20-001555 Agency For Health Care Administration vs. Gv Melbourne, Inc., D/B/A Grand Villa Of Melbourne Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Friday, May 29, 2020.

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 ARCA, 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 correcty of this Final Order was served on the below - named

persons by the method designated on this day of 2020.

Richard.— op, Ag Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

Telephone: ( 850) 412- 3630

Facilities Intake Unit Central Intake Unit

Agency for Health Care Administration Agency for Health Care Administration

Electronic Mail) Electronic Mail)

Mary J. Howard, Senior Attorney Mia L. McKown, Esq.

Office of the General Counsel Counsel for Respondent

Agency for Health Care Administration 315 South Calhoun Street, Suite 600

Electronic Mail) Tallahassee, Florida 32302

U. S. Mail)

Division of Administrative Hearings

Electronic Filing)

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Petitioner,

V. Case No. 2019015785

License No. 11991

GV MELBOURNE, INC. d/ b/ a GRAND Facility Type: Assisted Living

VILLA OF MELBOURNE,

Respondent.

ADMINISTRATIVE COMPLAINT

COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration

the Agency"), by and through its undersigned counsel, and files this Administrative Complaint

against the Respondent GV Melbourne, Inc. d/ b/ a Grand Villa of Melbourne (" Respondent"),

pursuant to Sections 120. 569 and 120. 57, Florida Statutes ( 2019), and alleges:

NATURE OF THE ACTION

This is an action against an assisted living facility to impose an administrative fine in the

amount of five thousand dollars ($ 5, 000. 00) based upon one ( 1) Class II 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 ( 2019).

2. Venue lies pursuant to Florida Administrative Code R. 28- 106. 207.

PARTIES M

X

3. The Agency is the regulatory authority responsible for licensure of assisted living =

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facilities and enforcement of all applicable federal regulations, state statutes and rules governing

assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes,

and Chapter 59A- 36, Florida Administrative Code, respectively.

4. Respondent operates a one hundred fifty- five ( 155) bed assisted living facility located at

964 S Harbour City Blvd, Melbourne, Florida 32901, and is licensed as an assisted living

facility, license number 11991.

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

6. The Agency re - alleges and incorporates paragraphs ( 1) through ( 5) as if fully set forth

herein.

7. 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

59A- 36. 012, 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.

e) Contacting the resident' s family, guardian, health care surrogate, or case

manager if the resident is discharged or moves out.

f) Maintaining a written record, updated as needed, of any significant changes,

any illnesses that resulted in medical attention, changes in the method of

medication administration, or other changes which resulted in the provision of

additional services.

Rule 59A- 36. 007( 1), Florida Administrative Code.'

8. That Florida law provides:

Formerly codified at Rule 58A- 5. 0182( 1), Florida Administrative Code.

7) The facility must notify a licensed physician when a resident exhibits signs

of dementia or cognitive impairment or has a change of condition in order to rule

out the presence of an underlying physiological condition that may be

contributing to such dementia or impairment. The notification must occur within

30 days after the acknowledgment of such signs by facility staff. If an underlying

condition is determined to exist, the facility shall arrange, with the appropriate

health care provider, the necessary care and services to treat the condition.

Section 429. 26( 7), Florida Statutes ( 2018).

9. That on March 18, 2019, the Agency completed an Assisted Living Facility ( ALF)

relicensure survey of Respondent' s facility.

10. That based upon the review of records, observation, and interview, Respondent failed to

provide care and services required to meet the needs of residents accepted for admission to the

facility, including 1 of 2 sampled residents who developed an un- stageable pressure sore, the

same being contrary to the requirements of law.

11. During the facility entrance on March 18, 2019, the director of nursing identified resident

number eight ( 8) as receiving home health services for a skin tear to the heel.

12. That Petitioner' s representative reviewed Respondent' s records for resident number eight

8) during the survey and noted as follows:

a. The resident' s health assessment report ( AHCA Form 1823) dated September 7,

2018 listed diagnoses of peripheral vascular disease, coronary artery disease,

neuropathy and atrial fibrillation. The health assessment indicated a " healing"

stage 2 pressure sore.

b. The Form indicated supervision was needed with ambulation, bathing, dressing

and toileting, and that the resident was independent with eating and grooming.

C. A facility note dated March 13, 2019, indicated the resident returned to the

facility after a hospital stay.

d. The facility care plan, dated March 13, 2019, indicated there were no pressure

sores and that the resident only needed physical therapy services.

e. An undated health assessment report indicated there were no pressure sores.

f. The home health care start of care order dated March 15, 2019, indicated skilled

nursing to treat left heel un- stageable ulcer. The description of the wound was

round and necrotic, ( English Oxford dictionary death of tissue due to injury or

failure of blood supply), measured 5 by 6 by 0. 1 centimeters.

g. A facility note dated March 26, 2019, indicated the resident had an open area on

the left heel covered ( no description in notes). This was the only documentation

available regarding the pressure sore.

h. Record review did not reveal any written evidence of measures the facility put in

place, and instructions given to caregivers, regarding the care of the resident who

was prone to the development of a pressure sore.

There were no facility notes that indicated the facility was aware of the pressure

sore.

13. That Petitioner' s representative interviewed Respondent' s home health nurse on March

18, 2019 who indicated:

a. She saw resident number eight ( 8)' s wound earlier that day and it looked like a

blister that never ruptured.

b. The home health nurse was concerned about the wound because when pressed

down it was " boggy ( spongy)".

14. That Petitioner' s representative observed resident number eight ( 8)' s heel and noted a

round necrotic area.

15. That Petitioner' s representative interviewed Respondent' s director of nursing on March

18, 2019 at 3: 30 p. m. who offered no comment on resident number eight ( 8)' s pressure sore.

16. No other documentation was provided.

17. That the above reflects the failure of Respondent to provide care and services appropriate

to resident needs.

18. 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 threatens

the physical or emotional health, safety, or security of the clients, other than class I violations.

19. That the same constitutes a Class II offense as defined in Florida Statute § 408. 813( 2)( b),

Fla. Stat. ( 2018).

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 ( 2018).

Respectfully submitted this 3 1 day of October, 2019.

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

The Sebring Building

525 Mirror Lake Dr. N., Suite 330

St. Petersburg, Florida 33701

Telephone: ( 727) 552- 1946

Fax: ( 727) 552- 1440

Mary. Howard@ahca. myflori com

By:

Mary J. H a ,

Fla. Bar No. 69 97

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.

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by

U. S. Certified Mail, Return Receipt No. 7019 1120 0000 9811 4303 on October ' 2019 to

Nina Corsi, Administrator, GV Melbourne, Inc. d/ b/ a Grand Villa of Melbourne, 964 S Harbour

City Blvd, Melbourne, Florida 32901 and by Regular U. S. Mail to Dennis Forte, Registered

Agent for GV Melbourne, Inc. d/ b/ a Grand Villa of Melbourne, 13770 581h St N, Suite 312,

Clearwater, Florida 33760. Z- 12

Copy furnished to:

Theresa DeCanio

Field Office Manager

Agency for Health Care Administration

6i

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

Re: GV Melbourne, Inc. d/ b/ a Grand Villa of Melbourne AHCA No. 2019015785

ELECTION OF RIGHTS

This Election of Rights form is attached to an Administrative Complaint. The Election of

Rights form may be returned by mail or by facsimile transmission, but must be filed with

the Agency Clerk within 21 days by 5. 00 p. m., Eastern Time, of the day that you received

the Administrative Complaint. If your Election of Rights form with your selected option ( or

request for hearing) is not timely received by the Agency Clerk, the right to an

administrative hearing to contest the proposed agency action will be waived and an adverse

Final Order will be issued. In addition, please send a copy of this form to the attorney of

record who issued the Administrative Complaint.

Please use this form unless you, your attorney or your qualified representative prefer to reply

according to Chapter 120, Florida Statutes, and Chapter 28, Florida Administrative Code.) The

address for the Agency Clerk is:

Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Building # 3, Mail Stop # 7

Tallahassee, Florida 32308

Telephone: [phone] Facsimile: 850- 921- 0158

PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS

OPTION ONE ( 1) I waive the right to a hearing to contest the allegations of fact

and conclusions of law contained in the Administrative Complaint. I understand that by

giving up my right to a hearing, a final order will be issued that adopts the proposed agency

action and imposes the fine, sanction or other agency action.

OPTION TWO ( 2) I admit the allegations of fact contained in the Administrative

Complaint, but I wish to be heard at an informal hearing ( 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, sanction or other agency action

should be reduced.

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

Administrative Complaint and request a formal hearing ( pursuant to Section 120. 57( 1),

Florida Statutes) before an Administrative Law Judge appointed by the Division of

Administrative Hearings.

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

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.

Licensee Name:

Contact Person: Title:

Address:

Number and Street City Zip Code

Telephone No. Fax No.

E - Mail ( Optional)

I hereby certify that I am duly authorized to submit this Election of Rights 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. DOAH No. 20- 1555

Case Nos. 2019015785

2020008322

License No. 11991

GV MELBOURNE, INC. d/ b/ a GRAND Facility Type: Assisted Living

VILLA OF MELBOURNE,

Respondent.

SETTLEMENT AGREEMENT

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

Agency"), through its undersigned representatives, and GV Melbourne, Inc. d/ b/ a Grand Villa

of Melbourne ( hereinafter " Respondent"), pursuant to Section 120. 57( 4), 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 licensed pursuant to Chapters 429,

Part I, and 408, Part II, Florida Statutes, Section 20. 42, Florida Statutes and Chapter 59A- 36,

Florida Administrative Code; and

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

authority over Respondent, pursuant to Chapters 429, Part I, and 408, Part 11, Florida Statutes;

and

WHEREAS, the Agency served Respondent with an Administrative Complaint on or

about October 31, 2019, notifying Respondent of the Agency' s intent to impose administrative

fines in the sum of five thousand dollars ($ 5, 000. 00); and

EXHIBIT 2

WHEREAS, the Agency completed surveys of Respondent on March 18, 2019 and May

13, 2019 ( hereinafter " Surveys"), during which deficient practices were cited; that included Tag

78 and Tag 25 on both dates; subjected Respondent to the imposition of Class III deficient

practices; and subjected Respondent to the imposition of administrative sanctions in Agency

Case Number 2020008322; and

WHEREAS, Respondent has timely filed a Petition for Formal Administrative Hearing

as to the Complaint; and

WHEREAS, the Agency completed a survey of Respondent and its Facility on March

18, 2019 ( hereinafter " Survey A"),' during which deficient practices, including " A0078" and

A0025," were cited; and

WHEREAS, the Agency completed a survey of Respondent and its Facility on May 13,

2019 ( hereinafter " Survey B"), 2 during which deficient practices, including " A0078" and

A0025," were cited; and

WHEREAS the citation of the above referenced deficient practice in Survey B subjects

Respondent to the imposition of administrative sanctions of five hundred dollars ($ 500. 00); and

WHEREAS, the Parties have agreed to an amicable resolution of these cases; and

WHEREAS, 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:

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

The findings of the survey were reduced to a state form 3020.

The findings of the survey were reduced to a state form 3020.

Page 2 of 6

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, informal

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

120. 57( 1), 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

party of its right to judicial enforcement of this Agreement. Respondent specifically waives the

necessity of the drafting of or service of an Administrative Complaint for the relief stipulated to

in this Agreement as the same relates to Survey A and Survey B ( hereinafter " Surveys").

4. Upon full execution of this Agreement, Respondent agrees to pay five thousand

five hundred dollars ($ 5, 500. 00) in administrative fines within thirty ( 30) days of the entry of the

Final Order; and

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 raised in the

Administrative Complaint and Surveys referenced herein, and the Agency asserts the validity of

the allegations raised in the Administrative Complaint and Surveys referenced herein.

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

from the Administrative Complaint and Surveys in any decision regarding licensure

of Respondent, including, but not limited to, a demonstrated pattern of deficient performance,

but the allegations will not be the sole basis for future Agency action. The Agency is not

precluded from using the subject events for any purpose within the jurisdiction of

Page 3 of 6

the Agency. 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 Survey. 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 cases.

9. Each party shall bear its own costs and attorney' s fees.

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, 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 eleven ( 11) of this Agreement.

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- 9. 070, Florida Administrative Code.

Page 4 of 6

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

are not paid within thirty- one ( 3 1) 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 Agreement may not be amended except in writing. Any attempted

assignment of this Agreement shall be void.

19. All parties agree that a facsimile signature suffices for an original signature.

20. The following representatives hereby acknowledge that they are duly authorized

to enter into this Agreement.

Moll 4WKKiSecretary Mia L. McKown, Esq.

Health Quality Assurance Counsel for Respondent

Agency for Health Care Administration 315 South Calhoun Street, Suite 600

2727 Mahan Drive Tallahassee, Florida 32302

Tallahassee, Florida 32308 Florida Bar No. 0897140

DATED: , 2 v DATED: 08/ 24/ 20

Page 5 of 6

Name

William H. Roberts Title: A s s Si C r.

Acting General Counsel GV Melbourne, Inc. d/ b/ a Villa of

Agency for Health Care Administration Melbourne

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

DATED: 1D` C

DATED:

Mary J. r . Senior Attorney

Agency for Ith Care Administration

525 Mirror Lake Drive North, Suite 330

St. Petersburg, Florida 33701

Florida Bar No. 69097

DATED:

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