14-003132 Agency For Health Care Administration vs. Grace Manor At Lake Morton, Llc Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Friday, October 10, 2014.

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR 2015 M1k. 11 1 A 11: 9- 1

HEALTH CARE ADMINISTRATION,

Petitioner,

CASE NOS. 2013013450

V. 2014002084

DOAH NO. 14- 3132

GRACE MANOR AT LAKE MORTON, LLC, RENDITION NO.: AHCA- 1 S - O E S- OLC

Respondent.

FINAL ORDER

Having reviewed the Administrative Complaint and Amended Administrative Complaint, and all

other matters of record, the Agency for Health Care Administration finds and concludes as follows:

1. The Agency has jurisdiction over the above- named Respondent pursuant to Chapter 408,

Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions.

2. The Agency issued the attached Administrative Complaint and Election of Rights form to

the Respondent. ( Ex. 1) The Election of Rights forms advised of the right to an administrative hearing.

3. The parties entered into the attached Settlement Agreement. ( Ex. 2)

Based upon the foregoing, it is ORDERED:

1. The Settlement Agreement is adopted and incorporated by reference into this Final Order.

The parties shall comply with the terms of the Settlement Agreement.

2. The Respondent shall pay the Agency $ 3, 00. 000. If full payment has been made, the

cancelled check acts as receipt of payment and no further payment is required. If full payment has not

been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory

interest and may be referred to collections. Any check made payable to the " Agency for Health Care

Administration" and containing the AHCA ten- digit case number should be sent to:

Office of Finance and Accounting

Revenue Management Unit

Agency for Health Care Administration

2727 Mahan Drive, MS 14

Tallahassee, FL 32308

ORDERED at Tallahassee, Florida, on this Zq day of~ 2015.

Eliz eth Dud Secretary

Ag y for H al Care Administration

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled to judicial review, which shall be

instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy,

along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district

where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be

conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30

days of rendition of the order to be reviewed.

CERTIFICATE OF SERVICE

I CERTIFY that a true and correct of this Final Order was served on the below- named

persons by the method designated on this 2eXPd y o 2015.

Richard Shoop, Agency Cler

Agency for Health Care Administration

2727 Mahan Drive, Bldg. # 3, Mail Stop # 3

Tallahassee, FL 32308- 5403

Telephone: ( 850) 412- 3630

Facilities Intake Unit Finance & Accounting

Electronic Mail) Revenue Management Unit

Electronic Mail)

David Selby, Assistant General Counsel Louis F. Gerrard, President

Office of the General Counsel Grace Manor at Lake Morton, LLC

Agency for Health Care Administration c/ o Mainstay Financial Services

Electronic Mail) 5578 Commercial Blvd. NW

Winter Haven, FL 33880

U. S. Mail)

J. Davis Connor, Esq.

Peterson & Myers, P. A.

225 East Lemon Street

Lakeland, FL 33802- 4628

U. S. Mail)

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

Petitioner,

CASE NO. 2013013450

V. 2014002484

GRACE MANOR AT LADE MORTON, LLC,

Respondentt

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, Grace Manor at Lake' Morton, LLC (" Respondent") pursuant to Sections

120. 569 and 120. 57, Fla. Stat. ( 2013), and alleges:

This is an action against _ an assisted living. facility (" ALp"') to impose a $ 2, 000 fine for

one State Class II violation ( Count I) and a $ 1, 000 fine for an uncorrected State Class III violation

a;

Count II).

JURISDICTION AND VENUE

1. The Agency has jurisdiction pursuant to Sections 20. 42, 120. 60, and Chapters 408, Part II, and 3

429, Part I, Fla. Stat. ( 2013).

2. Venue lies pursuant to Florida Administrative Code F. C.") A. Rule 28- 207. 106. 3

1 EXHIBIT

PARTIES

3. The Agency is the regulatory authority responsible for lieeosure of ALFs and enforcement of all

applicable State statutes and rules governing ALFs pursuant to Chapters 408, Part II, and 429, Part I,

Fla.. Stat., and Chapter 58A- 5, F. C., A. respectively,

4. Respondent operates a 50 bed ALF at 610 East Lime St, Lakeland, FL 33801, Standard license

5217.

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 I - $ 2, 000 CLASS II FINE

Case No. 2013013450; State Tag A0030: Resident Care - Rights & Facility Procedures)

6, The Agency re- alleges and incorporates paragraphs l - 5 as if fully set forth herein..

7, The Agency' s surveyor conducted an unannounced complaint investigation ( CCR 2013008974) on 8

October, 2013.

8: The surveyor learned this information during the survey:

m______~_ esident-# that- ta- ity- ie- r~ ce> an--$~-----_.._.._..__ ; . a- ews- lased:- rd- 1- and- faa~ failed- onnte~ unsure- li- a~- re eviews;#~

year old man, with received appropriate medical care in a timely manner which led to delayed

medical care and extreme continual pain.

b. Phone interview with Staff ` A', a former wed tech/ caregiver, on 10/ 9113 at about 4: 40

pm. She stated that the last night that Resident # I was sent to the hospital, Staff ` B' ( another

caregiver) and she were working. They did their final rounds. Resident 41 came out about 10: 30

11: 30 pra and complained about a burning, like a hot rod was in his eye. She called the resident care

coordinator ( RCC) and told her what was going on. She asked the RCC if she could give him a

brand name medication for Acetaminophen that he had scheduled for later in the morning. The RCC

4

t

said Staff ` A' wasn' t supposed to but she could just this one time. Staff ` A' stated Resident # 1 was

hurting. She could tell he was in pain by his demeanor. About 11: 30 to 12: 30 am he started vomiting

when he was in the recliner: He was in the recliner so they could keep an eye on him. She called the

RCC again and she said just keep an eye on him and she would deal with him in the morning. The

RCC told Staff ` A' that she knew the family would be upset if they sent him out because he had

done this thing before. At 12: 30 to 1: 30 am it got worse and his breathing got worse. He was

breathing funny. His vitals were going crazy. His blood pressure was 200 and something over 100

and something. His pulse was fast and oxygen saturation was low. His breathing was irregular, She

called the RCC again and she said to call the home health company. The guy she spoke to at home

health asked why did he need to come and she explained the, situation and the vitals. He stated based s

on Resident # 1' s vitals he should be sent nut to the hospital. She called the RCC again and told her

what home health said and the RCC said " no to not send him out and she would deal with him in

the morning. At 1: 30 to 2: 30 am he was panic screaming ( like yelling). He said nowI know what it

feels like to die alone.. He already had problems with his left eye and it was white and he could not

see out of it but he. could see out of his right eye. However, then he complained that he could not see

them a. nd they wererig- h iii front of ihm: She called tTie' RC~ again grid slie responded again that she -

would deal with him in the morning. At 3: 30 am he was puking but she could hear it gurgling back.

in his lungs. He was aspirating. She called the RCC and told her that she was sending this man out

even if she had to be written up. He was throwing up and now he is aspirating. She stated OK do

whatever you have to, do. EMTs ( emergency medical technicians) got there about 3:: 45 am. They

started to move him onto the stretcher. He couldn' t stand. He had a stroke. Emergency medical

services ( EMS) and the emergency room doctor asked her why the resident was not sent to the

hospital earlier. A friend who worked at the facility told her the next day that Resident # 1 died at

6: 45 am.

i

c. Phone interview with Staff ` B', a med teeb/ caregiver, on 10/ 13 9/ at approximately 5: 40

am. She reported that on the: night of the incident at 11: 00 pm, Resident # 1 complained that his eye

hurt and he had a bad headache. Staff ` A' called the RCC and she said to go ahead and give the

brand name medication for Acetaminophen he had scheduled at some point during the next morning.

In an hour he stated it was getting worse. Staff ` A' called the RCC and she stated he did this before

and to keep an eye on him. They sat with Resident # 1 throughout the night in the living room in

front. Resident # 1 would freak out if he could not see them. He stated he could not see them and they

were right in front of his face. He said to please not leave him because he, did not want to die alone.

Staff ` A' called again and finally got permission to call 911 from the RCC about 2: 00 to 3: 00 am.

Paramedics asked if leaning to the side was normal for him and they told them it was not normal.

They asked if his face- drooping was normal and they said, " no. " They did a stress test and he was

weaker on one side. He fell to the side when they stood him up and stated they thought he had a

stroke when they took him out on a. stretcher. Staff stated she felt like Resident # 1 should have

j

went out to the hospital the first time Staff ` A' called the RCC. Resident # 1 stated he felt like a hot s

rod was stabbing through his eye. It was not normal for him to come out of his room and complain.

d. Interview with the RCC about Resident # 1 on 10/ 13 8/ at about 2: 15 pm.. She stated that

Staff ` A' called her once for Resident # I Is headache and she asked Staff ` A' if he had anything she

could give him for pain and Staff ` A' said a brand name medication for Acetaminophen. The RCC

said, " well give him that. Staff ' A' called back later and stated he was throwing up and she told

Staff ` A' to send him to the hospital. It started about 1: 00 am and she did not know how long in

between before Staff ` A' called the second time. She stated she did not remember exact times

because ithappened almost a year ago.

1

e. Review of the EMS report dated 4/ 13. 30/ It indicated that the stroke alert was called at 3. 28

am and Resident 41 arrived at the hospital at 3: 43 am.

f. Review of the hospital Emergency Department Note - Physician final report dated

4/ 13. 30/ It noted that the physician spoke directly to the staff at the facility and was told that at

11: 00 pm or so Resident # 1 had severe pain behind his right eye. He walked out to the nursing

station to request help. Resident # 1 sat down in a chair near the nursing station and, stayed there for

the next few hours. Somewhere between 3: 00 and 3: 15 am Resident 41 became less responsive and

vomited and developed slurred speech. Facility staff did not notice left sided weakness. At the

hospital Resident # 1 was diagnosed with intracerebral hemorrhage ( a type of stroke where an artery

bursts in the brain and causes bleeding in the brain).

g. Death. The hospital death record indicated that the resident died at 7: 25 am on 4/ 13. 30/

h. Interview with the RCC on 1018/ 13 at about 2: 40 pm. Staff let them know if residents are

sick and then they contact the nurse ( a home health nurse because the facility has no nurses) and she

comes to evaluate, If the nurse states they need to go out to hospital then they send therm. If it' s night

time staff call her ( the RCC) and then the nurse is called and the nurse still comes to assess. They

send the erit fe-§[ d" outif the nurse says so: S` oxiiet mes a consult wig the nurse is tiorie on the phdne _

and the nurse might say to go ahead and send out.

L Interview with the executive director ( ED). The ED revealed that Resident # 1 ' s family

was adamant about not sending him out to the hospital ( not specifically talking about this event, but

previous ones).

j. Review of the hospital Emergency Department Note - Nursing final report dated 4/ 13. 30/

It revealed that EMS reported that the family was not thrilled with the idea of the resident being

transported to the hospital.

3

4

k. Review of the facility' s medical emergencies policy. It was located on page 93 and 94 of its

Assisted Living Policy and Procedure Manual. Section l indicated that the administrator should bey.

contacted immediately and section 2 indicated that the administrator makes the determination of the

severity of the situation.. Section 3 indicated that the community summons emergency medical

services - by calling 911 when the resident exhibits signs and symptoms of distress and / or emergency

condition One example included was sudden onset of severe pain, Resident # 1 had indicated to

staff that he felt like a: hot rod was stabbing through his eye but medical care was still delayed for

hours.

9. Florida' s law regarding residents having the right to a safe and decent living environment free

from abuse and neglect is stated as follows:

429. 28 Resident bill of rights.-

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.

Section 429. 28, Fla. Stat. ( 2013)

10. In sum, the facility failed to ensure that Resident # I was free from neglect, to wit, he did not

receive timely and appropriate medical care, which led to extreme continual pain because he first

alerted staff between the 10: 30 to 11: 30 pm time frame on 4/ 13 29/ that he was in extreme pain but, k

despite his, e, g., repeated complaints of extreme pain, panic yelling, expressing his fear of dying F

alone, vomiting, lack of vision, crazy vitals, aspirating, leaning to the side and drooping face, 911

was not notified until about 3: 30 am the next morning, an inappropriate delay of several hours.

11. Respondent was cited fora. Class II violation, defined as follows,

408. 813 Admuistrative fines; violations.-- As a penalty for any violation of

this part, authorizing statutes, or applicable rules, the agency may impose an

administrative fine.

2) Violations of this part, authorizing statutes, or applicable rules shall be

classified according to the nature of the violation and the gravity of its probable

effect. on clients.

Violations shall be classified on the written notice as follows::

b) Class " II" violations are those conditions or occurrences related to the

operation and maintenance of a provider or to the care of clients which the agency

determines directly threaten the physical or emotional health, safety, or security of

the clients, other than class I violations. The agency shall impose an

administrative fide as provided by law for a cited class 11 violation. A fine shall be

levied notwithstanding the correction of the violation,

Section 408. 813, Fla. Stat. ( 2013)

12. Florida law states as follows as regards the fine for an ALF for a Class II violation:

429. 19 Violations; imposition of administrative fines; grounds.

1) In addition to the requirements of part II of chapter 408, the agency shall impose

an administrative fine in the manner provided in chapter 120 for the violation of any

provision of this part, part II of chapter 408, and applicable rules by an assisted living

facility, for the actions of any person subject to level 2 background screening under s.

408. 809, for the actions of any facility employee,. or for an intentional or negligent act

seriously affecting the health, safety, or welfare of a resident of the facility.

2) Each violation of this part and adopted rules shall be classified according- to the

nature of the violation and the gravity of its probable effect on facility residents. The

agency shall indicate the classification on the written notice of the violation as

follows:

b) Class " II" violations are defined ins. 408. 813. The agency shall impose an

administrative fine for a cited class II violation in an amount not less than $ 1, 000 and

noexceedmgm$; 00Oor each vx` ofatiori:...

3) For purposes of this section, in determining if a penalty is to be imposed and in

fixing the amount of the fine, the agency shall consider the following factors, t

a) The gravity of the violation, including the probability that death or serious

physical or emotional harm to a resident will result or has resulted, the severity of the

action or potential harm, and the extent to which the provisions of the applicable laws

or rules were violated.

b) Actions taken by the owner or administrator to correct violations..

c)' Any previous violations:

d), The financial benefit to the facility of committing or continuing the violation.

e) The. licensed capacity of the facility.

Section 429. 19, Fla. Stat. ( 2013)

S

WHEREFORE, the Agency intends to impose a $ 2, 000 fine against Respondent

pursuant to Sections 408. 813 and 429. 19, Fla. Stat. ( 2013).

CQUNT II - $ 1, 000 UNCORRECTED CLASS III FINE

Case No. 2014002084; State Tag A0010 - Admissions Continued Residency)

13. The Agency re- alleges and incorporates paragraphs l - 5 as if fully set forth herein.

I' survey - 11/ 13 ( x1/ paras 14 - 19

14. A complaint investigation ( CCR.# 2013012071) was conducted on 21 November, 2013.

15. Based upon record review the facility failed to ensure that an interdisciplinary care plan was

developed and implemented for Resident # 1, an 89 year old female receiving, hospice care and

services.

A 11121/ 13 review of her records showed that although she was retained at the facility on

hospice care it failed to develop and implement an interdisciplinary care plan developed by hospice,

in coordination with her and/ or another responsible party in order to meet her needs.

16. Florida law provides as follows as regards an ALF resident receiving hospice services:

58A- 0181 5. Admission Procedures, Appropriateness of Placement and

Continued Residency' Criteria.

4) CONTINUED RESIDENCY. Except as follows in paragraphs ( a) through ( e) of

this subsection, criteria for continued residency in any licensed facility shall be, the

same as the criteria for admission. As part of the continued residency criteria, a

resident must have a face- face to- medical examination by a licensed health care

provider at least every 3 years after the initial assessment, or after a significant

change, whichever comes first. A significant change is defined in Rule 5$ 5. A- 0131,

F. C. A. The results of the examination must be recorded on AHCA Form 1823, which

is ' incorporated by reference in paragraph ( 2)( b) of this rule. The form must be

completed in accordance with that paragraph. After the effective date of this rule;

providers shall have up to 12 months to comply with this requirement.

e) A terminally ill resident who no longer meets the criteria for continued residency

may continue to reside in the facility if the following conditions are met:

1. The resident qualifies for, is admitted to, and consents to the services of a licensed

hospice which coordinates and ensures the provision of any additional care and

services that may be needed=

2. Continued residency is agreeable to the resident and the facility,

3. An interdisciplinary care plan is developed and implemented by a licensed hospice

in consultation with the facility; Facility staff may provide any nursing service'

permitted under the facility' s license and total help with the activities of daily living; a

and

4. Documentation of the requirements of this paragraph is maintained in the resident' s

file.

Rule 58A- 0181, 5. F. C. A.

17. In sum, the facility failed to develop and implement Resident O' s interdisciplinary plan for

hospice care and services;

18. Petitioner cited Respondent for a Class III violation, defined as follows:.

408. 813 Administrative fines, violations.- As a penalty for any

violation of this part, authorizing statutes, or applicable rules, the agency

may impose an administrative fine.

2) Violations of this part, authorizing statutes, or applicable rules shall

be classified according to the nature of the violation and the gravity of its

probable effect on clients,.

Violations shall be classified on the written notice as follows:

c) Class " Ill" violations are those conditions or occurrences related to

the operation and maintenance of a provider or to the care of clients which

the agency determines indirectly or potentially threaten the physical or

emotional health, safety, or security of clients, other than class I or class it

violations. The agency shall impose an administrative fide as provided in

this section for a cited class III violation. A citation for a class III violation

must specify the time within which the violation is required to be

corrected. If a class III violation is corrected within the time specified, a

fine may not be imposed.

Section 408. 813, Fla. Stat. ( 2013)

19. By letter dated 9 December, 2013, Respondent was notified of a mandatory correction date of

34 days from the letter' s 9 December date, to wit, on or about9 January, 2014.

YO Survey - 1131/ 14 ( tiara 20 - 25)

20. A revisit survey was conducted on 31 January, 2014, to check on the deficiencies cited during

the first survey on 21 November, 2013.

21. a. Based upon record review the facility failed to ensure that an interdisciplinary care plan was

developed. and implemented for resident # 1, an 89 year old female receiving hospice care and

services,

b. An 11121/ 13 review of Resident O' s records showed that although she was retained at the

facility on hospice care it failed to develop and implement an interdisciplinary care plan with

hospice in coordination with her and/ or another responsible party to meet her needs,

c. During the revisit, survey an interdisciplinary care plan was still not available for her. The

facility had a hospice ` Interdisciplinary Care Plans' form which was a blank form with the words

Interdicplii. nary Care Plans" hand written at the top of the page labeled as a T HA Plan of Care

and Note". The rest of the page consisted of a: check list to indicate the information for all areas

pertaining to pain level, mental status, bathing, grooming, dressing, nutrition, activity tolerance and

transfer In sum, the form was empty in content and did not meet the intent of the requirement.

d.. During a staff interview the surveyor determined that they did not have a good

understanding of the requirement to develop and implement this type of plan They indicated after

discussion that they were going to develop their own farm for this purpose.

22. In sum, the facility failed to correct the prior deficiency by still not having developed and

implemented the required interdisciplinary care plan for Resident # l who was still receiving

hospice care and services.

23. Florida law regarding an ALF resident receiving hospice services is cited in paragraph 16.

24. Petitioner cited Respondent for a Class III violation, defined in paragraph 18.

25. The - same constitutes an uncorrected Class III violation with the fine determined as follows:

429. 19 , Violations; imposition of administrative fines; grounds,

1) In addition to the requirements of part II of chapter 408, the agency_

shall impose an administrative fine in the manner provided in chapter 120

for the violation of any provision of this part, part 11 of chapter 408, and

applicable rules by an assisted living facility ,

2) Each violation of this part and adopted rules shall be classified

according to the nature of the violation and the gravity of its probable

effect on facility residents. The agency shall indicate the classification on

the written notice of the violation as follows

c) Class " III" violations are defined ins. 408. 813. The agency shall

impose an administrative fine for a cited class III violation in an amount

not less than $ 500 and not exceeding $ 1, 000 for each violation.

Section 429. 19, Fla. Stat. ( 2012)

WHEREFORE, the Agency intends to impose a $ 1, 000 fine against Respondent, an ALF

in the State of Florida, pursuant to § 429. 19 ( 2) ( c), Fla. Stat. ( 2013).

Submitted this day of April, 2014.

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

525 Mirror Lake Dr, N., Ste 330

S f' tad wn 3. 0 - - 3- 1111 11-

Ph: ( 727) 552- 1942

Fax: 1440

david, myflorida. selby@ahca. com

By: L9

Edwin D. Selby

Assistant General Counsel

Fla. Bar No. 262587

i1

3 s

g

NOTICE OF RIGHTS

The Respondent is notified that it/ she he/ 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/ she he/ 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, FI., 32308; Telephone ( 850) 412- 3630.

CERTIFICATE OF SERVICE

I CERTIFY that a true and correct copy of the foregoing has been served by U. S. Certified

Mail, Return ReceptNo. 7012 1640 0000 0115 1193 on April, 2014, to Administrator Susan

Martin, Grace Manor at Lake Marton, LLC, 601 East Lime St, Lakeland, FL 33801, and by regular U.;

S. mail to Registered Agent Christopher Desrochers, 2504 Ave G NW, Winter Haven, FL 33880.

Edwin D. Selby

Cc: Patricia Caufman, AHCA Area 6 Field Office Manager

i 3

t

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE. GRACE MANOR AT LAKE MORTON, LLC. Case No. 2013013450

2014002084

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed 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 must be returned by mail or by fax within 21 days of the day_ You.

receive the attached Notice of Intent to Impose a Late Fee Notice of Intent to Impose a Late

Fine or Administrative Complaint.

If your Election of Rights with your selected option is not received by AHCA within twenty-

one ( 21) days from the date you received this notice of proposed action by AHCA, you will have

given up your right to contest the Agency' s proposed 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 120, Florida Statutes and Rule 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

Phone: ( 850) 412- 3630 Fax: ( 850) 921- 0158

PLEASE SELECT ONLY J OF THESE 3 OPTIO S

OPTION ONE ( 1) I admit to the allegations of facts and law contained in the

Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my

right to object and to have a hearing. I understand that by giving and up my right the to a hearing, fine or a

final order will be issued that adopts the proposed agency action imposes penalty,

action.

OPTION TWO ( 2) I admit to the allegations of facts contained in the Notice of

Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative

Complaint, but I wish to be heard at an informal proceeding ( evidence pursuant to the to Section to 120. 2), show 57( that

Florida Statutes) where I may submit testimony and written Agency

the proposed administrative action is too severe or that the fine should be reduced.

OPTION THREE ( 3) I dispute the allegations of fact contained in the Notice of

Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative

Complaint, and I request a formal hearing ( pursuant to the Subsection Division 120. 1), of Administrative 57( Florida

Statutes) before an Administrative Law Judge appointed by

Hearings.

PLEASE NOTE: Choosing OPTION THREE ( 3), by itself, is NOT sufficient to obtain a

formal hearing. You also mast file a written petition in order to obtain a formal hearing

before the Division of Administrative Hearings under Section 120. 1), 57( Florida Statutes. It

must be received by the Agency Clerk at the address above within 21 days of your receipt of this

proposed administrative action. The request for formal hearing must conform to the

requirements of Rule 28- 2015, 106. Florida Administrative Code, which requires that it contain:

1. Your name, address, and telephone number, and the name, address, and telephone number of

your representative or lawyer, if any;

2. The file number of the proposed action;

3. A statement of when you received notice of the Agency' s proposed action; and

4. A statement of all disputed issues of material fact. If there are none, you must state that there

are none.

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:

Name Title

Address:

Street and number city Zip Code

Telephone No. Fax No,

E' optional) ail(

I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the

Agency for Health Care Administration on behalf of the licensee referred to above.

Signed: Date:

Print Name: Title:

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Petitioner,

V. AHCA NO. 2013013450

2014002084

DOAH NO. 14- 3132

GRACE MANOR AT LAKE MORTON, LLC,

Respondent.

SETTLEMENT AGREEMENT

Petitioner, State of Florida, Agency for Health Care Administration ( hereinafter the

Agency"), and Respondent, Grace Manor at Lake Morton, LLC ( hereinafter " Respondent"),

through their respective undersigned representatives, pursuant to Section 120. 4), 57( Florida

Statutes, each individually, a " party," collectively as " parties," hereby enter into this Settlement

Agreement (" Agreement") and agree as follows:

WHEREAS, Respondent is an Assisted Living Facility (" ALF") licensed pursuant to

pursuant to Chapters 408, Part II and 429, Part I, Florida Statutes, and Chapter 58A- 5, Florida

Administrative Code; and

WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing

authority over Respondent, pursuant to Chapters 408, Part II and 429, Part 1, Florida Statutes;

and

WHEREAS, the Agency served Respondent with an administrative complaint on 8

April, 2014, notifying Respondent of its intent to impose a $ 2, 000 administrative fine for one

Class II violation and a $ 1, 000 fine for one uncorrected Class III violation; and

EXHIBIT 2

VMEREAS, the parties have negotiated and agreed that the best interest of all the parties

will be served by a settlement of this proceeding; and

NOW THEREFORE, in consideration of the mutual promises and recitals herein, the

parties intending to be legally bound, agree as follows:

1. All recitals herein are true and correct and are expressly incorporated herein.

2. Both parties agree that the " whereas" clauses incorporated herein are binding

findings of the parties.

3. Upon full execution of this Agreement, Respondent agrees to waive any and all

appeals and proceedings to which it may be entitled including, but not limited to, an informal

proceeding under Subsection 120. 2), 57( Florida Statutes, a formal proceeding under Subsection

120. 1), 57( Florida Statutes, appeals under Section 120. 68, Florida Statutes; and declaratory and

all writs of relief in any court or quasi- court of competent jurisdiction; and agrees to waive

compliance with the form of the Final Order ( findings of fact and conclusions of law) to which it

may be entitled, provided, however, that no agreement herein shall be deemed a waiver by either

parry of its right to judicial enforcement of this Agreement.

4. Upon full execution of this Agreement, Respondent agrees to pay the total sum of

3, 00 000. within 30 days from the date of the Final Order.

5. Venue for any action brought to enforce the terms of this Agreement or the Final

Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida.

6. By executing this Agreement, Respondent denies the allegations set forth in the

administrative complaint, and the Agency asserts the validity of the allegations raised in the

administrative complaint referenced herein. No agreement made herein shall preclude the Agency

from imposing a penalty against Respondent for any deficiency/ violation of statute or rule

identified in a future survey of Respondent, which constitutes a " repeat" or " uncorrected"

deficiency from surveys identified in the administrative complaint.

7. No agreement made herein shall preclude the Agency from using the deficiencies

from the surveys identified in the administrative complaint in any decision regarding licensure of

Respondent, including, but not limited to, licensure for limited mental health, limited nursing

services, extended congregate care, or a demonstrated pattern of deficient performance. The

Agency is not precluded from using the subject events for any purpose within the jurisdiction of

the Agency. However, if the Agency seeks to use the facts recited in the administrative

complaint herein for any future administrative action, Respondent retains the right to contest

those facts in any such administrative action which is based solely, or in part, on the subject

events in the underlying administrative complaint. Further, Respondent acknowledges and agrees

that this Agreement shall not preclude or estop any other federal, state, or local agency or office

from pursuing any cause of action or taking any action, even if based on or arising from, in

whole or in part, the facts raised in the administrative complaint. This Agreement does not

prohibit the Agency from taking action regarding Respondent' s Medicaid provider status,

conditions, requirements or contract.

8. Upon full execution of this Agreement, the Agency shall enter a Final Order

adopting and incorporating the terms of this Agreement and closing the above- styled case.

9. Each party shall bear its own costs and legal fees, if any.

10. This Agreement shall become effective on the date upon which it is fully executed

by all the parties.

11. Respondent for itself and for its related or resulting organizations, its successors

or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State

of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys

of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses,

of any and every nature whatsoever, arising out of or in any way related to this matter and the

Agency' s actions, including, but not limited to, any claims that were or may be asserted in any

federal or state court or administrative forum, including any claims arising out of this agreement,

by or on behalf of Respondent or related facilities.

12. This Agreement is binding upon all parties herein and those identified in

paragraph 11.

13. In the event that Respondent was a Medicaid provider at the subject time of the

occurrences alleged in the complaint herein, this settlement does not prevent the Agency from

seeking Medicaid overpayments related to the subject issues or from imposing any sanctions

pursuant to Rule 59G- 070, 9. Florida Administrative Code.

14. Respondent agrees that if any funds to be paid under this agreement to the Agency

are not paid within 30 days of entry of the Final Order in this matter, the Agency may deduct the

amounts assessed against Respondent in the Final Order, or any portion thereof, owed by

Respondent to the Agency from any present or future funds owed to Respondent by the Agency,

and that the Agency shall hold a lien against present and future funds owed to Respondent by the

Agency for said amounts until paid.

15. The undersigned have read and understand this Agreement and have the authority

to bind their respective principals to it. Respondent has the capacity to execute this Agreement.

16. This Agreement contains and incorporates the entire understandings and

agreements of the parties.

17. This Agreement supersedes any prior oral or written agreements between the

parties.

18. This greement may not be amended except in writing. Any attempted

assignment of t is greement shall be void.

19. 1 pa i s a e that faxed and scanned signatures suffice for original signatures.

e f in re r entatives hereby acknowledge that they are duly authorized to enter

into t is e me t.

Edwin D. Selby, Assistant General Counsel Louis F. Gerrard, President

Florida Bar No. 262587 Grace Manor at Lake Morton, LLC

Agency for Health Care Administration c/ o Mainstay Financial Services

525 Mirror Lake Dr N, Suite 330 5578 Commercial Blvd NW

St. Petersburg, F 3 701 Winter Haven, FL 33880

DATED: DATED: l

Stuart F. Williams, General Counsel J. C r, Es

Florida Bar No. 670731 Florida Bar No. 714313

Agency for Health Care Administration Peterson & Myers, P. A.

2727 Mahan Drive, Mail Stop # 3 225 East Lemon St.

Tallahassee, FL 2308 Lakeland, FL 33802- 4628

DATED: DATED: 1 1

Mo y McK' str

Dep ty Secr

Agency for Health Care Administration

2727 Mahan Dr

Tallahassee, FL 32308

DATED: