STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2014003901 EMERITUS PROPERTIES NGN LLC d/b/a EMERITUS AT CONWAY, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State Of Florida, Agency For Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Emeritus Properties NGN LLC, d/b/a Emeritus at Conway (hereinafter “the Respondent”), pursuant to sections 120.569 and 120.57, Florida Statutes (2012), and alleges: | NATURE OF THE ACTION 1. This is an action impose an administrative fine in the amount of ($1,000.00), based upon one class II violations. PARTIES 2. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapter 408, Part II, Chapter 429, Part I, Florida Statutes, and Chapter . 58A-5, Florida Administrative Code, respectively. 3. The Respondent opérates a (103)-bed assisted living facility located at 5501 East Michigan Street, Orlando, Florida 32822 and is licensed as an assisted living facility, license number 9286, and was at all times material hereto required to comply with all applicable rules and statutes. COUNT I SUPERVISION 4. Under Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts, The resident may travel independently in the community.(d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out.(e) A written record, updated as needed, of any significant changes as defined in subsection S8A-5.0131(33), F.A.C., any: illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. 58A- 5.0182(1), Fla. Admin Code. 5. On or about March 6, 2014, the Agency conducted a complaint survey of the Respondent’s assisted living facility 6. Based on interviews and record review the facility failed to provide care and services appropriate to the need of 1 of 4 sampled residents (#1) and failed to ensure transfers were per resident's service plan, safely and without injury. 7. Resident record review on 3/6/14 at approximately 11:30 AM for resident #1 revealed a health assessment report dated April 9, 2012. The assessment indicated diagnoses of asthma, atrial fibrillations, obesity, left extremity venous insufficiency and decreased sensation in feet. She used a walker to ambulate; assistance was needed with all the activities of daily living. According to the assessment the resident tired easily. 8. The individualized service plan dated 5/17/12 indicated the resident used a walker and a wheelchair; was forgetful and required stand by assistance with toileting and was independent with transfers. 9. The bi-annual assessment indicated a change in level of care; the resident needed increased assistance with ADL's, since the last review. The resident assist with transfers has increased to 2 (staff). The left bottom of the page indicated 12/19/13 7:30 AM. The next assessment was due 2/2/14. 10. ‘Telephone order dated 11/4/13 requested Physical Therapy /Occupational Therapy /Skilled Nursing related to difficulty with transfers. The physician approved the request. Another order dated 11/14/13 requested a bed halo for transfers. 8/23/13 Physician's order for hospital bed. 11. Incident report dated 12/13/13 indicated that at approximately 5:40 AM the caregiver (G) reported that while transferring resident #1 to the bathroom, residents legs became weak and she lost her balance. Staff G lowered resident #1to the floor. The interventions ‘corrective measures to be implemented was to re-educate the staff that the resident was a 2 2 person assist, not one. The resident went to the hospital with " fracture outcome". The resident was a level 5 of care. The event management report dated 12/16/13 indicated staff A attempted to transfer resident alone, the resident panicked, stated her legs got weak and gave in, he lowered her to the floor to prevent injury. The "resident stated he dropped her, not understanding he lowered her to prevent injury". Resident went to the emergency room, daughter reported sustained two fractures from fall. In a statement given by staff to the facility he indicated he put the resident on the floor because she was closer to floor than to the bed, and went to get co-worker. When they returned and turned on the light “I saw her leg twisted and we call 911". 12. Facility note dated 10/29/13 9 AM indicated that caregivers complaint they were unable to lift resident #1 with one person only. “Staff educated about lifting with 2 people “. 13. Facility note dated 11/9/13 4 PM indicated "resident attendants and myself had a difficult time lifting resident. It took 3 people to transfer her and about 45 minutes to transfer her. We had to put her in her chair with her feet up because they looked swollen". 14. Facility note dated 11/11/13 10 AM indicated "had 3 people to help assist resident during transfers. Very hard to transfer, still no use of [illegible] board". 15. Facility note dated 11/12/13 10:15 AM Resident was difficult to transfer even with 3 people assisting. 16. Facility note dated 12/13/13 2 PM was informed resident was in hospital. 17. Facility note dated 10/14/13 10 AM Called hospital and was informed the resident had a fracture on each leg; one fracture is on the tibia, 18. Facility note dated 12/4/13 4 PM called hospital to inquire about resident, but no information was obtained. The note continued, it indicate the writer spoke with staff G, who stated he knew the resident needed 2 people to assist but decided to attempt the transfer on his own. He tried to transfer her by sitting her on side of the bed and transfer to wheelchair that was close by. The resident changed her mind and asked to be transferred back to bed. Both of them lost balance and he lowered her to the floor to avoid potential fall but instead, she complaint of discomfort and pain. The family and 911 were called. 19. On 11/7/13 there was a 1 hour staff meeting where ergonomics (work place safety)/transfers were reviewed. A Physical Therapist (PT) conducted the training. Staff G did not attend meeting. PT was doing individual training with the staff but the staff involved with resident #1 had not attended. 20. In an interview with the executive director on 3/6/14 at approximately 4 PM he offered no comment. 21. In an interview with staff #G on 3/7/14 at approximately 8 AM, he stated, “I do normally by myself. I take her from the bed to bathroom. I think she was not familiar with people of my color. She did not relate to me the same she related to caucasian. Very demanding, could not satisfy her. I was about to finish and go home. I heard the call bell, my mind told me not to go but J did. The roommate told me resident #1 wanted to go to the bathroom, in a demanding matter. I cannot remember if the lamp was on or not. Resident #1 was mumbling, crying maybe not wanting me close to her. She did not want me to change her. I asked if she was in pain. I had my hands under her arm pits. She was whining, she was losing her body. I was bearing her weight. I cannot put back in bed because the bed was higher than the chair. She was half way on her knees. I thought to lower to floor. I went to get a co-worker to put her back in chair. When I came back I noticed the leg was not in proper position. So we called 911. "I just did by myself — (transferred)". I believe I had the walkie talkie- there was no response so I walked to get somebody, 22. Review on 3/7/14 at approximately 3 PM of the Orlando Fire Department report dated 12/13/13 indicated a call was received about a fall victim. The staff stated they were helping the resident to the bathroom when she fell. The resident stated she experienced pain of 10 in a scale from 1 to 10. The impression was traumatic injury. Left leg fracture. 23. Review on 3/7/14 at approximately 4 PM of the hospital record revealed she was admitted with a fractured/displaced right femur and a left tibular fracture after sustaining a fall. On 12/15/13 she underwent surgery to repair the fractures. She was pronounced dead on 12/15 at 11:29 PM. 24. The Respondent’s actions or inactions constituted a class II violation. 25. Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2013). 26. Under Florida law, the Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation: § 429.19(2)(b), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $1,000.00 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1, Make findings of fact and conclusions of law in favor of the Agency. 2. Impose the relief against the Respondent as set forth above. Respectfully submitted on this 3 day of June 2014. /s/ John Bradley John E, Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration $25 Mirror Lake Drive St Petersburg, Florida 33701 Phone: (727) 552-1944 John.Bradley@ahca.myflorida.com NOTICE THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. 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, BLDG 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form has been served to: Manuel Gonzalez, Administrator, 5501 East Michigan Street, Orlando, Florida 32822 by U.S. Certified Mail; Return Receipt Requested (7004 1350 0004 2776 1595) by U.S. Mail on this 3 day of June 2014. __/s/JohnBradley John E. Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Tallahassee, Florida 32308 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 ’ John.Bradley@ahca.myflorida.com Copy furnished to: Theresa DeCanio, Field Office Manager Catherine Avery, Assisted Living Unit Manager wee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Emeritus at Conway AHCA No: 2014003901 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, Mail Stop #3 Tallahassee, Florida 32308. Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing. 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 28-106.2015, Florida Administrative Code, which requires that it contain: 1, The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License Type: (ALF? Nursing Home? Medical Equipment? Other Type?) Licensee Name: License Number: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: 10 SENDE! COMPLETE THIS SECTION — } COMPLETE THIS SECTION GN DELIVERY

Docket for Case No: 14-004027