled person who is responsible for the day-to-day operation of the provider. (c) The financial officer or similarly titled individual who is responsible for the financial operation of the licensee or provider. (d) Any person who is a controlling interest if the Agency has reason to believe that such person has been convicted of any offense prohibited by Section 435.04. For each controlling interest who has been convicted of any such offense, the licensee shall submit to the Agency a description and explanation of the conviction at the time of license application. (e) Any person, as required by authorizing statutes, seeking employment with a licensee or provider who is expected to, or whose responsibilities may require him or her to, provide personal care or services directly to clients or have access to client funds, personal property, or living areas; and any person, as required by authorizing statutes, contracting with a licensee or provider whose responsibilities require him or her to provide personal care or personal services directly to clients. Evidence of contractor screening may be retained by the contractor’s employer or the licensee. § 408.809(1), Fla. Stat. (2016). 248. Under Florida law, every 5 years following his or her licensure, employment, or entry into a contract in a capacity that under subsection (1) would require level 2 background screening under chapter 435, each such person must submit to level 2 background rescreening as a condition of retaining such license or continuing in such employment or contractual status. For any such rescreening, the agency shall request the Department of Law Enforcement to forward 46 the person’s fingerprints to the Federal Bureau of Investigation for a national criminal history record check unless the person’s fingerprints are enrolled in the Federal Bureau of Investigation’s national retained print arrest notification program. If the fingerprints of such a person are not retained by the Department of Law Enforcement under s. 943.05(2)(g) and (h), the person must submit fingerprints electronically to the Department of Law Enforcement for state processing, and the Department of Law Enforcement shall forward the fingerprints to the Federal Bureau of Investigation for a national criminal history record check. The fingerprints shall be retained by the Department of Law Enforcement under s.943.05(2)(g) and (h) and enrolled in the national retained print arrest notification program when the Department of Law Enforcement begins participation in the program. The cost of the state and national criminal history records checks required by level 2 screening may be borne by the licensee or the person fingerprinted. Until a specified agency is fully implemented in the clearinghouse created under s. 435.12, the agency may accept as satisfying the requirements of this section proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the agency, the Department of Health, the Department of Elderly Affairs, the Agency for Persons with Disabilities, the Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651, provided that: (a) The screening standards and disqualifying offenses for the prior screening are equivalent to those specified in s. 435.04 and this section; (b) The person subject to screening has not had a break in service from a position that requires level 2 screening for more than 90 days; and (c) Such proof is accompanied, under penalty of perjury, by an attestation of compliance with chapter 435 and this section using forms provided by the agency. § 408.809(2), Fla. Stat. (2016). 47 249. Under Florida law, in addition to the offenses listed in Section 435.04, all persons required to undergo background screening pursuant to this part or authorizing statutes must not have an arrest awaiting final disposition for, must not have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, and must not have been adjudicated delinquent and the record not have been sealed or expunged for any of the offenses or any similar offense of another jurisdiction listed in Section 408.809(4). § 408.809(4), Fla. Stat. (2016). 250. Under Florida law, if an employer or Agency has reasonable cause to believe that grounds exist for the denial or termination of employment of any employee as a result of background screening, it shall notify the employee in writing, stating the specific record that indicates noncompliance with the standards in this chapter. It is the responsibility of the affected employee to contest his or her disqualification or to request exemption from disqualification. The only basis for contesting the disqualification is proof of mistaken identity. § 435.06(1), Fla. Stat. (2016). 251. Under Florida law, (a) an employer may not hire, select, or otherwise allow an employee to have contact with any vulnerable person that would place the employee in a role that requires background screening until the screening process is completed and demonstrates the absence of any grounds for the denial or termination of employment. If the screening process shows any grounds for the denial or termination of employment, the employer may not hire, select, or otherwise allow the employee to have contact with any vulnerable person that would place the employee in a role that requires background screening unless the employee is granted an exemption for the disqualification by the Agency as provided under Section 435.07. (b) If an employer becomes aware that an employee has been arrested for a disqualifying offense, the employer must remove the employee from contact with any vulnerable person that places the 48 employee in a role that requires background screening until the arrest is resolved in a way that the employer determines that the employee is still eligible for employment under this chapter. (c) The employer must terminate the employment of any of its personnel found to be in noncompliance with the minimum standards of this chapter or place the employee in a position for which background screening is not required unless the employee is granted an exemption from disqualification pursuant to Section 435.07. (d) An employer may hire an employee to a position that requires background screening before the employee completes the screening process for training and orientation purposes. However, the employee may not have direct contact with vulnerable persons until the screening process is completed and the employee demonstrates that he or she exhibits no behaviors that warrant the denial or termination of employment. § 435.06(2){a)-(d), Fla. Stat. (2016). 252. Under Florida law, any employee who refuses to cooperate in such screening or refuses to timely submit the information necessary to complete the screening, including fingerprints if required, must be disqualified for employment in such position or, if employed, must be dismissed. § 435.06(3), Fla. Stat. (2016). 253. Under Florida law, all staff, who are hired on or after October 1, 1998, to provide personal services to residents, must be screened in accordance with Section 429.174, F.S. ... Rule 58A- 5.019(3)(a), Florida Administrative Code. 254. Under Florida law, “Staff” means any person employed by a facility; or contracting with a facility to provide direct or indirect services to residents; or employees of firms under contract to the facility to provide direct or indirect services to residents when present in the facility. The term includes volunteers performing any service which counts toward meeting any staffing requirement of this rule chapter. Rule 58A-5.0131(34), Florida Administrative Code. 255. That October 28, 2016, the Agency completed a revisit survey of Respondent’s facility. 49 256. Based upon record review and interview, the Respondents failed to ensure that the Facility staff had the required background screening or exemption for one (1) of four (4) sampled staff members, the same being contrary to law. 257. That Petitioner’s representative reviewed Respondent’s personnel records for staff member “A” during the survey and noted the following: a. The staff member was a medication technician b. There was no documentation reflecting a Level 2 criminal History ackground screening had been completed for the employee. c. Background screening documentation of record rflected “Screening in Progress.” 258. That Petitioner’s representative reviewed the Agency’s background screening website on October 28, 2016, and noted that employee “A” was determined eligible for employment on June 29, 2015. 259. That Petitioner’s representative interviewed Respondent’s human resources director who confirmed that the personnel records of staff member “A” did not have documentation of criminal history background screening eligibility or an application. 260. That providers are required to obtain and maintain such records as criminal history background screening for Agency review in personnel records. See, Rule 58A-5.024(2)(a), Florida Administrative Code. 261. That Respondent allowed individuals, in an employment or volunteer role, access to residents, their records, and property, without having obtained a criminal history background check on the individual, the same being contrary to the mandates of law. 262. The Respondent’s actions or inactions constituted a violation of Sections 429.174 and 408.809, Florida Statutes (2016). 50 263. Under Florida law, in addition to the requirements of part II of Chapter 408, the Agency may deny, revoke, and suspend any license issued under this part and impose an administrative fine in the manner provided in Chapter 120 against a licensee for a violation of any provision of Part I or Chapter 429, Part II of Chapter 408, or applicable rules, or for any of the following actions by a licensee, for the actions of any person subject to level 2 background screening under Section 408.809, Florida Statutes, or for the actions of any facility employee: ... Failure to comply with the background screening standards of Chapter 429, Part I, Section 408.809(1), or Chapter 435, Florida Statutes. § 429.14(1)(f), Fla. Stat. (2016). 264. Under Florida law, the Agency may impose an administrative fine for a violation that is not designated as a class I, class II, class III, or class IV violation. Unless otherwise specified by law, the amount of the fine may not exceed $500 for each violation. Unclassified violations include: Violating any provision of this part, authorizing statutes, or applicable rules. § 408.813(3)(b), Fla. Stat. (2016). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of five hundred dollars ($500.00) against the Respondent. COUNT XIII(167 265. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 266. That Florida law provides: The contract shall include a refund policy to be implemented at the time of a resident’s transfer, discharge, or death. The refund policy shall provide that the resident or responsible party is entitled to a prorated refund based on the daily rate for any unused portion of payment beyond the termination date after all charges, including the cost of damages to the residential unit resulting from circumstances other than normal use, have been paid to the licensee. For the purpose of this paragraph, the termination date shall be the date the unit is vacated by the resident and cleared of all personal belongings. If the amount of belongings does not preclude renting the unit, the facility may clear the unit and charge the resident or his or her estate for moving and storing the items at a rate equal to the actual cost to the facility, not to exceed 20 percent of the regular rate for the 31 unit, provided that 14 days’ advance written notification is given. If the resident’s possessions are not claimed within 45 days after notification, the facility may dispose of them. The contract shall also specify any other conditions under which claims will be made against the refund due the resident. Except in the case of death or a discharge due to medical reasons, the refunds shall be computed in accordance with the notice of relocation requirements specified in the contract. However, a resident may not be required to provide the licensee with more than 30 days’ notice of termination. If after a contract is terminated, the facility intends to make a claim against a refund due the resident, the facility shall notify the resident or responsible party in writing of the claim and shall provide said party with a reasonable time period of no less than 14 calendar days to respond. The facility shall provide a refund to the resident or responsible party within 45 days after the transfer, discharge, or death of the resident. The agency shall impose a fine upon a facility that fails to comply with the refund provisions of the paragraph, which fine shall be equal to three times the amount due to the resident. One- half of the fine shall be remitted to the resident or his or her estate, and the other half to the Health Care Trust Fund to be used for the purpose specified in s.429.18. § 429,.24(3){a), Fla. Stat. (2016). 267. That Florida law provides: (1) Pursuant to Section 429.24, F.S., the facility must offer a contract for execution by the resident or the resident’s legal representative before or at the time of admission. The contract must contain the following provisions: (a) A list of the specific services, supplies and accommodations to be provided by the facility to the resident, including limited nursing and extended congregate care services that the resident elects to receive; (b) The daily, weekly, or monthly rate; (c) A list of any additional services and charges to be provided that are not included in the daily, weekly, or monthly rates, or a reference to a separate fee schedule that must be attached to the contract; (d) A provision stating that at least 30 days written notice will be given before any rate increase; (e) Any rights, duties, or obligations of residents, other than those specified in Section 429.28, F.S.; (f) The purpose of any advance payments or deposit payments, and the refund policy for such advance or deposit payments; (g) A refund policy that must conform to Section 429.24(3), F.S.; (h) A written bed hold policy and provisions for terminating a bed hold agreement if a facility agrees in writing to reserve a bed for a resident who is admitted to a nursing home, health care facility, or psychiatric facility. The resident or responsible party must notify the facility in writing of any change in status that would prevent the resident from returning to the facility. Until such written notice is received, the agreed upon daily, weekly, or monthly rate may be charged by the facility unless the resident’s medical condition prevents the resident from giving written notification, such as when a resident is comatose, and the resident does not have a responsible party to act on the resident’s behalf; (i) A provision stating whether the facility is affiliated with any religious organization and, if so, which organization and its relationship to the facility; (j) A provision that, upon determination by the administrator or health care provider that 52 the resident needs services beyond those that the facility is licensed to provide, the resident or the resident’s representative, or agency acting on the resident’s behalf, must be notified in writing that the resident must make arrangements for transfer to a care setting that is able to provide services needed by the resident. In the event the resident has no one to represent him or her, the facility must refer the resident to the social service agency for placement. If there is disagreement regarding the appropriateness of placement, provisions outlined in Section 429.26(8), F.S., will take effect; (k) A provision that residents must be assessed upon admission pursuant to subsection 58A-5.0181(2), F.A.C., and every 3 years thereafter, or after a significant change, pursuant to subsection (4) of that rule; (1) The facility’s policies and procedures for self-administration, assistance with self- administration, and administration of medications, if applicable, pursuant to Rule 58A- 5.0185, F.A.C. This also includes provisions regarding over-the-counter (OTC) products pursuant to subsection (8) of that rule; and (m) The facility’s policies and procedures related to a properly executed DH Form 1896, Do Not Resuscitate Order. (2) The resident, or the resident’s representative, must be provided with a copy of the executed contract. (3) The facility may not levy an additional charge for any supplies, services, or accommodations that the facility has agreed by contract to provide as part of the standard daily, weekly, or monthly rate. The resident or resident’s representative must be furnished in advance with an itemized written statement setting forth additional charges for any services, supplies, or accommodations available to residents not covered under the contract. An addendum must be added to the resident contract to reflect the additional services, supplies, or accommodations not provided under the original agreement. Such addendum must be dated and signed by the facility and the resident or resident’s legal representative and a copy given to the resident or resident’s representative. Rule 58A-5.025, Florida Administrative Code. 268. That August 4, 2016, the Agency completed a complaint survey of Respondent’s facility. 269. That based upon observation, interview, and review of records, Respondent failed to provide resident refunds in accord with the requirements of law and the resident contract, the same being contrary to law. 270. That Petitioner’s representative telephonically interviewed resident number eight (8) on August 2, 2016 at 4:00 p.m. who indicated as follows: a. The resident was admitted to the facility on February 2, 2016. b. The resident was discharged to the hospital on March 3, 2016, with false information that the resident was having some issues going to the bathroom and some blood in the stool. 53 c. When discharged from the hospital to the facility on March 4, 2016, Respondent did not accept the resident back to the facility, and the resident had to find another place to stay. d. The Respondent facility never gave the resident a refund. 271. That Petitioner’s representative interviewed Respondent’s staff member “D” regarding resident number eight (8) on August 3, 2016 at 12:00 p.m., who indicated: a. The facility did not give a refund to the resident because they had to keep the resident’s belongings for a whole month. b. Asa result, the facility charged the resident for the whole month. 272. That Petitioner’s representative reiewed Respondent’s records related to resident number eight (8) during the survey and noted that the resident wrote the monthly check to Respondent for March 2016 on the same date the resident was discharged to the hospital, March 3, 2016. 273. That Petitioner’s representative telephonically interviewed on August 3, 2016 at 12:22 p.m., the adult sibling of resident number eight (8) who indicated as follows: a. Since the individual’s sibling was discharged from the hospital to the facility to go to the hospital, the problems started. b. When the individual’s sibling arrived back at the facility, they did not accept the sibling back into the facility. c. The following day, the individual went to the facility to get the sibling resident’s belongings and they told the individual that they could not give the sibling’s belongings to the individual because they did not have the keys to open the door of the room of resident number eight (8). d. The second and third times that the individual went to the facility, they told the individual the same story. 34 e. On the third attempt, the individual told them that the individual was going to call the police, and that is when they found the key for the room and the individual could collect the belongings of resident number eight (8). 274. That Petitioner’s representative reviewed Respondent’s records related to resident number seven (7) during the survey and noted that the resident was admitted to the facility on March 28, 2014, was discharge on April 20, 2016, and the resident was charged for the whole month of April 2016. 275. That Petitioner’s representative interviewed Respondent’s staff member “D” regarding resident number seven (7) on August 3, 2016 at approximately 12:30 p.m., and the staff member indicated: a. They charged the resident for the whole month because the resident’s adult child agreed to this. b. Staff member “D” produced an e-mail as documentation of the agreement that the facility could keep the resident's money, and the e-mail read, "I will return the gate remote control and request my $100.00 deposit to be returned at the time as well as the prorated monthly charge that is not used.” 276. That Petitioner’s representative interviewed Respondent’s Administrator on August 4, 2016 at 1:00 p.m. regarding refunds due to residents numbered seven (7) and eight (8), and the administrator indicated that they would try to get refunds to the residents as soon as possible. 277. That the above reflects Respondent’s failure to provide resident refunds in accord with the requirements of law and the resident contract. 278. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 55 279. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 280. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 281. That the Agency completed a re-visit to the August 4, 2016 survey of Respondent’s facility on November 3, 2016. 282. That based upon observation, interview, and review of records, Respondent failed to provide resident refunds in accord with the requirements of law and the resident contract, the same being contrary to law. 283. That on November 3, 2016, Petitioner’s representative requested Respondent’s representative produce for examination records related to residents numbered seven (7) and eight (8) as identified above to confirm resident refunds had been provided. 284. That Respondent could produce no records related to the residents despite a records retention requirement, see, Rule 58A-5.024(3)(q), Florida Administrative Code, or any documentation to reflect that the refunds above discussed had been satisfied. 285. 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 indirectly or potentially threaten the physical or emotional health, safety, or security of clients. 286. That Florida law requires that cited deficient practices be corrected within thirty (30) days. 287. That the same constitutes a Class III offense as defined in Florida Statute 429.19(2)(c) (2017), and Respondent was cited with a Class III deficient practice. 288. That the same constitutes an uncorrected Class III deficiency as defined by law. 56 WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2017). COUNT XIV(Survey) 289. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count XIV as if fully set forth herein. 290. That pursuant to Section 429.19(7), Florida Statutes (2016), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2016), to verify the correction of the violations. 291. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2016). COUNT XV (50 292. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count XIV as if fully set forth herein. 293. That Florida law provides; (1) SELF ADMINISTERED MEDICATIONS. (a) Residents who are capable of self-administering their medications without assistance must be encouraged and allowed to do so. (b) If facility staff observes health changes that could reasonably be attributed to the improper self-administration of medication, staff must consult with the resident concerning any problems the resident may be experiencing in self-administering the 57 medications. The consultation should describe the services offered by the facility that aid the resident with medication administration through the use of a pill organizer, through providing assistance with self-administration of medications, or through administering medications. The facility must contact the resident’s health care provider when observable health changes occur that may be attributed to the resident’s medications. The facility must document such contacts in the resident’s records. Rule 58A-5.0185(1), Florida Administrative Code. 294. That Florida law provides: (2) Residents who are capable of self-administering their own medications without assistance shall be encouraged and allowed to do so. However, an unlicensed person may, consistent with a dispensed prescription’s label or the package directions of an over-the- counter medication, assist a resident whose condition is medically stable with the self- administration of routine, regularly scheduled medications that are intended to be self- administered. Assistance with self-medication by an unlicensed person may occur only upon a documented request by, and the written informed consent of, a resident or the resident’s surrogate, guardian, or attorney in fact. For the purposes of this section, self- administered medications include both legend and over-the-counter oral dosage forms, topical dosage forms and topical ophthalmic, otic, and nasal dosage forms including solutions, suspensions, sprays, and inhalers. § 429.256(2), Florida Statutes (2016). 295. That on November 29, 2016, the Agency completed a re-visit survey of Respondent’s facility. 296. That based upon observation, interview, and the review of records, Respondent failed to recognize health changes, including multiple falls, that could be reasonably attributed to the improper self-administration of medication, and failed to consult with a resident about problems in self-administering medications, the same being contrary to the mandates of law. 297. That Petitioner’s representative, on October 28, 2016, observed and interacted with resident number forty-four (44) and noted as follows: a. 12:25 p.m. -— The resident stated, "I take my own medication. I keep it ina cabinet in the bathroom. I have had about six (6) falls in the past six (6) months. I had a fall on October 26, 2016, and I squashed my vertebrae. I was being stubborn and I tried to get from the bed to the nightstand. I didn't use my walker 38 and I fell. I had a pacemaker placed; my doctor said that will help me because I had a low heart rate." b. 1:20 p.m. i. The resident was sitting in a wheelchair in room C-201. ii. The resident's bed had attached full bed rail on both sides. iii. The resident stated, "I cannot remove the full bed rail by myself. I called staff to help me to get out of the bed. They take fifteen (15) minutes or twenty (20) minutes to get in here. I have to wait because sometimes they are helping another resident. I'm calling them and they do not answer me.” 298. That Petitioner’s representative observed the room of resident number forty-four (44) several times during the survey and noted as follows: a. October 28, 2016 at 2:30 p.m. - Observed a bottle of Percocet on the dresser. b. October 29, 2016 at 5:20 p.m. - Observed several medications in the room, several oxygen tanks, and insulin injections on top of the dresser. c. October 29, 2016 at 5:35 p.m. — Accompanied by Respondent’s staff member “22” and observed several medication bags from a pharmacy with medication inside the bags. Several of the medications had different dates. d. October 29, 2016 at 5:51 p.m.: i. Accompanied by Respondent’s staff member “V22”, noted the resident’s room door was unlocked. ii. Over twenty (20) medication bottles were scattered widely around the room, some still in bags from the pharmacy. 59 iii. The resident stated that once, the Percocet was not received and the resident contacted the pharmacy and was told that the medications were delivered to the facility and signed for by staff. The next time, a week or so later, the resident went in person to pick the medications up. iv. Medications observed in the residents room were: 1, Pradaxa 150 MG 1 cap 2 x a day 9/23/2016; 2. Azelastine Spray 1 spray daily one box 10/24/2016; 3. Ocuvite 1 tab daily bottle 10/24/2016; 4. Lactulose 10 GM 15 ML one bottle of liquid; 5. Ferrous Sulfate 325 MG 1 tab daily one bottle 07/26/2016; 6. Olapatadine 665 MCG nasal spray spray daily 08/25/2016; 7. Oxybutinin 10 mg 1 tab daily one bottle 09/23/2016; 8. Doxazosin 4 mg 1 tab by night time one bottle 09/23/2016; 9. Amitriptyline 25 mg 1 cap by night one bottle 10/24/2016; 10. Pantoprazole 40 mg 1 tab daily one bottle 08/25/2016; 11. Simvastatin 20 mg 1 tab by night 09/23/2016; 12. Pantoprazole 40 mg 1 tab daily one bottle 09/23/2016; 13. Doxazosin 4 mg 1 tab daily one bottle 08/26/2016; 14. Simvastatin 20 mg 1 tab daily one bottle 10/24/2016; 15. Oxybutynin 10 mg 1 daily one bottle 10/23/2016; 16. Doxazosin 4 mg 1 daily one bottle 10/24/16; 17. Escitalopram 20 mg 1 daily one bottle 10/24/2016; 18. Valsartan 160-12.5 mg 1 daily one bottle 10/24/206; 19. Azelastine Nasal spray, Tylenol one bottle; 60 20. Oxycodone 0-328 MG every 4 hours 10/26/2016; 21. Alprazolam 1 mg daily one bottle 09/06/2016; 22. Oxybutynin 10 mg daily 10/24/2016; 23. Ammonium lactate 12% daily 09/23/2016; 24. Enulose 10 g/mg daily 07/30/2016. v. In medicine cabinet was: 1. 2. 8. 9. Valsartan 160-12.5 MG 1 daily one bottle 07/14/2016; Oxybutynin 10 mg 1 daily one bottle 08/26/2016; . Pantoprazole 40 mg daily one bottle 10/24/2016; Pradaxa 150 mg daily one bottle 08/26/2016; Simvastatin 20 mg daily one bottle 08/26/2016; Alprazolam 1 mg daily one bottle 07/30/2016; Finasteride 5 MG 1 daily one bottle 10/24/2016; Amitriptyline 25 mg 1 daily one bottle 08/25/2016; Escitalopram 20 mg 1 daily one bottle 08/25/2016; 10. Doxazosin 4 mg 1 daily one bottle 07/30/2016; 11, Cyclobenzaprine 10 mg daily one bottle 10/24/2016. 299, That Petitioner’s representative reviewed Respondent’s records related to resident number forty-four (44) during the survey and noted as follows: a. The resident fell in the facility dining room while ambulating with a walker on June 14, 2016, and broke a hip. The resident had surgery went to a rehabilitation facility for six (6) weeks before returning to the facility. The resident was recommended to have fall precautions. 61 d. Hospital records for the resident documented: i. ili. On September 28, 2016 at 12:29 p.m., the resident was transferred to the Emergency room after a fall. ii. The record documented, "Fell while trying to get in to bed at 4 a.m. Complaint of pain to right hip/buttocks since the fall. [Patient] is concemed about prior right hip surgery that [patient] had in 07/16” Further documented, "On 09/28/16 at 3:32 p.m., patient discharged home to the assisted living facility with instructions given, verbalized understanding, left message with facility nurse director and front desk of facility in regards to updating on patients status." e. Progress notes reflect: o iii. The resident was admitted to the hospital on October 3, 2016, and discharged on October 17, 2016. ii. On October 14, 2016 at 5:45 a.m., the physician charted that the resident complained of a low blood pressure (LBP), stemming from a fall six (6) days earlier. Patient history of present illness stated: The patient presents complaining of lower back pain. [Patient] stated that [patient] fell several days ago, but did not seek medical care at the time. Hospital Course: patient was admitted for observations. [Patient] was placed on pain control. [Patient] was continued on [] usual medications. During the hospitalization patient was noted to be bradycardic and to have pauses. [Patient] was seen by EP and underwent a pacemaker placement. 62 vy. The resident was returned to the facility from a hospitalization on October 24, 2016, for an unknown reasons. The resident kept medications prescribed at discharge. vi. There was no documentation that staff observed the resident or the resident’s ability to self-administer the medication. f. Absent from the record was any indication the Respondent staff observed the surplus of medication in the resident's room or that staff spoke with the resident about having his ability to self-administer medications or to be reevaluated. g. The resident's health assessment, dated October 26, 2016, (AHCA form 1823), documented "Medication administration by resident." h. There was no documentation in the resident's file showing that staff contacted the resident's health care provider to report or coordinate care regarding the excessive unconsumed medication in the resident's room or the numerous falls with injury. 300. That the above reflects Respondent’s failure to recognize health changes, including multiple falls, that could be reasonably attributed to the improper self-administration of medication, and failed to consult with a resident about problems in self-administering medications. 301. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatened the physical or emotional health, safety, or security of the clients, other than class I violations. 302. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2016). 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 63 Florida, pursuant to § 429.19(2)(b), Florida Statutes (2017). COUNT XVI (25) 303. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 304. That Florida law provides: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the 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. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. Rule 58A-5.0182(1), Florida Administrative Code. 305. That on November 29, 2016, the Agency completed a re-visit survey of Respondent’s facility. 306. That based upon observation, the review of records, and interview, Respondent failed to provide care and services appropriate to meet the needs of residents including, but not limited to, the failure to provide timely assistance with assistance in personal care or supervision to prevent falls, the same being contrary to the mandates of law. 307. That Petitioner’s representative interviewed on October 28, 2016 at 6:11 a.m. Respondent’s staff member “V24” who indicated that he does not know how many residents are 64 in the facility and provided a census form dated October 23, 2016, which identified the census on that day as one hundred twenty-six (126) residents. 308. That Petitioner’s representative interviewed on October 28, 2016 at 6:12 a.m. Respondent’s staff member “V25,” a home health aide, who indicated that she had been working at the facility for about four (4) months, did not know the census, and opened the memory care unit stating there were residents living on floors two (2) and three (3). 309. That Petitioner’s representative interviewed on October 28, 2016 at 6:19 a.m. Respondent’s staff member “H” in room A204 who indicated: a. Staff member “V23” was on duty with her. b. They only had six (6) residents on the unit/floor, and that only floors two (2) and five (5) were in use. c. There were about seventeen (17) people on the fifth floor and she was providing care to seven (7) of them. 310. That Petitioner’s representative toured building C of the facility on October 28, 2016 and at 7:45 a.m. with Respondent’s kitchen manager, staff member “L-12,” and no facility staff were observed in the hallways and staff member “L-12” remarked, “We have one staff in this building but at this time she is assisting residents in their rooms. We have one elevator out of order. I don’t know where she is. She has a phone that she can be called on.” 311. That Petitioner’s representative interviewed on October 28, 2016 at 7:02 a.m. Respondent’s staff member “R” who indicated that the front desk guard should have known the census, and he had a sheet from the night before. 312. That Petitioner’s representative observed two (2) staff members signing off on the hourly rounds sheets from 3:00 a.m. to 7:00 a.m. on October 28, 2016 and at 7:10 a.m. and interviewed Respondent’s staff member “C” who indicated as follows: 65 a. Staff does not have time to initial the round/observation/care logs because they are bathing residents during those hours, so they sign the sheet before they leave their shift. b. It can take around thirty (30) minutes to shower the residents who are incontinent. c. When asked how staff can sign off that they have seen all of the other residents during the time that they were showering someone, since they are not making the rounds at those times, staff “C” stated they just do the best they can; trying to recall that residents were okay the last time they saw them. 313. That Petitioner’s representative reviewed Respondent’s internal incident log for September and October of 2016, and monthly care logs for October 2016, and identified several residents with hospitalizations or falls. 314. That Petitioner’s representative reviewed Respondent’s monthly care logs and noted that forty-six (46) residents who had monthly care logs needed or received assistance with adult incontinence briefs. 315. That Petitioner’s representative reviewed Respondent’s records related to resident number forty-six (46) during the survey and noted: a. The resident was receiving Hospice care and had an order for a hospital bed with rails. b. The Hospice Plan of care (POC) was updated on October 12, 2016. c. The resident’s health assessment, Agency for Health Care Administration form 1823, documented: i, The resident required assistance with ambulation. ii. The resident cannot bathe, dress, eat, toilet, or transfer independently. iii. The resident required assistance for all activities of daily living (ADL's). 66 iv. vi. The resident needed administration of medications. The resident’s medications are administered two (2) times per day at 8:00 a.m. and 5:00 p.m. The resident required a puree diet ordered and crushed medications ordered. d. The resident received hospice services three (3) times per week. e. The resident had lost twelve (12) pounds since admission on January 27, 2015. 316. That Petitioner’s representative on October 28, 2016 at 8:55 a.m. interviewed Respondent’s staff member “V22” who confirmed that resident number forty-six (46) is bedbound. 317. That Petitioner’s representative reviewed Respondent’s records related to resident number forty-three (43) during the survey and noted: a. The resident’s health assessment, form 1023, dated February 20, 2016, documented: i. ii. iii. Diagnoses included hypertension (HTN), diabetic, coronary artery disease (CAD), deep vein thrombosis (DVT), depression, psychosis, gastroesophageal reflux disease (GERD), hyperlipidemia, and chronic A- fib. The resident had physical or sensor limitations and ambulated with a walker. The resident's activities of daily living (ADL's) were independent with transferring and needing supervision with bathing and dressing. b. On June 21, 2016, the resident went to the hospital emergency room and had a diagnosis of a head injury. 67 c. An October 26, 2016, progress note by a physician documented the resident was wheelchair bound. 318. That Petitioner’s representative interviewed on October 28, 2016 at 11:40 a.m. resident number thirty-seven (37) who stated, "I do not remember how long I have been here. I can stand up, but I can only walk little steps because I am not strong enough. Yes, I wear adult briefs. If I need to have my brief changed, I will call them and I will let them know. I have my own phone. At night they will come to change me maybe once, occasionally once in a while they will leave me with my diaper unchanged until the point that it becomes uncomfortable." 319. That Petitioner’s representative interviewed resident number thirty-seven (37) on October 28, 2016 at 11:40 a.m. who indicated, “I don’t remember how long I have been here. I can stand up, but I can only walk little steps because I am not strong enough. Yes, I wear adult briefs. If I need to have my brief changed I will call them and I will let them know. I have my own phone. At night they will come to change me maybe once. Occasionally, once in a while, they will leave me with my diaper without a change until the point it becomes uncomfortable.” 320. That Petitioner’s representative observed and interviewed resident number forty-four (44) on October 28, 2016 and noted as follows: a. 12:25 p.m. i. "Yes, I take my own medication. I keep it in a cabinet in the bathroom. ii. “I have had about six (6) falls in the past six (6) months. iii. “I had a fall on October 26, 2016. I squashed my vertebrae. I was being stubborn and I tried to get from the bed to the nightstand. I did not use my walker and I fell. iv. “I had a pacemaker placed; my doctor said that will help me because I had a low heart rate." 68 b. 1:20 p.m. — In room C-201, the resident was sitting in a wheelchair, the resident's bed had an attached full bed rail on both sides, and the resident explained: i. "I cannot remove the full bed rail by myself. I called staff to help me to get out of the bed. ii. “They take fifteen minutes or twenty minutes to get in here. iii. “I have to wait because sometimes they are helping another resident." iv. The resident explained this is understandable, stating, “I'm calling them and they do not answer me.” 321. That Petitioner’s representative noted during the survey that resident number fifty (50) was incontinent and was on a list of residents who needed staff assistance for toileting and grooming 322. That Petitioner’s representative on October 29, 2016 at 2:43 p.m., observed resident number fifty (50) in a wheelchair in front of the table and he offered, “Usually we have two staff, but today we have only one staff. They change my briefs two times a day only.” 323. That the above reflects Respondent’s failure to ensure the provision of care, services, and supervision appropriate to the needs of residents. 324. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatened the physical or emotional health, safety, or security of the clients, other than class I violations. 325. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2017). 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 (2017). 69 Respectfully submitted this Y day of August, 2017. AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1947 Facsimile: (727) 552-1440 J. Walsh Il, Esq. la. Bar No. 566365 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. 70 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7016 2140 0001 1591 9632 on August r , 2017 to Peter A. Lewis, Counsel for AM Grand Court Lakes, LLC, 3023 North Shannon Lakes Drive, Suite 101, Tallahassee, Florida 32309. as J. Walsh Il, Esq. Copy furnished to: Arlene Mayo-Davis Field Office Manager 71 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: AM Grand Court Lakes LLC AHCA Nos. 2017005735 2017005736 2017005746 2017005744 2017005740 2017005741 ELECTION OF RIGHTS This Election of Rights torm 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 Chapter] 20, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing. ! 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 72 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. 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 (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. 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) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: 73 so that we can return the card to you. ® Attach this card to the back of the mallpiece, or on the front if space permits. 1. Article Addressed to: Peter A. Lewis, Counsel for AM Grand Court Lakes, LLC, : 3023 North Shannon Lakes Drive, # 101 Tallahassee, Florida 32309 O) Registered C1) Return Receipt for Merchandiae Dinsured Malt [1 C.0.D. a 4. Restricted Delivery? (Extra Fee) 0 Yes 703b 2240 0001 1591 432 "Py. f DO 160 51355 57 y , PS Form 3811, February 2004 Domestic Return Recelpt ~ 102595-02-M-1640 Tracking Number: 70162140000115919632 Delivered Product & Tracking Information See Available Actions Postal Features: Product: Certified Mail™ Your item was delivered at 9:35 am on August 9, 2017 in TALLAHASSEE, FL 32308. DATE & TIME STATUS OF ITEM LOCATION August 9, 2017, 9:35 am Delivered TALLAHASSEE, FL 32308 Y our item was delivered at 9:35 am on August 9, 2017 in TALLAHASSEE, FL 32308. August 7, 2017, 11:02 am Notice Left (No Authorized TALLAHASSEE, FL 32309 Recipient Available) August 7, 2017, 8:57 am Out for Delivery TALLAHASSEE, FL 32309 August 7, 2017, 8:47 am Sorting Complete TALLAHASSEE, FL 32309 August 7, 2017, 6:35 am Arrived at Unit TALLAHASSEE, FL 32308 August 7, 2017, 4:49 am Departed USPS Regional TALLAHASSEE FL Facility DISTRIBUTION CENTER August 7, 2017, 3:57 am Arrived at USPS Facility TALLAHASSEE, FL 32308 August 6, 2017, 6:48 pm Arrived at USPS Regional TALLAHASSEE FL Facility DISTRIBUTION CENTER DATE & TIME August 6, 2017, 8:51 am August 6, 2017, 8:51 am August 4, 2017, 10:49 pm August 4, 2017, 10:49 pm STATUS OF ITEM Departed USPS Regional Facility Arrived at USPS Regional Facility Departed USPS Regional Facility Arrived at USPS Regional Facility LOCATION JACKSONVILLE FL NETWORK DISTRIBUTION CENTER JACKSONVILLE FL NETWORK DISTRIBUTION CENTER YBOR CITY FL DISTRIBUTION CENTER YBOR CITY FL DISTRIBUTION CENTER

Docket for Case No: 18-000292