STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012012979 Return Receipt Requested: v. 7009 0080 0000 0585 8275 SNH SE TENANT TRS, INC. d/b/a FIVE STAR PREMIER RESIDENCES OF HOLLYWOOD , Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against SNH SE Tenant TRS, Inc. d/b/a Five Star Premier Residences of Hollywood (hereinafter “Five Star Premier Residences of Hollywood”), pursuant to Chapter 429, Part I, Chapter 408, Part II, and Section 120.60, Florida Statutes (2012), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $10,000.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2012), for the protection of public health, safety and welfare, and a survey fee in the amount of $500.00 pursuant to Section 429.19(2) (c) and 429.19(7), Florida Statutes (2012). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and Chapter 28-106, Florida Administrative Code (2012). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2012). PARTIES 4... AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Chapter 408, Part II, Florida Statutes (2012), and Chapter 58A-5 Florida Administrative Code (2012). 5. Five Star Premier Residences of Hollywood operates a 200-bed assisted living facility located at 2480 North Park road, Hollywood, Florida 33021. Five Star Premier Residences of Hollywood is licensed as an assisted living facility under license number 5622. Five Star Premier Residences of Hollywood was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I FIVE STAR PREMIER RESIDENCES OF HOLLYWOOD FAILED TO PROVIDE SUPERVISION APPROPRIATE TO THE NEEDS OF A RESIDENT WHICH RESULTED IN DEATH. RULE 5@A-5 -0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE AND SUPERVISION STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Five Star Premier Residences of Hollywood was cited with one (1) Class I deficiency as the result of a complaint investigation survey that was conducted on September 17, 2012 8. A complaint investigation survey -was conducted on September 17, 2012. Based on record review and interview, it was determined that the facility did not provide supervision appropriate to the needs of 1 out of 3 residents (resident #1), which resulted in the death of the resident. The findings include the following. 9. Review of resident #1's record indicated that she was admitted to the facility on 12-16-08 with diagnoses including Alzheimer's disease, depression, hypothyroidism, vertigo, memory loss, and functional decline. Review of the resident's health assessment dated on 3-20-12 indicated that the resident needed a walker to ambulate, needed assistance with ambulation, bathing, dressing and transferring, and she was to receive oversight of her well-being and whereabouts on a daily basis. Further review of the resident's health assessment dated on 3-20-12 indicated that the facility staff began providing daily ambulation and transferring services to the resident on 2-1-11. 10. In an interview with the administrator on 9-17-12 at 1:25pm, she stated that resident #1 was found lifeless floating in the lake by a facility maintenance director on 9-16-12 at approximately 9:30am. The administrator also stated at this time that the resident was last seen when alive by two direct care nursing assistants on 9-16-12 at approximately 5:00am. 11. In an interview by telephone with the nursing assistant on 9-17-12 at 3:00pm, she stated that she last saw resident #1 on 9-16-12 at approximately 5:15am, when she completed assisting another nursing assistant bathe and groom the resident. The nursing assistant also stated at this time that resident #1 was combative while she was assisting the resident in the shower on 9-16-12 to the point that the resident received a laceration on her foot, which was treated by the facility nurse on 9-16-12 at approximately 5:00am, and the resident had calmed down by the time she left the resident sitting on the couch in her room on 9-16-12 at about 5:15am. 12. In an interview by telephone with the direct care nurse on 9-17-12 at 3:30pm, he stated that he began his work shift at 7:00am on 9-16-12. At approximately 9:20am the facility maintenance supervisor alerted all staff over 2-way radio that a resident was found floating in the lake and he immediately responded to the lake which was located on the southern end of the facility. The direct care nurse stated at this time. that when he arrived to the lake on 9-16-12 at approximately 9:25am, him and the maintenance supervisor were the only ones at the scene when he first arrived and he saw a body floating in the lake approximately 12 feet from the shoreline, the fire department (FD) was also. responding to this emergency since they were in the facility dealing with a smoke alarm issue and a FD staff member retrieved the body from the lake. 13. The direct care nurse also stated on 9-17-12 at 3:35pm that the FD staff attempted to revive the person they removed from the lake on 9-16-12, a police officer asked him to identify the person and he identified the person to be resident #1, and resident #1's body was later removed from the facility by a medical examiner staff member on 9-16-12 at approximately 12:30pm. 14. In an interview with the administrator on 9-17-12 at 3:45pm, she stated that resident #1 received private duty aide (PDA) assistance from 1:00pm to 11:00pm every day, the resident was used to going unassisted or unsupervised to the lake most mornings to feed the ducks and on 9-16-12 in the morning hours the PDA was not with the resident. The administrator stated at this time that on the morning of 9-16-12, resident #1 most likely independently transferred and ambulated from her room on the fourth floor of the facility to the first floor southern exit and into the walkway next to the lake to sit by the bench next to the lake, and not knowing how the resident fell from the rolling grassy shoreline into the lake. 15. In an interview with the administrator on 9-17-12 at 3:50pm, she stated that there were no current physician orders to allow resident #1 to transfer or ambulate independently, without supervision or assistance. Review of the resident's record indicated that on 8-27-12 the resident's family provided her with a PDA for 10 hours per day to assist with her activities of daily living. 16. %In an interview with the police detective on 9-17-12 at 4:10pm he stated that he responded to the facility on the morning of 9-16-12 to investigate the accidental death of resident #1, the resident did not have any unusual markings on her body to indicate a struggle with someone else and he did not yet receive the cause of death from the medical examiner's office. 17. %In an interview with resident #1's contact person on 9-17-12 at 4:30pm, she stated that she was hired by the resident's out-of-state family to be the resident's care manager for approximately 4 years, she would usually receive telephone calls from the facility regarding the resident's physician appointments or when the resident was involved in a fall and she was very familiar with the resident's care needs. 18. The resident's contact person stated at this time. that the resident required supervision with transfers and ambulation and that she was called by the facility on 9-16-12 at approximately 9:30am to get the resident's family contact information due to an incident that the facility would not share with her and the resident's family member later that day shared with her. 19. Review of resident #1's record did not indicate that the resident underwent a significant change in condition after her health assessment dated on 3-20-12. Review of a letter from the facility to the resident dated on 2-15-10 indicated that based on an evaluation completed on 2-11-10 the resident's care level needed to be increased from level 1 to level 2 and she was to be charged by the facility $550.00 extra per month due to this increase in care level requirement. 20. Review of the resident's contract with the facility dated on 6-7-12 indicated that the resident was to receive a service care level 2 for an additional $600.00 per month paid to the facility which included ' supportive’ physical assistance with transferring and ambulation. 21. %In an interview with a medical examiner investigator on 9-20-12 at 11:20am, he stated that medical examiner case #1271 represented resident #1's death by accidental asphyxia due to drowning on 9-16-12. 22. Based on the foregoing .facts, Five Star Premier Residences of Hollywood violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $10,000.00. SURVEY FEE Pursuant to Section 429.19(7), Florida Statues (2012), AHCA may assess a survey fee in the amount of $500.00 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. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Five Star Premier Residences of Hollywood on Count I. 2. Assess an administrative fine of $10,000.00 against Five Star Premier Residences of Hollywood on Count I for the violation cited above. 3. Assess a survey fee of $500.00 against. Five Star Premier Residences of Hollywood on Count I for the violation cited above. 4, Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2012). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER Pre cetos Alea aary, Lourdes A. Naranjo, Esq. Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53°¢ Street Suite 300 Miami, Florida 33166 305-718-5609 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Carla Lehman, Administrator, Five Star Premier Residences of Hollywood, 2480 North Park Road, Hol\_ywood, Florida 33021 on this 7. day of Ath , 2013. D022, Coleman, ourdes A. Naranjo, Bat 10 i COMPLETE THIS SECTION ON DELIVERY S$ NDER COMPLETE THIS SECTION U; S. Postal Séivice in, : ‘CERTIFIED:MAILi: RECEIPT. (Domestic ‘Mail: Only; No.Insurance Coverage: Provided) ‘For delivery information: visit-our website at. wwwiusps:com: Postmark Return Rilcelpt Fee (Endersemen ecuech Festrloted DUlivery Fae (Endorsement Required) svc a Achanutin LEV we. Stina. Prvanioar.. or PO Box No, pie. ath Phak Reta Chi, Bias Pe 4 004 0080 0000 0585 8275 PS: Fonin. 3800, “Aiigusit: 2006.

Docket for Case No: 13-001150

Orders for Case No: 13-001150