STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2015006008 SNH SE TENANT TRS, INC, d/b/a SEASONS BY RIVIERA, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, SMH SE Tenant TRS, Inc. d/b/a Seasons by Riviera( the “Respondent”), pursuant to Section 120.569 and 120.57, Florida Statutes (2014), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s assisted living facility license and impose an administrative fine in the amount of $2,000.00 based upon one Class II deficiency. PARTIES 1. 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. 2. The Respondent operates a licensed assisted living facility located at 515 Tomoka Avenue, Ormond Beach, Florida 32174 and was at all times material required to comply with all applicable state and federal rules and statutes. COUNTI SUPERVISION 3. 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 58A-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. 4. On or about May 21, 2015, the Agency conducted a complaint survey of the Respondent. 5. Based on record review and staff interviews, the facility failed to provide care and services appropriate to the needs and have an awareness of the general health of 1 of 3 sampled residents (Resident #1). This resulted in Resident #1's toe being amputated. 6. The followings facts were observed during the above referenced survey: wea Record review for Resident #1 revealed a 92 year old female admitted on 2/12/15. Her diagnosis included dementia. Review of the Health Assessment (1823) dated 2/10/15 revealed she was alert with periods of confusion, needed supervision with bathing and dressing, required set up for meals, and used walker to ambulate independently. A review of the Resident #1's care note written by the Executive Director (ED) dated 3/31/15 at 7:30 am revealed Resident #1 was found to have a swollen second toe on her right foot and complained of mild pain. The resident stated she had stubbed her toe. Upon examination of the toe, it was found to have a cloth wrapped around the base of the toe. The resident stated she had wrapped up the toe. The documentation showed that Resident #3's toe was red, but the top of her foot was pink and warm to the touch. The ED documented that the cloth appeared to be cutting off the circulation and there was an open area on the underside of the toe. A loose gauze dressing was applied and documented he would evaluate later. Also the toe was red but top of the foot was pink and warm to touch. An interview was conducted with the ED on 5/21/15 at 1:18 pm. When asked when he first became aware of Resident #1's toe being red and sore, he stated the medication technician (MT) (Employee A) had told him on 3/26/15. He reported that she told him Resident #1 had stubbed her toe and it was red and slightly swollen. The ED stated that he got busy and did not go and observe Resident #1's toe on 3/26/15 .He stated that the facility did not have a nurse at the time of the incident; however, he was a Licensed Practical Nurse (LPN) and was able to evaluate the residents. The ED stated that he came in early on the morning of 3/31/15 around 7:15 am. The caregiver on duty told him that he needed to look at Resident #1's toe on her right foot. The ED stated that when he observed Resident #1's second toe on her right foot, he found a piece of cloth wrapped tightly around the base of the second toe. He reported that the cloth was so tight; it appeared to cut off the circulation and stated that the toe was twice the size of the big toe with pus and blood observed. The ED stated that he applied a dressing and told the resident she should stay in bed. The ED stated that he left the facility and instructed the caregiver to observe Resident #1 and notify him if there were any changes. He stated that Employee A called him mid- morning and reported that the dressing had drainage and the toe was more swollen. The ED reported that a new Resident Care Director (RCD) had started on 3/31/15 and that he called her to request that she examine Resident #1's toe and decide what needed to be done. The ED reported that the RCD observed Resident #1's toe and sent Resident #1 to the emergency room for evaluation. The ED stated that he took responsibility for not seeing the resident when he was first told by the staff of the injury. He was asked if he had notified the physician or family, he stated "no. An interview was conducted with Employee A (MT) on 5/21/15 at 2:12 pm. She reported that she had been told by Employee B (caregiver) about the condition of Resident #1's toes on her right foot. Employee A reported it was 3/25/15 when the Employee B showed her the resident's toe. Employee A stated Resident #1's toe was slightly red and swollen. Resident #1 told Employee A that she had stubbed her toe and it was hurting. Resident #1 stated that she could not put her shoe on. When asked if she reported the injury, Employee A stated that she informed the ED and asked him to look at Resident #1's toe. She stated the facility did not have a nurse on staff at that time; however, the ED was a LPN. She stated that on 3/31/15 Resident #1 was sent to the hospital. Employee A reported that Employee B came to her on 3/31/15 and reported that Resident #1's toe was worse and needed attention. She stated she contacted the ED and told him he needed to look at Resident #1's toe. Employee A then said, when the ED looked at the toe on 3/31/15, it looked bad with drainage and bleeding. . Review of the hospital records for Resident #1 revealed she was seen on 3/31/15 for right second toe edema, redness and drainage of wound. An X-ray taken of Resident #1's right foot showed extensive osteomyelitis (bone infection). The hospital records revealed that Resident #1 was diagnosed with ulceration (open wound to the skin) of the second right toe with extensor tendon showing and underneath that, bone exposure. A consultation dated 4/1/15, assessed Resident #1's condition and read that "surgical intervention would be the best" and recommended partial to total amputation of Resident #1's second toe on her right foot. 7. Respondent’s actions constitute a Class II deficiency. 8. 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 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. § 408.813(2)(a), Fla. Stat. (2014). 9. 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. § 429.19(2)(b), Fla. Stat. (2014). Wherefore the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $2,000.00. s/ John Bradley John E. Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North, Ste. 330D St. Petersburg, Florida 33701 Telephone: (727) 552-1944 Facsimile: (727) 552-1440 John.Bradley@ahca.myflorida.com 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 Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this 23" day of September 2015. 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 North, Ste. 330D St. Petersburg, Florida 33701 Telephone: (727) 552-1944 Facsimile: (727) 552-1440 John.Bradley@ahca.myflorida.com wee =< Rob Dickson, Field Office Manager Local Field Office Agency for Health Care Administration (Electronic Mail) Blake Breedlove Administrator Seasons by Riviera 515 Tomoka Avenue Ormond Beach, Florida 32174 US. Certified Mail - (7008-0500 0001 9503 9645) Catherine Avery, Unit Manager Licensure Unit Agency for Health Care Administration (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Seasons by Riviera AHCA No. 2015006008 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. | 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. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: : Title: ).. SENDER: COMPLETE THIS SECTION f PETES j98)

Docket for Case No: 15-005878