STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No.: 2014005903 MERRITT ISLAND RHF HOUSING, INC. d/b/a COURTENAY SPRINGS VILLAGE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint Merritt Island RHF Housing, Inc. d/b/a Courtenay Springs Village against (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2013), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing May 12, 2014, and ending June 23 , 2014, and to impose an administrative fine in the amount of ($10,000.00) based on one Class I deficiency, and to impose survey fee of six thousand dollars ($6,000.00).. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2013). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4,. Florida Administrative Code. 4. Respondent operates a (96) bed nursing home, located at 1100 South Courtenay Parkway, Merritt Island, Florida 32952 and is licensed as a skilled nursing facility license number 11070961. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to’ comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through (5), as if fully set forth herein. . 7. Under Florida law, in addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: An intentional or negligent act materially affecting the health or safety of residents of the facility. § 400.102(1), Fla. Stat. (2013). 8. Under Florida law, each facility shall maintain policies and procedures in the following areas: the reporting of accidents or unusual incidents involving any resident, staff member, volunteer or visitor. This policy shall include reporting within the facility and to the ahca. 59A- 4.106(4)(cc), Florida Administrative Code. 9. On or about June 12, 2014, the Agency completed a complaint survey of the Respondent’s facility. 10. Based on interview and record review, the facility failed to report immediately, thoroughly investigate, and prevent further potential abuse for an allegation of sexual assault for 1 of 6 sampled residents (#1) in a total census of 71 residents. 11. Resident #1 was identified with bleeding from her vaginal area on Saturday, 3/01/14. At that time, the resident was agitated, resisting care, moaning, and crying while trying to put her hand near her vaginal area. The resident has dementia, was unable to make her needs known, and was totally dependent upon staff for all activities of daily living. The resident was sent to the hospital for evaluation and treatment for bleeding in the vaginal area, but the facility did not suspect abuse, report immediately, and initiate an abuse investigation. After the resident arrived in the hospital, the medical examination revealed vaginal trauma, bleeding, swelling to the vaginal area, and bruises to the inner thigh and abdomen. Sexual assault was suspected, a rape kit was performed, and the police and adult protective investigator were notified. 12. The administrator and director of nursing indicated that they became aware of the hospital allegation of sexual assault on 3/01/14, but since they did not consider the resident's injuries to be from sexual abuse, they did not think they needed to report abuse, conduct an investigation, and protect any other residents from potential abuse. 13. As of 5/05/14, the facility had not reported the abuse allegation to state officials to include the Agency for Healthcare Administration and the Department of Children and Families, The facility had not conducted a thorough investigation or implemented measures to prevent potential abuse to other residents. These practices resulted in a situation in which immediate corrective action is necessary because the facility's noncompliance caused, and is likely to cause, serious harm, injury, impairment, or death starting on 3/01/14 and it was determined to be ongoing as of 5/12/14. 14. On 4/16/14 at approximately 9:50 AM, an interview with the administrator (ADM) me" revealed the following: Resident #1 had blood in her brief at noon on 3/01/14 when the occupational therapist (OT) changed the brief. The OT notified licensed practical nurse (LPN) #C who was caring for resident #1 that day, and LPN #C notified the registered nurse (RN) supervisor. LPN #C notified the physician who said to send resident #1 to the emergency room (ER) for further evaluation and treatment. The ADM said apptoximately 3 hours later, at 3 PM, the facility received a call from the hospital saying they would be admitting the resident and they have suspicions of sexual abuse due to her injures. The ADM said the resident did not return to the facility. 15. On 4/16/14 at 12:15 PM, the ADM stated she was the abuse coordinator responsible for reporting and investigating all abuse allegations. She said she did not have any Federal immediate or 5-day abuse investigation reports for any residents. 16. Review of the abuse log book for March 2014 and April 2014 revealed there was no documentation that an allegation of a sexual abuse occurred. The ADM said written statements were completed on 3/01/14 by the RN supervisor on 3/01/14 after the hospital called to say resident #1 had injuries that indicated sexual assault. She said the Department of Children and Families (DCF) investigator and a representative from the Brevard County Sheriffs Office (BCSO) arrived at the facility to investigate the sexual assault allegation on Monday, 3/03/14, two days after the resident's injuries were identified. 17. In an interview with the ADM on 4/16/14 at 4:30 PM, she stated she did not think the allegation of sexual abuse from the hospital applied to the facility, therefore she did not follow the policies and procedures for abuse. She said she did not think they needed to investigate and report because "we are not the ones who suspect abuse, the hospital is." She said the resident was catheterized for a urine sample on 2/28/14 and she believed the catheter was the cause of the were’ bleeding. She said did not have reasonable suspicion of abuse when the resident was identified with bleeding in the vaginal area at noon on 3/01/14 while still in the facility. She said neither the OT, RN supervisor, nor LPN #C reported any suspicion of abuse to her. 18. In an interview with the ADM on 4/30/14 at 11:57 AM, the ADM said was notified by the director of nursing (DON) on 3/01/14 at 3 PM, 3 hours after the vaginal bleeding was identified, that resident #1 was sent to the hospital with bleeding and the DON told her the hospital suspected sexual assault due to the location and severity of the resident's injuries. She said she spoke with the DON on 3/01/14 regarding any issues with the resident's catheterization done on 2/28/14. She said the DON later spoke with the nurse who catheterized the resident and the DON reported no problems with the catheterization. The ADM said she thought the bruises on the resident's legs as noted when in the hospital were from staff holding the resident's legs to clean her on 3/01/14 before she went to the hospital. The ADM stated she did not suspect abuse when the BCSO and DCF came into the facility on Monday, 3/03/14. She said "they stated that she, resident #1, was assaulted." The ADM was asked "What is your policy and your protocol?" The ADM stated, "if there is an individual suspected of abuse, we suspend them and based on this situation I would have had to suspend my entire staff and would have no one to take care of the residents. We sat down with the staff and did a time line of events." 19. An interview with the OT on 4/30/14 at 10:48 a.m. revealed that she was aware of the abuse policies and procedures. She said her last in-service was on 12/01/13 via computer. She stated, "I evaluated resident #1 for therapy. She was confused, had poor cognition, was not participating in activities of daily living (ADLs), and did not have any behavioral issues. The resident was in the independent living apartment before her admission to the skilled nursing unit. She said she saw the resident on Saturday 3/01/14. She went into the resident's room at approximately noon. The resident was in bed. Her daughter-in-law (DIL) was in the room at that time. The resident was lying in bed with her shirt on and she was covered with a blanket. She said she spoke to the DIL, and then the DIL stepped out of the room. The OT said she checked the resident's incontinence brief to see if it was dry, which she normally did before providing therapy treatment. When she pulled the covers down and unfastened the brief, she noticed blood from the resident's vaginal area. The blood was clumpy in the front of the brief, spotty and localized on the resident's labia. The bloody spot was about 1-2 inches and dark red. She covered the resident and immediately went to get the LPN #C. She said LPN 4C inspected the resident's brief. With the OT's assistance, LPN #C cleaned the resident. The OT held the resident's left leg and LPN #C held her right leg. She said the resident then became "very resistive. She did not want us to do this". The OT said she did not notice any discoloration or bruising. LPN #C wiped the vaginal area clean and then went to report the incident to the RN supervisor. LPN #C and the RN supervisor looked at the resident again. Then the RN supervisor told LPN #C to call the physician. The OT put a new brief on the resident who was very resistive when rolled onto her side. The resident held on to the bed rail and would not let go. The OT gently removed her hands from the rail. She said the resident was very rigid. She said the resident had not behaved that way prior to that day. 20. Review of the nurses' notes did not reveal any documentation of any examination of the resident when the bleeding was identified. 21. When questioned about the resident's clothing, the OT stated that the resident was not wearing any pants or shorts when she first entered the room. When she returned to the room later, she said she noticed the resident was fidgeting and trying to put her hands down into the brief, pulling at her brief. The brief was not tight. The brief that had the blood in it was snug against the resident and not too tight. She stated that she informed LPN #C that the resident was pulling at her brief. 22. ‘In an interview on 4/30/14 at 11:30 AM with the hospitalist physician who cared for resident #1 after she was admitted to the hospital on 3/01/ 14, indicated the physician in the emergency room (ER) did a pelvic exam on the resident and identified bruising around the vagina and bleeding from the vagina. A rape kit was completed in the ER. The resident was admitted to the hospital. She had bleeding for the few days while she was at the hospital. The hospitalist physician said the resident had vaginal trauma and small vaginal tears. She said the family was notified that the resident was possibly assaulted. The hospitalist physician said bruising was present on the lower abdomen. She said she saw the resident at approximately 7-8 PM that evening. The resident had progressive delirium and was bed bound. There was no blood under the resident's fingernails. She said she was aware the nursing home stated they catheterized the resident on 2/28/14, but that would not explain why the resident had blood, bruising and vaginal tears. She said if there was any trauma from the catheterization, the resident might have blood in the opening that goes to the bladder, the urethra, not the vagina. 23. Review of the ER disposition summary read, "Order for admission - medical. Preliminary diagnoses are sexual assault adult - alleged, vaginal bleeding, and chronic dementia." 24. An interview was conducted with the ADM/Abuse Coordinator on 5/01/14 at 11:57 a.m. She said she received a call from the DON around 3 PM on 3/01/14 requesting release of a urinalysis report for resident #1 to the hospital. She said the DON then told her about the resident "bleeding from the clitoris."" When the ADM was asked if she was aware that the hospital informed the facility that resident #1 had signs and symptoms of sexual assault from her stay in the nursing home, she stated, "Yes." The ADM said that the RN supervisor told her that the resident was catheterized on 2/28/14, so "I thought the blood was related to the catheterization." The administrator said the urinalysis had identified a large amount of blood in the urine sample. 25. Review of the laboratory report for the urinalysis results indicated the resident's urine sample was yellow and cloudy. It had characteristics indicative of a urinary tract infection, including blood and nitrites. 26. The ADM continued to say that on 3/03/14 she was informed that a law enforcement officer (LEO) was at the facility for the sexual assault investigation resident #1. During the same time, a DCF investigator was also in the facility for resident #1. The ADM said she told the DCF investigator that resident #1 was on blood thinner and felt the bruises were from the staff holding the resident's legs to clean her. 27. Review of the medical record revealed resident #1 was receiving 325 milligrams of Aspirin daily. 28. The ADM said, "once DCF and the LEO came to the facility, I didn't believe I still had to do my own investigation and file the immediate and 5-day reports." She said she still thought the bleeding was from the catheterization on 2/28/14, and not due to sexual assault in the facility. However, she provided no evidence of an investigation as to how a catheterization could cause the bleeding, bruising, and tears to the vaginal area. 29, On 5/01/14 at 12:41 PM, a phone interview with LPN #D revealed that she catheterized resident #1 on 2/28/14. She stated she performed the catheterization without assistance using a #16 French Foley catheter. She made one attempt and obtained dark, concentrated, yellow urine. The resident did not have any adverse reaction to the catheterization. She did not have any signs of pain, fidgeting or scratching in her groin area. Her vaginal area was a normal pinkish color, clitoris was pink and normal size and there were no bruises or blood. 30. Document 1 "Courtenay Springs Village Abuse Reporting.". The ADM provided a policy on 4/16/14 titled "Courtenay Springs Village Abuse Reporting." It did not include a date of implementation or a review date. The "Policy Statement" read, "All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source. An incident or suspected incident of resident abuse must be reported either to the Abuse Hot Line Number or to the administrator or his/her designee." 31. "Policy Interpretation and Implementation" read in part, "Any alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source....must be . reported to either the administrator, other management staff, or the corporate office. When an alleged or suspected case of mistreatment, neglect or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of the incident: a. State Licensing and Certification Agency b. Ombudsman; if necessary c. Resident Representative d Law Enforcement officers; if needed... All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse or suspected-incident-of -abuse. Such reports may be made without fear or retaliation from the facility or its staff. Reports can be made directly to the Abuse Hotline....Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion or sexual assault....Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment....The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to their supervisor. The following information should be reported to their supervisor: a. The name of the resident involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The names(s) of the person(s) committing the incident, if known; e. The type of abuse that was committed (i.e..: verbal, physical, sexual, etc.); f. Other information that may be requested by the supervisor....Upon receiving reports of physical or sexual abuse, a charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident‘s medical records... The charge nurse must complete a Resident Abuse Report Form and obtain a written signed and dated statement from the person reporting the incident....A completed copy of the Resident Abuse Report Form and written statements from witnesses, if any, will be provided to the administrator or designee within twenty-four (24) hours of the occurrence of such incident. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the.administrator within five (5) working days of the occurrence of such incidents..." 32. The Addendum to "Abuse and Neglect Policy", revised on 8/01/10 included, "Training" - The Director of Social Services will review the Facility Abuse and Neglect Policy with new employees during required general orientation before starting work....Identification - Includes but is not limited to: Residents complaint of unusual pain or discomfort. New bruising or discoloration which is unexplained. Resident exhibiting fear, anger or crying." 33. The abuse definitions table included "reasonable suspicion as an objectively reasonable suspicion that a person would entertain, based upon facts that could cause a reasonable person in a like position, drawing upon his/her training and experience, to suspect abuse." 34, | The ADM was asked to provide any and all abuse policies and procedures on 4/30/14 at 9:30 AM. Document 4 "Abuse Reporting" The "Abuse Reporting Policy and Procedure" was provided on 5/02/14. Review of the Corporate-Wide "Abuse Reporting" CCP#11-03, prepared by corporate compliance and privacy officer, dated 6/11/103, approved by RHF corporate compliance committee 10/23/03, received on 5/02/14 read, "Purpose: To provide employees and facilities with the framework to fulfill their duty to report any known, suspected, or witnessed resident abuse or neglect incidents. Policy: All employees and facilities shall immediately report to the appropriate parties/entities any known, suspected, or witnessed incident(s) of resident abuse or neglect. 35. Procedure - A. Legal Reporting Duty - All employees and those acting on the behalf of any RHF facility are under a mandatory legal duty to report any known, suspected, or witnessed incident(s) of resident abuse/neglect in any form by any person. B. Reporting by Employees - Each employee has the duty to report any resident abuse/neglect concern to both external and internal parties as described below. 1. External Reporting by Employees-Each employee is a mandatory abuse reporter under applicable federal and state law. These laws impose a duty on each employee to immediately report any known, suspected, and/or witnessed incident(s) of resident abuse/neglect in any form to the applicable government agencies....Internal Reporting by Employees - a. How to Report Abuse/Neglect - Any employee who knows, suspects, or witnesses resident abuse/neglect in any form shall report the incident(s) immediately to their facility's Abuse Prevention Coordinator. This report may be made prior to or after the employee reports the incident to any external parties. In addition, the employee shall. immediately complete a "Resident Abuse Report Form" and an Incident Report form, along with any other applicable documents as required by law. These documents shall be submitted immediately to their facility's Abuse Prevention Coordinator. b. Response to an Internal Report 36. Upon receipt of any report of resident abuse/neglect, the Abuse Prevention Coordinator shall promptly . take the following steps: If signs and symptoms of physical or sexual abuse/neglect or other issues requiring medical attention are present, ensure that the resident's we” eee physician is immediately notified or emergency care is provided. If the reporter has not already done so, have the reporter complete a Resident Abuse Report Form, an Incident Report and any other requires documentation. 37. Immediately notify the Administrator and/or Director of Nursing of the allegation so that immediate protective and other intervening actions can be identified and implemented in accordance with the General Abuse Policy. 38. Immediately initiate the investigation process as describe in the Abuse Investigation policy. Initiate the reporting process on the behalf of the facility. E. Reporting on Behalf of the Facility 2. External Reporting 39. Upon receipt of a report of an abuse allegation or upon suspicion of a potential abuse incident, the Abuse Prevention Coordinator, Administrator, and his/her designee shall immediately follow all applicable legal reporting obligations. In addition, all applicable | documents shall be completed and submitted to the appropriate government agency (ies) within the prescribed time frames. 3. Documentation of Facility Reporting - To aid in compliance with all the facility reporting obligations and to ensure proper documentation, the Abuse Prevention Coordinator or others as assigned shall complete the state-specific RHF Facility abuse Reporting Form. The completed form shall be retained with all other abuse related documentation." 40. | The ADM was asked to provide all abuse policies and procedures on 4/30/14 at 9:30 AM. Document 3 "Abuse Investigation" The ADM provided the "Abuse Investigation Policy and Procedure" on 5/05/14. Review of the Corporate-Wide "Abuse Investigation" #CCP 11-02, prepared by the corporate compliance and privacy officer, approved by RHF corporate compliance committee dated 10/23/03 and reviewed on 11/11/05 read, "Purpose: To provide a standard framework to follow when conducting an abuse-related investigation. 12 so 41. Policy: Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted.and documented according to this policy. Procedure: A. Upon report of any resident abuse/neglect allegations in any form or some other indication of a potential abuse/neglect concern, a thorough investigation shall be immediately conducted and documented by the Abuse Prevention Coordinator, Administrator, Director of Nursing or others as assigned. C. Timing and Initial Steps of Abuse-Related Investigations. Upon notification of an abuse-related report or indication of an abuse-related concern, the assigned investigator shall immediately commence the investigation process. The investigation should be completed within two (2) working days, unless extenuating circumstances. In addition to initiating the investigative process, the protective actions described in the General Abuse policy shall be immediately implemented. D. The Investigation Process - The assigned investigator shall lead and coordinate the investigation with assistance from other members of the disciplinary team. Once the need to conduct an abuse related investigation has been identified, the following steps shall be immediately completed as applicable: 1. Review any Abuse Report Forms or Incident Reports, Grievance Forms, or other completed documents: specifically related to the allegation. 2. Interview all reporters. 3. Interview the resident(s) who is the subject of the abuse allegation. 4. Interview any witnesses to the alleged incident. 5. Interview the alleged abuser(s). 6. Interview staff members, agency staff, contractors, volunteers, and others from all shifts who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 7. Interview the resident's roommate, family members, visitors, and others who have had contact with the resident immediately preceding, during, and immediately after the alleged incident. 8. Interview any other residents who have had recent contact with the alleged abuser(s). 9. Interview the — resident's physician or other health care providers who have had recent contact with the resident. 10. If applicable, review the resident's medical/health record. 11. As appropriate, have the resident's physician or the Medical Director physically examines the resident. 12. Conduct a social services consultation with the resident regarding the resident's feelings and reaction to the alleged incident. 13. Perform any other investigative activities as appropriate based on the allegation and other investigative findings. E. Documentation of the Investigation - 1. All reporters, alleged abusers, and witness interviews shall be documented in writing and dated and signed by the interviewee. 2. Results of the physical examination and social services interview shall be documented as appropriate in the resident's medical/health record. 3. All follow-up and additional information required for the Incident Report shall be completed. 4. A RHF Resident Abuse Investigation Report form shall be used to formally document all investigative findings, recommended course of actions, and follow-up. F. Steps Following the Conclusion of the Investigation 42. Following the conclusion of an abuse related investigation, the following steps shall be taken: 1. Discuss the investigative findings with the Administrator and the other members of the interdisciplinary team and Corporate Office as appropriate. 2. Complete any additional documentation and/or steps at are required to meet external reporting obligations (refer to the Abuse Reporting policy). 3. As appropriate, communicate the findings with the resident, the resident's family/responsible party, the reporter, and others as appropriate. 4. Identify the course of action and implement immediately." 43. Review of the “Retirement Housing Foundation (RHF) Resident Abuse Investigation Form “received on 5/02/14 revealed it was one page without a date and signature of the person completing the form. The form was not completed with required information. Under Alleged 14 oe Abuse Incident (attach additional pages as necessary), the "report made to” was blank. The form documents-type of alleged abuse - sexual. Accused Individual (attach additional pages as necessary) listed “unknown.” The ADM indicated she was the person who filled out the form However, she was not in the facility on the day the alleged abuse occurred on 3/01/14, or on 3/02/14. She said she had no other attached pages to the Resident Abuse Investigation Form. The investigation provided by the ADM and DON consisted of the " Resident Abuse. Investigation Form " , statements from 4 staff members, the DON notes of whether staff "knew anything or not," and a timeframe completed by the DON. It was not thorough and did not include a summary of the findings. The "Abuse Investigation" #CCP 11-02, indicated the " Resident Abuse Investigation report Form shall be used to formally document all investigative findings, recommended course of actions, and follow up." The form does not include all of the required information as listed in the policy. 44. As. of 5/05/14, the ADM had not reported the sexual assault, had not completed a thorough investigation, had not implemented measures to ensure all residents were protected from potential abuse, and had not submitted her investigative reports to state officials to include the Agency for Healthcare Administration. 45. The Agency determined that this deficient practice presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility, and cited Respondent with a patterned Class I deficient practice. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2013). COUNT II 46. Based upon Respondent’s cited State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(a), Florida Statutes (2013). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2013) commencing May 12, 2014, and ending June 23, 2014. COUNT II 47. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Counts I and II of this Complaint as if fully recited herein. 48. That Respondent has been cited with one (1) State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section.400.19(3), Florida Statutes (2013). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of six thousand dollars ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2013). Respectfully submitted this 5 day of August, 2014. _/s/JohnEliotBradley John Bradley, Esquire Fla. Bar. No. 92277 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) John.Bradley@ahca.myflorida.com 16 DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2011), Respondent shall post the most current license in-a——___ prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE T HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No: (7010 0780 0001 9836 2671) Jessica Pierre, Administrator, Courtenay Springs Village, 1100 South Courtenay Parkway, Merritt Island, Florida 32952 on this 5 day of August, 2014. John Eliot Bradley John Eliot Bradley, Esquire Copy furnished to: Theresa DeCanio, Field Office Manager, Agency for Health Care Admin. Bernard Hudson, Long Term Care Unit Manager, Agency for Health Care Admin. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: MERRITT ISLAND RHF HOUSING, INC. d/b/a ACHA No. 2014005903 COURTENAY SPRINGS VILLAGE ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but_must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter! 20, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form 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 fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged 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 18 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. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) Thereby certify that | am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 19

Docket for Case No: 14-005238