STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2015010380 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 (2015), 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 $25,000.00 based upon two Class I deficiencies, one class II deficiency and a survey fee in the amount of ($500.00). 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 I, 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. COUNT I 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 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 September 17, 2015, the Agency conducted a complaint survey of the Respondent. 5. Based on interview and record review, the facility failed to provide the care and service, including but not limited to supervision, appropriate to 1 of 4 sampled residents (Resident #1) when the resident sexually abused another resident. The Respondent was aware of _.quantity_and_quality of resident diets in accordance with Rule 58A-5.020, F.A.C._(b)_Daily_ we the resident #1 propensity for aggressive sexual behavior and failed to take reasonable steps to prevent harm to other residents. The ED failed to put interventions in place to provide supervision of Resident #2 after prior knowledge and incidents’ involving Resident #2 's sexual acting out. The ED also then falsified records to cover up the assault, failed to seek medical care for Resident #1 after the assault, failed to report the assault to the responsible parties for Resident #1 and Resident #2 and failed to report the assault to the authorities for investigation. 6. The followings facts were observed during the above referenced survey: 1- On 8/14/2015 at 2:04 PM, an interview was conducted with the ED. The ED stated that the previous administrator accepted Resident #2 for admission to the facility knowing Resident #2's history of being overly affectionate with the female residents during a prior stay at a different facility. The ED stated no plan was put in place to address Resident #2's behaviors toward female residents and there was no plan to keep female residents safe. On 8/13/2015 at 3:31 PM, an interview was conducted with Staff C. Staff C stated that Resident #2. was moved from another area of the facility due to his sexual advances toward a female resident in that part of the facility. StaffC stated when Resident # 2 was moved, no plan was put In place to monitor Resident #2's behaviors toward female residents. On 8/14/2015 at 1:34 PM, an interview was conducted with Resident #2' s treating physician. He stated that he was Resident #2's doctor at a previous facility. He stated that Resident #2 acted out sexually at the other facility. He stated that Resident #2's behavior has been consistent. He stated that the previous facility tried to keep him separate from the female residents because Resident #2 touched and kissed the female residents. On 8/24/2015 an interview was conducted with Staff A who verified that Resident #2 was moved May 5,2015 to another area of the facility as a result of his aggressive sexual behavior towards female residents. In addition, the transfer of room was completed without putting a plan in place to protect female residents in the area of the facility where Resident #2 now resided. On 8/19/2015 at 3:11 PM, an interview was conducted with both Staff F and Staff G. They both confirmed that Resident #2 was moved to a different area in the facility because of his aggressive and sexual behavior with a female resident. Staff F and Staff G-stated that the ED failed to be proactive in addressing the issues relating to Resident # 2's behavior with the female residents in the facility. Both stated that no plan was implemented to secure the safety of the female residents. On 8/14/2015 at 3:11 PM, an interview was conducted with Staff A. Staff A stated that she prepared a handwritten report regarding an incident involving Resident # 2 having sexual contact with Resident #1 and placed the report under the ED's office door. Staff A stated the ED was supposed to rewrite the report with Staff A. Instead, the ED re-wrote the incident report without Staff A leaving out the details of the incident. Staff A stated that the ED presented the re-written incident report for Staff A to sign. Staff A stated that the ED completed the form without her leaving out the information that Resident B admitted to sexually touching Resident A. On 8/14/2015 at 1:15pm, an interview was conducted with the Executive Director (ED). The ED admitted to writing the report without the assistance of Staff A., the caregiver on duty when the incident occurred. On 8/14/2015 at 1:15pm the ED admitted throwing away the original handwritten incident report submitted by the caregiver- Staff A. (See photographic evidence of the note written by Staff A.) The ED was asked why the original handwritten incident report was thrown out. The ED responded that the handwritten statement was “inappropriate.” In addition, the ED admitted he re-wrote the incident report without the assistance of Staff A. “=== On 8/13/15 and 8/14/2015 the original hand written incident report was reviewed. This rep completed by Staff revealed that Resident #2 admitted to having sexual contact with Resident #1. The report completed by the ED stated only stated that Resident #2 was found in bed with Resident #1 wearing his boxer and a T-shirt. On 8/13/2015, a review of Resident #1's record was conducted. The record dated 8/8/2015 revealed that the ED attempted to call Resident #1's medical doctor on Saturday 8/8/2015 at 09:30 AM. The ED wrote the doctor's recorded message suggested he call on Monday when the office was opened. Further review of the file revealed no additional attempts were made to re-contact Resident #1's doctor to inform him of the possible sexual assault. On 8/13/2015, a review of the nurse notes in Resident #1's file was conducted. A note dated 8/11/2015 revealed that Staff F performed a visual assessment of Resident #1's vaginal area. Per the notes, Staff F stated no trauma or bruising was observed. This assessment was completed 4 days after the incident. In an interview conducted on 8/13/2015 at 10:05 AM with Staff F, Staff F revealed that the ED ordered the assessment. Staff F stated no follow-up was completed with Resident #1's primary physician. In addition, Staff F stated that it was the ED's decision to not file an adverse incident report with the agency or notify the Department of Children and Families (DCF) regarding the possible sexual assault by Resident #2 to Resident #1. On 8/14/2015 at 2:04 PM, an interview was conducted with the ED. He admitted not filing an adverse incident report to the agency because "no physical assault occurred" and Resident # 1 denied anything happened to her. When asked how he would know there wasn't a physical assault if Resident # 1 was never examined by a physician, the ED stated "Resident #1 welcomed Resident #2 into her bedroom”. He also admitted not contacting the Department of Children and Families or law enforcement because Resident # 1 "consented" by allowing Resident #2 into her room. On 8/19/2015 at 3:19 p.m., an interview was conducted with Staff.F and Staff G. Both Staff F and Staff G stated that the ED has not been honest with the residents ‘family members. He failed to tell them that Resident #2 admitted to sexually touching Resident #1. 7. Respondent’s actions constitute a Class I deficiency. 8. Class “T” 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. (2015). 9. Under Florida law, the Agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. § 429.19(2)(a), Fla. Stat. (2015). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $10,000.00. Count I Resident Rights 10. Florida Administrative Code Rule 58A-5.0182(6) states in pertinent part: Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of Residents accepted for admission to the facility. (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible Resident area, and included in the admission package provided pursuant to Rule 58A- 5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to Resident complaints, and for Residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible to all Residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1(888)831-0404; the Advocacy Center for Persons with Disabilities, 1(800)342-0823; the Florida Local Advocacy Council, 1(800)342-0825; and the Agency Consumer Hotline 1(888)419-3456. (d) The statewide toll-free telephone number of the Florida Abuse Hotline “1(800)96-ABUSE or 1(800)962-2873” shall be posted in full view in a common area accessible to all Residents. Section 429.28 Florida Statutes states in pertinent part: ~~~ Resident bill of rights. — (1) No Resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a Resident of a facility. Every Resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. RR (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the Residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. (2) The administrator of a facility shall ensure that a written notice of the rights, obligations, and prohibitions set forth in this part is posted in a prominent place in each facility and read or explained to Residents who cannot read. This notice shall include the name, address, and telephone numbers of the local ombudsman council and central abuse hotline and, when applicable, the Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council, where complaints may be lodged. The facility must ensure a Resident’s access to a telephone to call the local ombudsman council, central abuse hotline, Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council. (3)(a) The agency shall conduct a survey to determine general compliance with facility standards and compliance with Residents’ rights as a prerequisite to initial licensure or licensure renewal. (b) In order to determine whether the facility is adequately protecting Residents’ rights, the biennial survey shall include private informal conversations with a sample of Residents and consultation with the ombudsman council in the planning and service area in which the facility is located to discuss Residents’ experiences within the facility. (c) During any calendar year in which no survey is conducted, the agency shall conduct at least one monitoring visit of each facility cited in the previous year for a class I or class II violation, or more than three uncorrected class HI violations. (d) The agency may conduct periodic followup inspections as necessary to monitor the compliance of facilities with a history of any class J, class II, or class III violations that threaten the health, safety, or security of Residents. (e) The agency may conduct complaint investigations as warranted to 11. Respondent. 12. of 4 sampled residents (Resident#1) from sexual abuse by another resident (Resident #2) with a known history of aggressive sexual behavior. The facility also failed to report the abuse to authorities and seek follow up care for Resident #1 after the abuse. Failure to address abuse to ~ investigate any allegations of noncompliance with requirements required © = under this part or rules adopted under this part. (4) The facility shall not hamper or prevent Residents from exercising their rights as specified in this section. 8 He (7) Any person who submits or reports a complaint concerning a suspected violation of the provisions of this part or concerning services and conditions in facilities, or who testifies in any administrative or judicial proceeding arising from such a complaint, shall have immunity from any civil or criminal liability therefor, unless such person has acted in bad faith or with malicious purpose or the court finds that there was a complete absence of a justiciable issue of either law or fact raised by the losing party. On or about September 17, 2015, the Agency conducted a complaint survey of the Based on observation, interview and record review, the facility failed to protect 1 residents places all residents in the facility at immediate risk of harm. 13. The following facts were observed during the above referenced survey: 1. A review of Resident # I's resident record revealed that she was diagnosed with dementia. A cognitive assessment completed on 4/16/2015 revealed that Resident #1 suffers from short and long term memory loss, a lack of orientation to home and impaired decision making ability. 2. A review of Resident #2's resident record revealed that he was diagnosed with senile dementia and a history of prostate cancer. 3. On 08/13/2015 at 2:04 p.m., an interview was conducted with the Executive Director (ED). The ED stated that he was called around 11:48 PM on 8/7/2015 and was told that Resident #2 was found in the room and in the bed of Resident #1. The ED further stated he contacted family members of Resident #1 and #2 on 8/8/2015. The ED stated that during an interview with Resident #1 and her family member; Resident 1 denied any sexual contact with Resident #2 and stated that they were just friends. The ED stated girlfriend (Resident #1) and that she invited him into her room. Additionally, during the same interview on 8/13/2015, the ED stated that a week earlier, Resident #2 attempted to kiss Resident #1. The ED stated that Resident #1 would not allow the kiss from Resident #2. 4.) On 8/13/2015 at 3:31 PM, an interview was conducted with Staff C. She stated that she was told that Resident #2 was found in bed with Resident #1. Staff C described Resident #2 as being aggressive and combative and "is always kissing and touching on the female residents." 5) ) On 8/14/2015 at 8:29 AM, an interview was conducted with Staff A. Staff A stated that on 8/7/2015 at approximately 11:00 PM, she observed Resident #2 leaving his room. Resident #2 stated that he was going to the bathroom. After a 5 minute time lapse, Staff A noticed that Resident #2 had not been seen returning to his bedroom. Around 11:25 PM, after a search, Staff A found Resident #2 in bed with Resident #1 in Resident #1's room wearing only his boxer shorts and a T-shirt. Resident #2 was directed to get out of Resident #1's bed and return to his room. Staff A stated when Resident #1 was asked what happened, Resident #1 stated Resident #2 put his penis in her vagina. Staff A stated that Resident #2 was questioned about the incident and he confirmed there was a sexual contact but stated he used his hands and not his penis. Staff A stated that the ED was notified by telephone and Resident #2 was put on observation at 15 minute intervals. During a continuation of the interview on 8/14/2015 at 3:11 PM , Staff A stated although Resident #2 was put under staff observation and 15 minute checks, Resident #2 continued to try and enter Resident #1's bedroom. Staff A stated on one such attempt, Resident #2 became violent, pushing Staff A and then pinning Staff A up against a wall. Staff A stated that Resident #2 has a tendency to take female residents' hand and place them on his genital area. 6.) On 8/13/2015 at 3:31 PM, an interview was conducted with Staff C. Staff C stated that Resident #2 was moved from another area of the facility due to his sexual advances towards another female resident in the facility. She stated when Resident # 2 was moved, no plan was put in place to monitor Resident #2's behaviors towards female residents. 7.) On 8/14/2015 at 2:48 p.m., an interview was conducted with Staff B. Staff B stated that she was advised of the incident in which Resident #2 was found in the bed with Resident #1. Staff B stated that Resident #2 "acts like he can do whatever he wants.” She stated about Resident #2 that he has a "problem with sexual things." Staff B stated when Resident #2 lived on the other side of the facility, Resident # 2 was after another female resident. Staff B stated it took numerous complaints before the ED took any action to prevent the abuse towards the other female resident. Staff B stated that although Resident #2 was moved, no plan was implemented to prevent further unsolicited sexual advances by Resident #2 toward female residents. continued to kiss and touch on the female residents. In addition, Staff B stated that Resident #2 got into physical altercations with other male residents at least two times because he didn't want them speaking to a female resident that he liked. Staff B stated Resident #2 was always sexually acting out by touching the female residents. She stated that resident # 2's family members said that Resident #2 was moved from a previous facility due to his inappropriate sexual behavior toward female residents. 8.) On 8/14/2015 at 1:34 PM, an interview was conducted with Resident #2’s treating physician. He stated that he was Resident #2's doctor at a previous facility. He stated that Resident #2 acted out sexually at the other facility. He stated that Resident #2's behavior has been consistent. He stated that the previous facility tried to keep him separate from the female residents because Resident #2 touched and kissed the female residents. 9.) On 8/14/2015 at 2.04 PM, an interview was conducted with the ED. The ED stated that the previous ED accepted Resident #2 in the facility knowing Resident #2's history of being overly affectionate with the female residents. He admitted no plan was put in place to address Resident #2's behaviors with female residents. 10.) On 8/19/2015 at 3:11 PM, an interview was conducted with both Staff F and Staff G. They both confirmed that Resident #2 was moved to a different area in the facility because of his aggressive and sexual behavior with a female resident. Staff F and Staff G stated that the ED failed to be proactive in addressing the issues relating to Resident # 2's behavior with the female residents in the facility. Both stated that no plan was implemented to secure the safety of the female residents, 11.) On 8/13/2015 at 10:30 AM, an interview was conducted with Staff G. Staff G stated that the ED "is trying to sweep things under the table as though it didn't exist". Staff A stated that the ED was aware Resident #2 would out act out sexually with the female residents. Staff A stated that the ED has not been honest with the residents ' family members as he is trying to protect himself and not the residents. 12.) On 8/13/2015, a review of Resident #1's record was conducted. The record dated 8/8/2015 revealed that the ED attempted to call Resident #1's medical doctor on Saturday 8/8/2015 at 09:30 AM. The ED wrote the doctor's recorded message suggested he call on Monday when the office was opened. Further review of the file revealed no additional attempts were made to re-contact Resident #1's doctor to inform him of the possible sexual assault. 13.) On 8/13/2015, a review of the nurse notes in Resident #1's file was conducted. A note dated 8/11/2015 revealed that Staff F performed a visual assessment of Resident #1's vaginal area. Per the notes, Staff F stated no trauma or bruising was observed. This “assessment was completed 4 days after the incident. ~ In an interview conducted on ~ 8/13/2015 at 10:05 AM with Staff F, Staff F revealed that the ED ordered the assessment. Staff F stated no follow-up was completed with Resident #1's primary physician. In addition, Staff F stated that it was the ED's decision to not file an adverse incident report with the agency or notify the Department of Children and Families (DCF) regarding the possible sexual assault by Resident #2 to Resident #1. 14.) On 8/14/2015 at 2:04 PM, an interview was conducted with the ED. He admitted not filing an adverse incident report to the agency because "no physical assault occurred" and Resident # 1 denied anything happened to her. When asked how he would know there wasn't a physical assault if Resident # 1 was never examined by a physician, the ED stated "Resident #1 welcomed Resident #2 into her bedroom." He also admitted not contacting the Department of Children and Families or law enforcement because Resident # 1 "consented" by allowing Resident #2 into her room. 14. The above referenced facts constitute a Class I deficiency. 15. Class “I” 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. (2015). 16. | Under Florida law, the Agency shall impose an administrative fine for a cited class I violation in an amount not less than $5,000 and not exceeding $10,000 for each violation. § 429.19(2)(a), Fla. Stat. (2015). 17. WHEREFORE, the Petitioner, State of. Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $10,000.00 COUNT II ‘18. Pursuant to Florida law any person who fraudulently alters, defaces, or falsifies ~~~ any medical or other record of an assisted living facility, or causes or procures any such offense to be committed, commits a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083. § 429.49(1), Fla. Stat. (2015). 19. Pursuant to Florida law in addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility, for the actions of any person subject to level 2 background screening under s. 408.809, for the actions of any facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. § 429.19(1), Fla. Stat. (2015). 20. | Onor about September 17, 2015, the Agency conducted a complaint survey of the Respondent. 21. Based on interview and record reviews the facility failed to ensure that the facility documentation related to an incident involving sexual assault of a resident (Resident #1) was accurate and truthful. 22. The following facts were observed during the above referenced survey: On 8/14/2015 at 3:11 PM, an interview was conducted with Staff A. Staff A stated that she prepared a handwritten report regarding an incident involving Resident # 2 having sexual contact with Resident #1 and placed the report under the office door of the Executive Director/administrator (ED). Staff A stated the ED was supposed to rewrite the report with Staff A. Instead, the ED re-wrote the incident report without Staff A leaving out the details of the incident, including the disclosure of both Resident #1 and Resident #2 having sexual contact. Staff A stated that the ED presented the re-written incident report for Staff A to sign. On 8/14/2015 at 1:15 PM, an interview was conducted with the ED. The ED admitted to writing the report without the assistance of Staff A., the caregiver on duty when the incident occurred. On 8/14/2015 at 1:15 PM the ED admitted throwing away the original handwritten incident report-submitted-by the caregiver- Staff A. (See photographic evidence-of the note written by Staff A.) The ED was asked why the original handwritten incident report was thrown out. The ED responded that the handwritten statement was “inappropriate. In addition, the ED admitted he re-wrote the incident report without the assistance of Staff A. On 8/13/15 and 8/14/2015 the original hand written incident report was reviewed. This report stated that Resident #2 had sexual contact with Resident #1. The report completed by the ED stated only that Resident #2 was found in bed with Resident #1 wearing his boxer and a T-shirt. 23. The above referenced facts establish a Class II deficiency. 24. — 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. The agency shall impose an administrative fine as provided by law for a cited class IT violation. A fine shall be levied notwithstanding the correction of the violation. § 408.813(2)(b), Fla. Stat. (2015). 25. 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. (2015). Wherefore the Petitioner, State of Florida, Agency for Health Care Administration, seeks ~~ an administrative fine against the Respondent in the amount of $5,000.00. Count IV Assessment of Survey Fee 26. The Agency re-alleges and incorporates by reference Counts I, II, and, Count III. 27. The Agency received a complaint about the Respondent regarding alleged sexual abuse. 28. In response to the complaint, the Agency conducted a complaint survey of the Respondent on September 17, 2015. 29. As aresult of the complaint survey, the Respondent was cited for violations. — 30. The basis for the violation alleged in this Administrative Complaint relates to the complaint made against the Respondent and its Facility. 31. | Under 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 429.28(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(7), Fla. Stat. (2015). 32. In this instance, the Agency is entitled to assess a survey fee of $500.00 against the Respondent. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose a survey fee against the Respondent in the amount of $500.00. s/ John Bradley John E. Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 13 525 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. ERTIFI ERVIC. 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 14 day of Octoberr 2015. 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 =" 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 . USS. Certified Mail - (701007800001 98357226) 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. 2015010380 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 t 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: a Contact Person: : Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) 1 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: fee ae wah ear - SENDER: COMPLE? HSS ON ON DELIVERY i

Docket for Case No: 15-006181