22-000530 Agency For Health Care Administration vs. Gv Deerfield Beach, Llc D/B/A Grand Villa Of Deerfield Beach Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Friday, August 19, 2022.

ORDERED at Tallahassee, Florida, on thi daY o2022. f 1

W10r,

em) Kimberly

Rumoak, Deputy Secretary Agency

for Health 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 copy oLthis Final Order was served on the below - named

persons by the method designated on thi day of , 2022. Agency

for Health Care Administration 2727

Mahan Drive, Mail Stop 3 Tallahassee,

Florida 32308 Telephone: (

850) 412- 3630 N

Facilities Intake Unit Central Intake Unit

Agency for Health Care Administration Agency for Health Care Administration

Electronic Mail) Electronic Mail)

Thomas W. Walsh Il, Senior Attorney Amy W. Schrader, Esq.

Nicola L. C. Brown, Senior Attorney Aldo M. Leiva, Esq.

Office of the General Counsel Baker, Donelson, Bearman, Caldwell &

Agency for Health Care Administration Berkowitz, PC

Electronic Mail) Counsel for Respondent

aschraderna bakerdonelson com

al ei va(& bakerdonel son. com

Electronic Mail)

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Petitioner,

AHCA No.: 2021010620

V. License No.: 8697

Provider Type: Assisted Living Facility

GV DEERFIELD BEACH, LLC d/ b/ a

GRAND VILLA OF DEERFIELD BEACH,

Respondent.

ADMINISTRATIVE COMPLAINT

Petitioner, State of Florida, Agency for Health Care Administration (" the Agency"), files

this Administrative Complaint against Respondent, GV Deerfield Beach, LLC d/ b/ a Grand Villa

of Deerfield Beach (" Respondent" or " Sterling"), pursuant to Sections 120. 569 and 120. 57, Florida

Statutes, and alleges as follows:

NATURE OF THE ACTION

This is an action to revoke Respondent' s license to operate this assisted living facility, to

impose administrative fines in the sum of twenty thousand dollars ($ 20, 000. 00), and impose a

survey fee of five hundred dollars ($ 500. 00) for a total assessment of twenty thousand five hundred

dollars ($ 20, 500. 00) based upon two ( 2) Class I violations.

PARTIES

1. The Agency is the licensing and regulatory authority that oversees assisted living

facilities in Florida. Ch. 408, Part Il, and Ch. 429, Part 1, Fla. Stat. ( 2021); Ch. 59A- 35, Ch. 59A-

36, Fla. Admin. Code. The Agency may deny, revoke, and suspend any license issued to an assisted

living facility and impose an administrative fine for a violation of the Health Care Licensing

EXHIBIT 1

Procedures Act, the authorizing statutes or applicable rules. § § 408. 812, 408. 813, 408. 815, 429. 14,

429. 19, Fla. Stat. ( 2021).

2. 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 the Chapters 408, Part II, and 429, Part I, Florida Statutes, and

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

3. Respondent operates a two hundred forty ( 240) bed assisted living facility located

at 1050 Southwest 24a' Avenue, Deerfield Beach, Florida 33442, and is licensed as an assisted

living facility, license number 8697.

4. 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

Under Florida Statutory authority, in pertinent part:

3) Assistance with self - administration of medication includes:

a) Taking the medication, in its previously dispensed, properly

labeled container, including an insulin syringe that is prefilled with

the proper dosage by a pharmacist and an insulin pen that is prefilled

by the manufacturer, from where it is stored, and bringing it to the

resident.

b) In the presence of the resident, confirming that the medication

is intended for that resident, orally advising the resident of the

medication name and dosage, opening the container, removing a

prescribed amount of medication from the container, and closing the

container. The resident may sign a written waiver to opt out of being

orally advised of the medication name and dosage. The waiver must

identify all of the medications intended for the resident, including

names and dosages of such medications, and must immediately be

updated each time the resident' s medications or dosages change.

c) Placing an oral dosage in the resident' s hand or placing the

dosage in another container and helping the resident by lifting the

container to his or her mouth.

d) Applying topical medications.

e) Returning the medication container to proper storage.

f) Keeping a record of when a resident receives assistance with

self - administration under this section.

g) Assisting with the use of a nebulizer, including removing the

cap of a nebulizer, opening the unit dose of nebulizer solution, and

pouring the prescribed premeasured dose of medication into the

dispensing cup of the nebulizer.

h) Using a glucometer to perform blood - glucose level checks.

i) Assisting with putting on and taking off antiembolism

stockings.

0) Assisting with applying and removing an oxygen cannula but

not with titrating the prescribed oxygen settings.

k) Assisting with the use of a continuous positive airway pressure

device but not with titrating the prescribed setting of the device.

1) Assisting with measuring vital signs.

m) Assisting with colostomy bags.

429. 256( 3), Fla. Stat., ( 2021).

6. Pursuant to Florida law:

3) ASSISTANCE WITH SELF - ADMINISTRATION.

a) Any unlicensed person providing assistance with self -

administration of medication must be 18 years of age or older,

trained to assist with self administered medication pursuant to the

training requirements of rule 59A- 36. 011, F. A. C., and must be

available to assist residents with self- administered medications in

accordance with procedures described in section 429. 256, F. S. and

this rule.

b) In addition to the specifications of section 429. 256( 3), F. S.,

assistance with self - administration of medication includes, in the

presence of the resident, reading the medication label aloud and

verbally prompting a resident to take medications as prescribed.

c) In order to facilitate assistance with self - administration, trained

staff may prepare and make available such items as water, juice,

cups, and spoons. Trained staff may also return unused doses to the

medication container. Medication, which appears to have been

contaminated, must not be returned to the container.

d) Trained staff must observe the resident take the medication. Any

concerns about the resident' s reaction to the medication or suspected

noncompliance must be reported to the resident' s health care

provider and documented in the resident' s record.

e) When a resident who receives assistance with medication is away

from the facility and from facility staff, the following options are

available to enable the resident to take medication as prescribed: 1.

t3

The health care provider may prescribe a medication schedule that

coincides with the resident' s presence in the facility, 2. The

medication container may be given to the resident, a friend, or

family member upon leaving the facility, with this fact noted in the

resident' s medication record, 3. The medication may be transferred

to a pill organizer pursuant to the requirements of subsection ( 2),

and given to the resident, a friend, or family member upon leaving

the facility, with this fact noted in the resident' s medication record,

or 4. Medications may be separately prescribed and dispensed in an

easier to use form, such as unit dose packaging.

f) Assistance with self - administration of medication does not

include the activities detailed in section 429. 256( 4), F. S. 1. As used

in section 429. 256( 4)( g), F. S., the term " competent resident" means

that the resident is cognizant of when a medication is required and

understands the purpose for taking the medication. 2. As used in

section 429. 256( 4)( h), F. S., the terms " judgment" and " discretion"

mean interpreting vital signs and evaluating or assessing a resident' s

condition.

g) All trained staff must adhere to the facility' s infection control

policy and procedures when assisting with the self - administration of

medication.

Rule 59A- 36. 008( 3), F. A. C.

7. The Agency re - alleges and incorporates paragraphs one ( 1) through five ( 5) as if

fully set forth herein.

8. That on July 9, 2021, the Agency completed a complaint survey, complaint number

2021009148, of Respondent' s facility.

9. Based on record review, interview, and observation the Agency determined that

Respondent' s facility failed to follow the correct procedures when assisting with self -

administration of medication for a resident resulting in an overdose, the same being contrary to the

mandates of law.

10. That Petitioner' s representative reviewed Respondent' s medication management

policies and procedures, created November 2000 and revised January 2016 and April 2017, and

noted:

Cl

a. Policy: It is the policy of the community to provide medication management to

residents as indicated on the Agency for Health Care Administration Health

Assessment ( AHCA 1823) or per written physician order. Residents who are

deemed capable of self- administering their medications without assistance by

their physician shall be encouraged and allowed to do so. Medication

management must be provided by trained unlicensed or licensed staff per state

regulations. Staff providing medication management shall be at least 18 years

old and able to read and speak English.

b. Definitions: Assistance with self - administration of medications: Resident

requires assistance with taking medications. Assistance includes reminders,

cueing, assisting with containers, storing and re - ordering medications. The

resident' s physician must select this option on the AHCA 1823 or provide a

written order indicating the resident may receive assistance with self -

administration of medications.

c. Procedure:

i. The resident care supervisor, memory care supervisor and/ or designee

is responsible for ensuring medication management is provided as

required or requested.

ii. Assistance with self - administration of medications:

1. All assisted living residents with assistance with self -

administration of medication indicated on the AHCA 1823 must

be provided assistance with self - administration of medications.

P?

2. Assistance with self - administration of medications shall be

provide as outlined in the Department of Elder Affairs assistance

with medication study guide for ALF staff ( PER- DOEA

assistance with medication study guide)

3. All medications for residents receiving assistance with self -

administration of medication must be ordered through the

community preferred pharmacy unless the resident requests a

pharmacy of their choice. ( a) The resident' s choice pharmacy

must provide unit dose packaging.

4. All medications for residents requiring assistance with self -

administration of medication are required to be unit dose

packaged prior to distribution.

a. Any medications that are not unit dose packed must be

sent to the pharmacy for re - packaging at the resident' s

expense.

b. Medications requiring repackaging must be delivered to

the pharmacy unopened

5. Unless prescribed by the physician, the community must assist

with all medications for residents receiving assistance with self -

administration of medication.

6. Active medications must be centrally stored in medication carts

and/ or medication refrigerator for all residents receiving

assistance with self - administration of medication.

on

7. Residents with medical conditions that require immediate

availability of emergency medication ( eg, epi pen, inhaler,

nitroglycerine) for life saving purposes may maintain the

medication in the resident' s possession with the following

limitations.

a. The resident' s physician has provided the community

with an order stating that the resident is capable of self-

administering the medication.

b. The medication must be secured in the residents'

possession or stored in the residents' room in a lockable

cabinet, drawer or container in the residents' room.

11. That Petitioner' s representative reviewed Respondent' s medication pass policies

and procedures, created January 2016, and noted:

a. Policy: It is the policy of the community to ensure residents receive their

medications as prescribed by their physician in a timely manner.

b. Procedure:

i. The resident care supervisor, memory care supervisor and/ or designee

is responsible for ensuring residents who are receiving assistance with

self - administration of medication or medication administration receive

their medication timely.

ii. Perform all steps in the order outlined below:

1. Bring the resident to the cart:

a. If the resident is not already in the medication area,

locate the resident.

b. Confirm you have the correct resident by verifying

against the photo on the MOR.

c. If delivery is required, medications must be brought to

the resident in their original packaging and all steps

below must also be followed.

2. Verify medication:

a. Review the MOR to determine medications required.

b. Individually select the medication from the cart and

perform the following steps:

i. Verify the instructions to confirm the scheduled

delivery time.

ii. Verify the label against the MOR to ensure it

matches.

1. If there is an order change sticker on the

label, follow the instructions on the

MOR..

2. Hold medications that have discrepancies

until a supervisor or nurse can be notified.

iii. After each medication has been verified, set it

aside.

iv. If the medication is not required to be passed at

this time, return the medication to its proper

location in the cart.

v. If a medication is not available, reference the no

pass policy.

3. Read aloud:

a. All medication technicians are required to complete this

step. Nurses are encouraged to follow this step, however

it is not required.

b. Take all scheduled medications in its original package to

the resident.

c. Read the following aloud to the resident for each

medication prior to dispensing:

i. Name.

ii. Dosage.

iii. Directions.

d. If the resident is hearing impaired; and/ or the resident

does not want their medications read aloud, show the

resident the label of each medication.

4. 4. Dispense medication:

a. Dispense each medication as indicated.

i. Medication technicians must dispense

medications in the presence of the resident or it

is considered administration of medications.

ii. Only nurses are permitted to administer

medications.

b. If the medication must be crushed, follow the crush

orders policy.

5. Observe:

a. Hand the resident the dispensed medications and a drink,

if necessary.

b. Stop all other tasks.

c. Ensure you are observing the resident take each

medication. ( 1) It is easy for residents to drop or

pocket medications.

6. Document medication pass:

a. After you have observed the resident take all scheduled

medications.

b. Document the medication observation in the MOR.

7. No pass:

a. If the resident does not receive the medication, reference

the " no pass policy."

b. Examples include:

i. Medication refusal.

ii. Out of the building.

iii. Medication not available.

iv. Doesn' t receive a medication for any other

reason.

12. That Petitioner' s representative reviewed Respondent' s narcotics policies and

procedures, created January 2016, and noted:

a. Policy: It is the policy of the community to maintain narcotics and other

controlled substances double locked. All these medications will be counted as

they enter the community and a narcotic count must be kept. Those medications

that are centrally stored in the medication cart or refrigerator must be counted

at each shift change.

b. Procedure: The resident care supervisor, memory care supervisor and/ or

designee is responsible for ensuring narcotics and other controlled substances

are kept double locked.

c. Narcotic and controlled substance delivery:

i. Upon receipt of a narcotic or controlled substance, the Staff Are

required to verify the quantity of the medication.

ii. Notify the supervisor, resident administrative coordinator or nurse on

call.

iii. The supervisor, resident administrative coordinator or nurse on call

must add the quantity of the medication to the eMOR and place in the

narcotic box of the medication cart.

1. ( a). If the medication is not immediately placed in the narcotic

box of the medication cart. The supervisor, resident

administrative coordinator or nurse on call must complete a

narcotic count form ( RES- 29) and attach the form to the narcotic

2. ( b). Then place the narcotic or controlled substance in an

appropriate secured storage area as defined above with the

narcotic count form ( RES- 29) attached.

13. That Petitioner' s representative reviewed Respondent' s records related to resident

number one ( 1) during the survey and noted:

a. The resident was admitted to the facility' s memory care unit on May 24, 2021.

b. The resident' s Health Assessment, AHCA form 1823, dated May 24, 2021

documented:

i. The resident weighed one hundred six ( 106) pounds with a height of

five ( 5) foot three ( 3) inches.

ii. Diagnoses included dementia, osteoarthritis, generalized anxiety

disorder and unsteady gait.

iii. The resident required assistance with activities of daily living ( ADLs)

including bathing, dressing and grooming, and required supervision

with ambulation, toileting and transfers.

iv. The resident required medication management and assistance with self -

administration of medications.

v. The resident was prescribed medications to include the antianxiety

medication Xanax 0. 25 milligrams ( mg) every twelve ( 12) hours.

c. A Physician Order, dated May 27, 2021, was signed by the resident' s Nurse

Practitioner ( NP), documenting the resident' s current Xanax 0. 25 mg dose be

discontinued and to increase the dose to Xanax 0. 5 mg oral medication, one ( 1)

tablet three ( 3) times daily.

d. Progress Notes of May 27, 2021 documented:

i. At approximately 8: 05 p. m., Respondent' s staff member " B," a licensed

practical nurse, received the resident' s Xanax 0. 5 mg medication from

the pharmacy, which included eighteen ( 18) tablets, in a blister pack

format.

ii. Staff member ` B" handed this Xanax medication to Respondent' s staff

member " A," a resident care assistant/ medication technician, in the

facility' s memory care unit, where the resident resided, and instructed

staff member " A" to give the resident the 8: 00 p. m. dose of Xanax

medication.

iii. Staff member ` B" received a call from staff member " A" around 8: 44

p. m. and staff member " A" informed staff member ` B" that staff

member " A" got the resident to take " all of them," and staff member

B" questioned staff member " A" about this, but staff member " A" did

not respond.

iv. Staff member " B" went to the memory care unit at approximately 8: 49

p. m. and found the resident to be very lethargic and 911 was called at

approximately 8: 51 p. m.

v. Emergency medical personnel arrived at approximately 9: 00 p. m. and

the resident was transported to the hospital at approximately 9: 05 p. m.

e. A Progress Note dated June 9, 2021 at 2: 14 p. m. documented the resident had

passed away in the hospital.

f. The resident' s May 2021 Medication Observation Record ( MOR) documented:

i. The resident received one Xanax 0. 25 mg tablet every twelve ( 12) hours

from May 25 to 27, 2021, at 9: 00 a. m., and the resident refused the 9: 00

p. m. dose on May 26, 2021.

ii. Respondent' s staff member " A," a medication technician, assisted the

resident with the Xanax 0. 25 mg medication on May 25, 2021 at 9: 00

p. m.

iii. Respondent' s director of nursing documented the resident' s Xanax 0. 5

mg medication dose on May 27, 2021 at 8: 00 p. m. was not given due to

other problems."

g. Respondent' s Controlled Substance Log showed:

i. The resident' s Xanax 0. 25 mg medication was discontinued on May 27,

2021.

ii. The Xanax 0. 5 mg medication was ordered on May 27, 2021 and

eighteen ( 18) tablets of this medication were removed from the

resident' s medication count on May 31, 2021, four ( 4) days after the

incident .

iii. The Controlled Substance Log revealed the deduction of the eighteen

18) tablets of the Xanax 0. 5 mg medication was currently being

reviewed by the facility.

14. That Petitioner' s representative reviewed Respondent' s Adverse Incident Report

regarding resident number one ( 1) dated May 28, 2021 and noted:

a. Respondent' s staff member " B," a licensed practical nurse, received the

resident' s Xanax 0. 5 mg medication from the pharmacy, and handed this

medication to Respondent' s staff member " A," a medication technician in

Respondent' s memory care unit.

b. Staff member " B" received a call from staff member " A" at approximately 8: 44

p. m. and staff member " A" informed staff member ` B" that staff member " A"

got the resident to take " all of them."

c. Staff member " B" questioned staff member " A" about this, and staff member

A" did not respond.

d. Staff member " B" went to the memory care unit and found the resident to be

very lethargic and she called 911 at approximately 8: 51 p. m.

e. The resident was transported to the hospital at approximately 9: 05 p. m.

f. Staff member " A" gave the resident eighteen ( 18) tablets of Xanax 0. 5 mg

medication and the reason for the actions of staff member " A" were unknown

at that time.

15. That Petitioner' s representative reviewed Incident Investigation dated May 28,

2021, and noted:

a. Staff member " A," a medication technician, gave all eighteen ( 18) tablets of

Xanax 0. 5 mg medication to resident number one ( 1) on May 27, 2021,

sometime between 8: 00 and 8: 44 p. m. which led to the resident' s hospitalization

on the same date.

b. This medication error may have been avoided had Respondent' s staff member

A" conducted the proper process of assistance with self - administration of

medications with the resident.

c. The specific process staff member " A" failed to do was not identified, and in

order to prevent future occurrences of medication errors, the facility will

provide medication education training to its staff members who assist residents

with self - administration of medications.

d. Respondent did not determine the root cause of the overmedicating of resident

number one ( 1) by staff member " A" on May 27, 2021.

16. That Petitioner' s representative interviewed the responsible party for resident

number one ( 1) on July 2, 2021 commencing at 10: 15 a. m. who indicated:

a. The resident was hospitalized on May 27, 2021, due to being overdosed with

Xanax medication by Respondent' s staff member " A" while the resident was in

the facility' s memory care unit.

b. The resident was admitted to the facility on May 24, 2021, and was prescribed

0. 25mg of Xanax medications at that time for anxiety.

c. On or about May 27, 2021, the facility reported that the resident became more

agitated and combative, and requested the Xanax medication dose be increased.

d. The responsible party received the resident' s pharmacy' s billing statement, and

it stated the facility received eighteen ( 18) tablets of 0. 25 mg Xanax on May

24, 2021, and eighteen ( 18) tablets of 0. 5 mg of Xanax on May 27, 2021.

e. The resident passed away in the hospital on June 9, 2021.

17. That Petitioner' s representative reviewed www. webmd. com website which recites:

a. Xanax is used to treat anxiety and panic disorders and it is classified as a

benzodiazepine, which acts on the central nervous system to produce a calming

effect.

b. Xanax must be taken as directed by your doctor and its dosage is based on your

medical condition, age and response to treatment, and one must follow your

doctor' s instructions closely to reduce the risk of side effects.

c. Side effects of this medication include drowsiness and dizziness, and if any of

the side effects persisted or worsened, tell your doctor promptly.

d. Xanax is prescribed by your doctor because he or she has judged that the benefit

to you is greater than the risk of side effects, but serious side effects like

mental/ mood changes ( such as hallucinations, thoughts of suicide), trouble

speaking, loss of coordination, trouble walking, and memory problems may

occur.

e. Xanax must be taken exactly as prescribed to lower the risk of addiction and if

someone has overdosed on this medication and developed serious symptoms

such as passing out or trouble breathing, call 911 or a poison control center right

away.

18. That Petitioner' s representative interviewed Respondent' s administrator regarding

resident number one ( 1) commencing at 11: 00 a. m. on July 2, 2021, who indicated:

a. The resident was overdosed by staff member " A" on May 27, 2021, and this led

to the resident being hospitalized on the same date.

b. The resident # 1 passed away in the hospital a couple of weeks after being

hospitalized.

c. Since staff member " A" did not cooperate with the facility' s questioning about

the events relating to the resident' s hospitalization, the staff member was

immediately dismissed from employment in the facility after this event on May

27, 2021.

d. The facility did not contact the police to further investigate the actions of staff

member " A" that led to the resident being hospitalized.

19. That Petitioner' s representative reviewed the unit dose blister package for the

Xanax 0. 5 mg medication for resident number one ( 1) on July 2, 2021 at 11: 15 a. m. and noted:

a. The prescribed directions were for the resident to take one ( 1) tablet by mouth

three ( 3) times a day.

b. Eighteen ( 18) out of the thirty- one ( 31) clear plastic blisters, labeled from one

1) to eighteen ( 18), were broken and empty.

c. The order was filled and originated by the pharmacy on May 27, 2021.

Photographic evidence was obtained.)

20. That Petitioner' s representative telephonically interviewed Respondent' s staff

member " A," a medication technician, regarding resident number one ( 1) commencing at 12: 35

p. m. on July 2, 2021, who indicated:

a. She worked at the facility for almost two ( 2) years.

b. She was not able to speak about her work in the facility at this time and she

disconnected from the call.

21. That Petitioner' s representative interviewed the nurse practitioner for resident

number one ( 1) commencing at 10: 55 a. m. on July 6, 2021, who indicated:

a. He initially examined the resident on May 24, 2021, at his office and determined

the resident had memory issues, unsteady gait and prescribed Xanax 0. 25 mg

for the resident.

b. It was appropriate for the resident to move into the facility' s memory care unit

at that time.

c. He increased the resident' s Xanax dose to 0. 5 mg due to a report from the

facility on May 27, 2021, that the resident had increased agitation.

d. He received a call from the facility on or about May 29, 2021, to inform him

that the resident was hospitalized due to an overdose of Xanax on May 27, 2021.

e. He did not understand the reason why the staff gave the resident so many

medications all at once, and that eight to nine ( 8- 9) milligrams of

benzodiazepine ( Xanax) was likely to place anyone in a comatose state,

regardless of their body composition or weight.

22. That Petitioner' s representative interviewed Respondent' s staff member ` B," a

licensed practical nurse, regarding resident number one ( 1) commencing at 11: 30 a. m. on July 6,

2021, who indicated:

a. On May 27, 2021, at around 7: 30 p. m., she received the resident' s Xanax 0. 5

mg medication from the pharmacy, and she entered the medication into the

medication observation system and handed this medication to staff member " A"

a medication technician, in the facility' s memory care center at around 8: 00 p. m.

b. The Xanax 0. 5 mg medication came in unit dose packaging that contained

eighteen ( 18) tablets inside the clear plastic blisters, labeled from one ( 1) to

eighteen ( 18).

c. She told staff member " A" to give the resident the prescribed 8: 00 p. m. dosage

and that she commented to staff member " A" the resident could have used this

higher dose of Xanax medication earlier that day when the resident was more

agitated.

d. Since the resident was more agitated earlier on May 27, 2021, this led to the

resident being ordered an increased dosage of Xanax by the nurse practitioner.

e. She received a call from staff member " A" sometime after 8: 00 p. m., and staff

member " A" informed her that she had given the resident all the tablets of the

Xanax 0. 5 mg medication in the unit dose packaging.

f. She rushed over to the memory care unit area of the facility to see the resident

and staff member " A" did not say anything else to her.

g. She immediately called 911 to respond to the resident' s potential overdose from

the Xanax medication and she was aware that the resident may go through

severe adverse effects from this increased Xanax dosage.

h. She examined the resident before the emergency response personnel arrived at

around 8: 30 p. m., and the resident presented to be lethargic, was slumped over

on the chair and was minimally responsive.

i. She did not see staff member " A" ever again and she believed staff member

A" departed the facility shortly after this event happened.

j. The resident # 1 was hospitalized on May 27, 2021, due to this Xanax

overdosing and she was aware the resident passed away a couple weeks after

this in the hospital.

23. That Petitioner' s representative interviewed Respondent' s administrator regarding

resident number one ( 1) commencing at 1: 50 p. m. on July 6, 2021, who indicated:

a. In order to prevent a reoccurrence like the medication error involving the

resident on May 27, 2021, the facility provided a medication pass in- service on

June 10, 2021, to its medication technician staff and planned to re- train all of

the medication technician staff with the most current assistance with self -

administration of medication course.

b. Staff member ` B," a licensed practical nurse, and any other of the facility nurses

did not receive this training.

c. The facility presently had only in - serviced five ( 5) medication technician staff

members, staff members " C," " D," " E," " F," and " G," on the proper medication

pass techniques, and he could not provide a reason why the remaining ten ( 10)

medication technician staff members did not yet receive this in- service training.

d. The facility employee roster confirmed that there were presently a total of

fifteen ( 15) unlicensed staff members who performed medication assistance

tasks for residents and the remaining staff members who did not participate in

the in- service were identified as staff members " H " " I " " J " " K " " L " " M "

N," " 0," P," and " Q "

e. Any one of the medication technician staff members may be scheduled to work

in the facility' s memory care unit depending on the resident load and staff

availability.

f. At the time, he did not have documentation that any of the current fifteen ( 15)

medication technician staff members had completed an updated assistance with

self - administration of medication course since the event on May 27, 2021.

g. The facility did not hire and/ or contract any pharmacy consultant to audit the

facility' s medication practices or to train its staff members.

24. That Petitioner' s representative reviewed Respondent' s personnel records related

to Respondent' s staff member " A," a medication technician, during the survey and noted:

a. She was hired at the facility on November 12, 2019, as a resident care assistant,

whose duties included providing direct care to residents, to assist residents with

self - administration of medications and that she must receive and stay current

with medication certification training.

b. She received an initial four ( 4) hour medication training on January 21, 2017,

which was followed with two ( 2) hour continuing medication trainings on

January 31, 2018, June 10, 2019, and June 21, 2020.

c. None of the medication training certificates were validated by the facility to

ensure she was able to perform the procedures and techniques for assisting

residents with self - administration of medication.

d. There was not proof to having completed an " annual" two ( 2) hour continuing

education medication training before the expiration of the initial medication

training on January 21, 2018, and there was also no proof in the personnel

record that the staff member completed an initial four ( 4) or six ( 6) hour

medication training during the periods between the expired " annual" two ( 2)

hour medication trainings from January 31, 2018 to June 21, 2020.

25. That Petitioner' s representative interviewed Respondent' s administrator regarding

resident number one ( 1) commencing at 2: 55 p. m. on July 7, 2021, who indicated:

a. The purpose of the facility' s Narcotics and Controlled Substances Policy and

Procedure that required the facility' s licensed nurses to place every resident' s

controlled substance medication into the medication cart after entering the

medication data into the medication observation record was to ensure the safety

and security of said medication.

b. He confirmed he became aware that this was not done by Respondent' s staff

member " B," a licensed practical nurse, when she directly handed the Xanax

for the resident to staff member " A" on May 27, 2021.

c. He was not aware if staff member " A" stayed current with her medication

training, which involved staying current from her initial four ( 4) hour

medication training on January 21, 2017, to having all subsequent two ( 2) hour

continuing medication trainings, which must be completed on an annual basis.

26. That Petitioner' s representative reviewed the hospital records related to resident

number one ( 1) during the survey and noted:

a. The resident arrived at the Emergency Department via 911 ambulance on May

27, 2021, at 9: 28 PM, had an estimated weight of one hundred ten ( I 10) pounds

and presented with altered mental status and accidental overdose.

b. Documented on May 28, 2021, at 12: 25 a. m. was the resident was somnolent

and moaning; a referral was made to an intensivist physician; and the resident

would be admitted to the hospital' s intensive care unit.

c. A critical care consulting physician report of May 28, 2021 at 1: 40 a. m.,

documented the chief complaint for the resident' s consult was for " lethargy post

possible overdose on Xanax" and documented the resident was assessed as a

critically ill patient with accidental benzodiazepine overdose."

d. A psychiatry consulting physician report of May 29, 2021, at 11: 55 a. m.

documented the chief complaint for the resident' s consult was for " altered

mental status" and " patient is confused," and documented the resident' s

assessment to include " Benzodiazepine overdose, altered mental status," and

further documents " Patient was inadvertently administered higher doses of

benzodiazepines at the assisted living where her meds are being distributed"

and " Patient is not responsible for self - administration of medications and

therefore is unlikely to have intentionally overdosed."

e. The hospital discharge summary dated June 18, 2021, at 2: 30 p. m., documented

the resident' s final diagnoses included pneumonitis due to inhalation of food

and vomit and benzodiazepine overdose.

27. That resident number one ( 1) was administered eighteen ( 18) tablets of Xanax on

May 27, 2021, by Respondent' s staff member " A," a medication technician, which required

hospitalization of the resident as a result, the resident developing pneumonia after being

administered the Xanax overdose and subsequently passing away in the hospital on June 9, 2021.

28. That Petitioner' s representative telephonically interviewed Respondent' s

administrator and regional executive director regarding resident number one ( 1) commencing at

3: 05 p. m. on July 9, 2021, who indicated:

a. They both acknowledged that this was not normal for an individual to give

eighteen ( 18) Xanax pills to a resident.

b. When questioned if they had contacted the local police authorities to report this

matter, they replied that the facility did not contact the police to investigate the

reason why staff member " A" overmedicated the resident on May 27, 2021.

c. The facility also did not contact the Department of Health to report this event

regarding the certified nursing assistant license of staff member " A."

d. The facility does not validate any of the medication technician' s medication

training certificates upon hire.

e. Therefore, they could not confirm the qualifications of staff member " A" to be

able to perform assistance with the self - administration of medications in a safe

manner for their residents.

f. The facility was unable to provide any further documentation indicating how

they had thoroughly investigated this matter and implemented a system - wide

corrective action plan to prevent the reoccurrence of medication overdose of a

resident.

29. 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 the agency

determines present an imminent danger to the clients of the provider or a substantial probability

that death or serious physical or emotional harm would result therefrom. The condition or practice

constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period,

as determined by the agency, is required for correction. The agency shall impose an administrative

fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the

correction of the violation.

30. That the same constitutes a Class I offense as defined in Florida Statute

429. 19( 2)( a) ( 2021).

WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten

thousand dollars ($ 10, 000. 00) against Respondent, an assisted living facility in the State of Florida,

pursuant to § 429. 19( 2)( a), Florida Statutes ( 2021).

COUNT II

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

forth herein.

32. That Florida law provides:

6) ASSISTANCE WITH THE SELF - ADMINISTRATION OF MEDICATION AND

MEDICATION MANAGEMENT. Unlicensed persons who will be providing assistance

with the self - administration of medications as described in rule 59A- 36. 008, F. A. C., must

meet the training requirements pursuant to section 429. 52( 6), F. S., prior to assuming this

responsibility. Courses provided in fulfilment of this requirement must meet the following

criteria:

a) Training must cover state law and rule requirements with respect to the supervision,

assistance, administration, and management of medications in assisted living facilities;

procedures and techniques for assisting the resident with self - administration of medication

including how to read a prescription label; providing the right medications to the right

resident; common medications; the importance of taking medications as prescribed;

recognition of side effects and adverse reactions and procedures to follow when residents

appear to be experiencing side effects and adverse reactions; documentation and record

keeping; and medication storage and disposal. Training shall include demonstrations of

proper techniques, including techniques for infection control, and ensure unlicensed staff

have adequately demonstrated that they have acquired the skills necessary to provide such

assistance.

b) The training must be provided by a registered nurse or licensed pharmacist who shall

issue a training certificate to a trainee who demonstrates, in person and both physically and

verbally, the ability to:

1. Read and understand a prescription label;

2. Provide assistance with self - administration in accordance with section 429. 256, F. S.,

and rule 59A- 36. 008, F. A. C., including:

a. Assist with oral dosage forms, topical dosage forms, and topical ophthalmic, otic and

nasal dosage forms;

b. Measure liquid medications, break scored tablets, and crush tablets in accordance with

prescription directions;

c. Recognize the need to obtain clarification of an " as needed" prescription order;

d. Recognize a medication order which requires judgment or discretion, and to advise the

resident, resident' s health care provider or facility employer of inability to assist in the

administration of such orders;

e. Complete a medication observation record;

f. Retrieve and store medication;

g. Recognize the general signs of adverse reactions to medications and report such

reactions;

h. Assist residents with insulin syringes that are prefilled with the proper dosage by a

pharmacist and insulin pens that are prefilled by the manufacturer by taking the medication,

in its previously dispensed, properly labeled container, from where it is stored, and bringing

it to the resident for self - injection;

i. Assist with nebulizers;

j. Use a glucometer to perform blood glucose testing;

k. Assist residents with oxygen nasal cannulas and continuous positive airway pressure

CPAP) devices, excluding the titration of the oxygen levels;

1. Apply and remove anti - embolism stockings and hosiery;

m. Placement and removal of colostomy bags, excluding the removal of the flange or

manipulation of the stoma site; and,

n. Measurement of blood pressure, heart rate, temperature, and respiratory rate.

c) Unlicensed persons, as defined in section 429. 256( 1)( b), F. S., who provide assistance

with self- administered medications and have successfully completed the initial 6 hour

training, must obtain, annually, a minimum of 2 hours of continuing education training on

providing assistance with self- administered medications and safe medication practices in

an assisted living facility. The 2 hours of continuing education training may be provided

online.

d) Trained unlicensed staff who, prior to the effective date of this rule, assist with the self -

administration of medication and have successfully completed 4 hours of assistance with

self - administration of medication training must complete an additional 2 hours of training

that focuses on the topics listed in sub - subparagraphs ( 6)( b) 2. h.- n. of this section, before

assisting with the self - administration of medication procedures listed in sub - subparagraphs

6)( b) 2. h.- n.

Rule 59A- 36. 01( 6), Florida Administrative Code.

32. That Florida law provides:

Staff involved with the management of medications and assisting with the self -

administration of medications under s. 429. 256 must complete a minimum of 6 additional

hours of training provided by a registered nurse, a licensed pharmacist, or agency staff. The

agency shall establish by rule the minimum requirements of this additional training.

Section 429. 52( 6), Florida Statues ( 2021).

33. That on July 9, 2021, the Agency completed a complaint survey, complaint number

2021009148, of Respondent' s facility.

34. That based upon observation, interviews, and the review of records, Respondent

failed to ensure that its non - licensed staff providing assistance with the self - administration of

medications maintained required training for completing such services, the same being contrary to

the mandates of law.

35. That Petitioner' s representative reviewed Respondent' s Adverse Incident Report

regarding resident number one ( 1) dated May 28, 2021 and noted:

a. Respondent' s staff member " B," a licensed practical nurse, received the

resident' s Xanax 0. 5 mg medication from the pharmacy, and handed this

medication to Respondent' s staff member " A," a medication technician in

Respondent' s memory care unit.

b. Staff member " B" received a call from staff member " A" at approximately 8: 44

p. m. and staff member " A" informed staff member " B" that staff member " A"

got the resident to take " all of them."

c. Staff member " B" questioned staff member " A" about this, and staff member

A" did not respond.

d. Staff member " B" went to the memory care unit and found the resident to be

very lethargic and she called 911 at approximately 8: 51 p. m.

e. The resident was transported to the hospital at approximately 9: 05 p. m.

f. Staff member " A" gave the resident eighteen ( 18) tablets of Xanax 0. 5 mg

medication and the reason for the actions of staff member " A" were unknown

at that time.

36. That Petitioner' s representative reviewed Incident Investigation dated May 28,

2021, and noted:

a. Staff member " A," a medication technician, gave all eighteen ( 18) tablets of

Xanax 0. 5 mg medication to resident number one ( 1) on May 27, 2021,

sometime between 8: 00 and 8: 44 p. m. which led to the resident' s hospitalization

on the same date.

b. This medication error may have been avoided had Respondent' s staff member

A" conducted the proper process of assistance with self - administration of

medications with the resident.

c. The specific process staff member " A" failed to do was not identified, and in

order to prevent future occurrences of medication errors, the facility will

provide medication education training to its staff members who assist residents

with self - administration of medications.

d. Respondent did not determine the root cause of the overmedicating of resident

number one ( 1) by staff member " A" on May 27, 2021

37. That Petitioner' s representative reviewed Respondent' s records related to resident

number one ( 1) during the survey and noted:

a. A Physician Order, dated May 27, 2021, was signed by the resident' s Nurse

Practitioner ( NP), documenting the resident' s current Xanax 0. 25 mg dose be

discontinued and to increase the dose to Xanax 0. 5 mg oral medication, one ( 1)

tablet three ( 3) times daily.

b. Progress Notes of May 27, 2021 documented:

i. At approximately 8: 05 p. m., Respondent' s staff member " B," a licensed

practical nurse, received the resident' s Xanax 0. 5 mg medication from

the pharmacy, which included eighteen ( 18) tablets, in a blister pack

format.

ii. Staff member " B" handed this Xanax medication to Respondent' s staff

member " B," a resident care assistant/ medication technician, in the

facility' s memory care unit, where the resident resided, and instructed

staff member " A" to give the resident the 8: 00 p. m. dose of Xanax

medication.

iii. Staff member ` B" received a call from staff member " A" around 8: 44

p. m. and staff member " A" informed staff member " B" that staff

member " A" got the resident to take " all of them," and staff member

B" questioned staff member " A" about this, but staff member " A" did

not respond.

iv. Staff member ` B" went to the memory care unit at approximately 8: 49

p. m. and found the resident to be very lethargic and 911 was called at

approximately 8: 51 p. m.

v. Emergency medical personnel arrived at approximately 9: 00 p. m. and

the resident was transported to the hospital at approximately 9: 05 p. m.

c. A Progress Note dated June 9, 2021 at 2: 14 p. m. documented the resident had

passed away in the hospital.

38. That Petitioner' s representative reviewed the hospital records related to resident

number one ( 1) during the survey and noted:

a. The resident arrived at the Emergency Department via 911 ambulance on May

27, 2021, at 9: 28 PM, had an estimated weight of one hundred ten ( 110) pounds

and presented with altered mental status and accidental overdose.

b. Documented on May 28, 2021, at 12: 25 a. m. was the resident was somnolent

and moaning; a referral was made to an intensivist physician; and the resident

would be admitted to the hospital' s intensive care unit.

c. The resident was diagnosed with pneumonitis due to inhalation of food and

vomit and benzodiazepine overdose.

d. The resident subsequently passed away in the hospital on June 9, 2021.

39. That Petitioner' s representative reviewed Respondent' s personnel records during

the survey and noted:

a. Staff member " A," a medication technician:

i. She was hired at the facility on November 12, 2019, as a resident care

assistant.

ii. Duties included providing direct care to residents, to assist residents

with self - administration of medications and must receive and stay

current with medication certification training.

iii. She received an initial four ( 4) hour medication training on January 21,

2017, which was followed with two ( 2) hour continuing medication

trainings on January 31, 2018, June 10, 2019, and June 21, 2020.

iv. None of the medication training certificates were validated by the

facility to ensure she was able to perform the procedures and techniques

for assisting residents with self - administration of medication.

v. There was not proof to having completed an " annual" two ( 2) hour

continuing education medication training before the expiration of the

initial medication training on January 21, 2018, and there was also no

proof in the personnel record that the staff member completed an initial

four ( 4) or six ( 6) hour medication training during the periods between

the expired " annual" two ( 2) hour medication trainings from January 31,

2018 to June 21,

b. Respondent' s staff members " D," " G," and " H," medication technician/

resident care assistants, who worked in Respondent' s memory care unit and

assisted living unit, were not current with their medication training.

c. Staff member " D," a medication technician/ resident care assistant:

i. The staff member was hired at the facility on February 15, 2017, as a

resident care assistant.

ii. Duties included to provide direct care to residents, to assist residents

with self - administration of medications and must receive and stay

current with medication certification training.

iii. The staff member received an initial six ( 6) hour medication training on

June 14, 2006, from a registered pharmacist, which was followed up

with a two ( 2) hour continuing medication trainings on September 19,

2012, from an education provider, on November 23, 2016, at the facility

by a registered nurse, on January 22, 2018, from an education provider,

on August 20, 2018, from a pharmacy, and on June 7, 2021, from an

education provider.

iv. The staff member did not have proof to have completed an initial six ( 6)

hour medication training at least one ( 1) year prior to the " annual" two

2) hour medication training dated on June 7, 2021.

d. Staff member " G," a medication technician/ resident care assistant:

i. The staff member was hired at the facility on September 1, 2016, as a

resident care assistant.

ii. Duties included to provide direct care to residents, to assist residents

with self - administration of medications and she must receive and stay

current with medication certification training.

iii. There was no certificate to reflect the staff member received an initial

six ( 6) hour medication training.

iv. The staff member received the following two ( 2) hour continuing

medication trainings: January 22, 2018; June 25, 2018, from an

education provider; August 20, 2018, from a pharmacy; January 17,

2020, from an education provider; and on October 13, 2020, from a

registered nurse.

v. The staff member did not have proof of completion of an initial six ( 6)

hour medication training at least one ( 1) year prior to her most recent

annual" two ( 2) hour medication training dated on October 13, 2020.

e. Staff member " H," a medication technician/ resident care assistant:

i. The staff member was hired at the facility on April 16, 2016, as a

resident care assistant.

ii. Duties included to provide direct care to residents, to assist residents

with self - administration of medications and must receive and stay

current with medication certification training.

iii. The staff member received an initial four ( 4) hour medication training

on April 26, 2011, from an education provider, and a six ( 6) hour

medication training on November 6, 2018, from a pharmacy.

iv. These trainings were not followed up with any two ( 2) hour continuing

medication trainings.

v. There were no documentation establishing the staff member had

completed any " annual" two ( 2) hour continuing medication trainings

after her most recent six ( 6) hour medication training dated November

16, 2018.

40. That Petitioner' s representative interviewed Respondent' s commencing at 3: 20

p. m. on July 7, 2021, who indicated:

a. He was not aware if staff members " D," " G," and " H" stayed current with their

medication training, which involved completing subsequent two ( 2) hour

continuing medication trainings annually or completing an initial six ( 6) hour

medication training before their annual medication training became expired.

b. He confirmed that the aforementioned staff members work in the memory care

unit and the assisted living unit for non - memory care.

41. 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 the agency

determines present an imminent danger to the clients of the provider or a substantial probability

that death or serious physical or emotional harm would result therefrom. The condition or practice

constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period,

as determined by the agency, is required for correction. The agency shall impose an administrative

fine as provided by law for a cited class I violation. A fine shall be levied notwithstanding the

correction of the violation.

42. That the same constitutes a Class I offense as defined in Florida Statute

429. 19( 2)( a) ( 2021).

WHEREFORE, the Agency intends to impose an administrative fine in the amount of ten

thousand dollars ($ 10, 000. 00) against Respondent, an assisted living facility in the State of Florida,

pursuant to § 429. 19( 2)( a), Florida Statutes ( 2021).

COUNT III

43. The Agency re - alleges and incorporates by reference Counts I and II of this

complaint.

44. Pursuant to Florida law, in addition to any administrative fines imposed, the

Agency may assess a survey fee, equal to the lesser of one half of the 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 400. 428( 3)( c), Florida Statutes, to verify the correction of the violations. §

429. 19( 10), Fla. Stat. ( 2021).

45. The Agency received a complaint or complaints about Respondent' s Facility.

46. In response to the complaint or complaints, the Agency conducted a complaint

survey of Respondent' s Facility ending July 9, 2021.

47. The Agency found instances of deficient practice that were the subject of the

complaint or complaints while conducting the survey.

48. The Agency is entitled to a survey fee pursuant to Florida statutory authority.

49. Respondent' s biennial license and bed fee exceeds five hundred dollars ($ 500. 00).

WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration,

seeks a survey fee of $ 500. 00 against Respondent.

COUNT IV

50. The Agency re - alleges and incorporates paragraphs one ( 1) through five ( 5) and

Counts I and II as if fully set forth herein.

51. That under Florida law,

In addition to the grounds provided in authorizing statutes, grounds that may be

used by the agency for denying and revoking a license or change of ownership application

include any of the following actions by a controlling interest:

b) An intentional or negligent act materially affecting the health or safety of a

client: of the provider.

c) A violation of this part, authorizing statutes, or applicable rules.

408. 815( 1)( b- c), Fla. Stat. ( 2021).

52. That 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 this part, part II of chapter 408, or applicable rules, or for any of the

following actions by a licensee, any person subject to level 2 background screening

under s. 408. 809, or any facility staff -

a) An intentional or negligent act seriously affecting the health, safety, or welfare

of a resident of the facility.

e) A citation for any of the following violations as specified in s. 429. 19:

1. One or more cited class I violations.

2. Three or more cited class II violations.

3. Five or more cited class III violations that have been cited on a single survey and

have not been corrected within the times specified.

f) Failure to comply with the background screening standards of this part, s.

408. 809( 1), or chapter 435.

429. 14( 1)( a), ( e), ( f), Fla. Stat. ( 2021).

53. That Respondent has been cited with two ( 2) Class I violations of on a single survey

of July 9, 2021.

54. That Respondent has violated the minimum requirements of law of Chapters 429,

Part 11, and Chapter 58A- 5, Florida Administrative Code as described with particularity within this

complaint.

55. That Respondent' s acts and omissions as described with particularity within this

complaint constitute intentional or negligent acts materially affecting the health or safety of

Respondent' s residents.

56. That Respondent has a duty to maintain its operations in accord with the minimum

requirements of law and to provide care and services at mandated minimum standards.

57. That based thereon, individually and collectively, the Agency seeks the revocation

of the Respondent' s licensure.

WHEREFORE, the Agency intends to revoke the license of the Respondent to

operate an assisted living facility in the State of Florida.

Respectfully submitted this day of October 2021.

STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION

525 Mirror Lake Dr. N., Suite 330

St. Petersburg, Florida 33701

Telephone: ( 727) 552- 1947

Fax: ( 727) 552- 1440

walsht@ahca. flonda. com

By: /////

Thomas J. Walsh II, Esq.

Fla. 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.

CERTIFICATE OF SERVICE

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

U. S. Certified Mail, Return Receipt No. 7020 2450 0000 5234 6253 on October, 2021, to

Eric L. Townes, Administrator, GV Deerfield Beach, LLC d/ b/ a Grand Villa of Deerfield Beach,

1050 Southwest 241" Avenue, Deerfield Beach, Florida 33442, and b Regular U. S. Mail to

Timothy R. Barnes, Registered Agent for GV Deerfield Beach, L,, 770 58 h Street North,

Suite 312, Clearwater, Florida, 33760.

J. Walsh II

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE: AHCA v. GV Deerfield Beach, LLC d/ b/ a Grand Villa of Deerfield Beach

AHCA No. 2021010620

ELECTION OF RIGHTS

This Election of Rights form is attached to a proposed agency action by the Agency for Health

Care Administration ( AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of

Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be

returned by mail or by facsimile transmission but must be filed within 21 days of the day that

you receive the attached proposed agency action. If your Election of Rights with your selected

option is not received by AHCA within 21 days of the day that you received this proposed

agency action, you will have waived your right to contest the proposed agency action and a

Final Order will be issued.

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

Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.)

Please return your Election of Rights to this address:

Agency for Health Care Administration

Attention: Agency Clerk

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

Tallahassee, Florida 32308

Telephone: [phone] 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. I understand

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

action and imposes the penalty, fine or action.

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

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

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

Florida Statutes) where I may submit testimony and written evidence to the Agency to show that

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

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

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

and I request a formal hearing ( pursuant to Section 120. 57( 1), Florida Statutes) before an

Administrative Law Judge appointed by the Division of Administrative Hearings.

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. 2. 015, 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:

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR

H13ALTH CARE ADMINISTRATION,

AIICA Case No.: 2021010620

DOAH Case No.: 22- 0530

Petitioner, Facility Type: Assisted Living

vs.

GV DEERFIELD BEACII, LLC d/ b/ a

GRAND VILLA OF DEERFIELD BEACH,

Respondent.

SETTLEMENT AGREEMENT

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

Agency"), through its undersigned representatives, and GV Deerfield Beach, LLC d/ b/ a Grand

Villa of Deerfield Beach ( 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 1, and 408, Part II, Florida Statutes;

and

WHEREAS the Agency served Respondent with an Administrative Complaint dated

October 28, 2021, consisting of an action to revoke Respondent' s licensure to operate an assisted

living facility in the State of Florida based upon two alleged Class I violations and to impose

EXHIBIT 2

administrative fines in the sum of twenty thousand dollars ( S20, 000. 00), and a survey fee of five

hundred dollars ($ 500. 00) for a total assessment of' twenty thousand five hundred dollars

S20, 500. 00); and

WHEREAS Respondent disputed the Agency' s findings that gave rise to the alleged

Class I violations, as well as the Agency' s determination that Class I violations should be

imposed against Respondent, and filed a formal petition for hearing; and

WHEREAS the parties have agreed that a fair, efficient, and cost- effective resolution of

this dispute would avoid the expenditure of substantial sums to litigate the dispute; and

WHEREAS the parties stipulate to the adequacy of considerations exchanged; and

WHEREAS the parties have negotiated in good faith 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.

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

findings of the parties.

3. Upon full execution of this Agreement, Respondent agrees to withdrawal of its

petition for administrative proceedings, 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,

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however, that no agreement herein shall be deemed a waiver by either party of its right to judicial

enforcement of this Agreement.

4. Upon full execution of this Agreement:

a. Count I of the Administrative Complaint is amended from a Class I deficient

practice to a Class II deficient practice.

b. Count 11 of the Administrative Complaint is amended from a Class I deficient

practice to a Class III deficient practice.

C. Count IV of the Administrative Complaint is voluntarily dismissed.

d. Provider agrees to pay two thousand dollars ($ 2, 000. 00) in administrative fines to

the Agency within thirty ( 30) days of entry 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, a) Respondent denies the allegations raised in the

Amended Administrative Complaint referenced herein and b) The Agency asserts the validity of

the allegations raised in the Administrative Complaint referenced herein. 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 referenced

herein. The Agency, however, acknowledges and agrees that it shall not deny Respondent' s

pending application for renewal of its assisted living facility license based solely on the facts

alleged int the Administrative Complaint. This agreement does not prohibit the Agency from

taking action regarding Respondent' s Medicaid status, conditions, requirements, or contract, if

applicable.

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7. 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.

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

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

by all the parties.

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

transferees, attorneys, heirs, and executors or administrators, do 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 and its related or resulting facilities/ organizations. Nothing in this

paragraph limits the parties from enforcement of this Agreement as provided in paragraph four

4) of this Agreement.

i 1. This Agreement is binding upon all parties and those persons and entities that are

identified in the above paragraph.

12. 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.

13. 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.

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14. This Agreement contains and incorporates the entire understandings and

agreements of the parties.

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

parties.

16. This Agreement may not be amended except in writing. Any attempted

assignment of this Agreement shall be void.

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

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

to enter into this Agreement.

Kimberl . Smoak, Deputy Secretary Amy W. Schrader, Esq.

Health Quality Assurance Aldo M. Leiva, Esq

Agency for Health Care Administration Counsel for Respondent

2727 Mahan Drive, Building # I Baker, Donelson, Bearman, Caldwell &

Tallahassee, Florida 32308 Berkowitz, PC

3301 Thomasville Road, Suite 201

Tallahassee, Florida 32308

DATED: v - W DATED: 9- 6- 2022

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Andrew Sl eran, Acting Genera Counsel A istrator

Office of the General Counsel GV Deerfield Beach, LLC d/ b/ a

Agency for Health Care Administration Grand Villa of Deerfield Beach

2727 Mahan Drive, MS # 3 1050 Southwest 24"' Avenue

Tallahassee, Florida 32308 Deerfield Beach, Florida 33442

DATED: - 17 r2' v 6- . DATED: t b Z 2.

i r

Thomas J. Walsh, Il, Senior Attorney

Nicola L. C. Brown, Senior Attorney

Counsel for the Agency

Office of the General Counsel

Agency for Health Care Administration

15500 Lightwave Drive

Clearwater, Florida 33760

DATED: q?

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