13-003273 Five Star Premier Residences Of Hollywood vs. Agency For Health Care Administration Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Tuesday, February 11, 2014.

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

SNH SE TENANT TRS, INC. d/b/a 2014 MA YIb A 8= 54

FIVE STAR PREMIER RESIDENCES

OF HOLLYWOOD,

Petitioner, AHCA NO.: 2013008373

vs. DOAH NO.: 13-3273

STATE OF FLORIDA, AGENCY FOR RENDITION NO.: AHCA· ILf

HEALTH CARE ADMINISTRATION,

Respondent

-----------------_./

FINAL ORDER

Having reviewed the Statement of Deficiencies, and all other matters of record, the Agency for

Health Care Administration finds and concludes as follows:

1. The Agency has jurisdiction over the above-named Petitioner pursuant to Chapter 408,

Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions.

2. The Agency issued the attachedStatement of Deficiencies to the Respondent. (Ex. 1)

3. The Petitioner requested a formal hearing to challenge the Agency's findings.

4. The parties have since entered into the attached Settlement Agreement. (Ex. 2)

Based upon the foregoing, it is ORDERED:

1. The Settlement Agreement is adopted and incorporated by reference into this Final Order.

The parties shall comply with the terms of the Settlement Agreement.

2. The Petitioner's petition for a formal administrative hearing is withdrawn.

ORDERED at Tallahassee, Florida, on this Dctayof ,2014.

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled to judicial review, which shall be

instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy,

along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district

where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be

conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30

days of rendition of the order to be reviewed.

CERTIFICATE OF SERVICE

I CERTIFY that a true and correct-wpy of this Final Orde was served on the below-named

persons by the method designated on this of c:1. ,2014.

Richard Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Bldg. #3, Mail Stop #3

Tallahassee, Florida 32308-5403

Telephone: [phone]

Jan Mills Finance & Accounting

Facilities Intake Unit Revenue Management Unit

(Electronic Mail) (Electronic Mail)

Lourdes A. Naranjo, Senior Attorney Thomas W. Caufman, Esq.

Office of the General Counsel Quintairos, Prieto, Wood & Boyer, P.A.

Agency for Health Care Administration 4905 West Laurel Street

(Electronic Mail) Tampa, Florida 33607

(U.S. Mail)

Edward T. Bauer

Administrative Law Judge

Division of Administrative Hearings

(Electronic Mail)

PRINTED: 11/21/2013

FORM APPROVED

Aaencv for Health Care Administration

STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: _ COMPLETED

AL11953616 B.WING 05/16/2013

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

FIVE STAR PREMIER RESIDENCES OF HOLLY 2480 HOLLYWOOD, NORTH PARK FL 33021 ROAD

(X4)ID (EACH SUMMARY DEFICIENCY STATEMENT MUST BE OF PRECEDED DEFICIENCIES BY FULL ID (EACH PROVIDER'S CORRECTIVE PLAN ACTION OF CORRECTION SHOULD BE COMPLETE (X5)

PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX CROSS-REFERENCED TO THE APPROPRIATE DATE

TAG TAG DEFICIENCY)

A 000 Initial Comments A 000

Surveyor: 28825

An Assisted living Facility Complaint inspection

survey CCR# 2013002354 was conducted on

05/16/2013. The Five Star Premier Residences

of Hollywood Assisted Living Facility had no

deficiencies found at the time of the visit related

to this allegation. Deficient practice was identified

at the time of the survey unrelated to the

complaint.

A 152 58A-5.023(3) FAC Physical Plant - Safe living A 152

Environ/Other

(3) OTHER REQUIREMENTS.

(a) All facilities must:

1. Provide a safe living environment pursuant to

Section 429.28(1)(a), F.S.; and

2. Must be maintained free of hazards; and

3. Must ensure that all existing architectural,

mechanical, electrical and structural systems and

appurtenances are maintained in good working

order.

(b) Pursuant to Section 429.27, F.S., residents

shall be given the option of using their own

belongings as space permits. When the facility

supplies the furnishings, each resident bedroom

or sleeping area must have at least the following

furnishings:

1. A clean, comfortable bed with a mattress no

less than 36 inches wide and 72 inches long, with

the top surface of the mattress a comfortable

height to ensure easy access by the resident;

2. A closet or wardrobe space for hanging

clothes;

3. A dresser, chest or other furniture designed for

storage of personal effects;

4. A table, bedside lamp or floor lamp, and waste

basket; and

5. A comfortable chair, if requested.

AHCA Form 3020-0001 TITLE (X6) DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM 6899 8GJI11 If continuation sheet 1 of 4

EXHIBIT 1

PRINTED: 11/21/2013

FORM APPROVED

Aaencv for Health Care Administration

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLlER/CLlA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: _ COMPLETED

AL11953616 B.WING 05/16/2013

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

FIVE STAR PREMIER RESIDENCES OF HOLLY HOLLYWOOD, 2480 NORTH PARK FL 33021 ROAD

(X4)ID (EACH SUMMARY DEFICIENCY STATEMENT MUST BE OF PRECEDED DEFICIENCIES BY FULL ID (EACH PROVIDER'S CORRECTIVE PLAN ACTION OF CORRECTION SHOULD BE COMPLETE (X5)

PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX CROSS-REFERENCED TO THE APPROPRIATE DATE

TAG TAG DEFICIENCy)

A 152 Continued From page 1 A 152

(C) The facility must maintain master or duplicate

keys to resident bedrooms to be used in the

event of an emergency.

(d) Residents who use portable bedside

commodes must be provided with privacy during

use.

(e) Facilities must make available linens and

personal laundry services for residents who

require such services. Linens provided by a

facility shall be free of tears, stains and not be

threadbare.

This Statute or Rule is not met as evidenced by:

Surveyor: 28825

Based on observation, interview and record

review, the facility failed to provide a safe

environment, free from hazards. As evidenced by

facility failure to prevent resident access to

construction areas on the facility grounds.

The findings include:

During a tour of the facility on 5/16/2013 at

approximately 12:00 PM with the Administrator

and Corporate Attorney, residents were observed

ambulating with rolling walkers throughout the

facility and going outside to the front of the

building. The complex was undergoing

renovation. Multiple buildings were covered with

scaffolding engulfing them completely. The

demolition construction on the buildings was very

loud and construction vehicles were coming and

going throughout the facility parking lots and the

facility entrance. Construction debris was noted in

AHCA Form 3020-0001 6899

STATE FORM 8GJI11 If continuation sheet 2 of 4

PRINTED: 11/21/2013

FORM APPROVED

Aaencv for Health Care Administration

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: _ COMPLETED

AL11953616 B.WING 05/16/2013

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

FIVE STAR PREMIER RESIDENCES OF HOLLY 2480 HOLLYWOOD, NORTH PARK FL 33021 ROAD

(X4)ID (EACH SUMMARY DEFICIENCY STATEMENT MUST BE OF PRECEDED DEFICIENCIES BY FULL ID (EACH PROVIDER'S CORRECTIVE PLAN ACTION OF CORRECTION SHOULD BE COMPLETE (X5)

PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX CROSS-REFERENCED TO THE APPROPRIATE DATE

TAG TAG DEFICIENCY)

A 152 Continued From page 2 A 152

the parking lots.

During the tour inside the facility, the main

resident elevators were observed. During an

interview with the Administrator at 12:40 PM on

05/16/13, she stated the facility had put up an

enclosure fence for safety, which prevents

resident access to the lakes edge. She stated

that due to the renovation construction, the

benches along the sidewalk had been removed.

The surveyor observed scaffolding on the entire

building next to the lake enclosed area. A white

metal fence was observed to enclose the lake

walkway and building frontage. Key pad access

was noted on the outside entrance gates coming

int%ut of this gated area. The Administrator

stated that the residents would need to know the

pass code to enter or leave this enclosed area

when outside the building. She stated that due to

the renovation, residents should not have access

to the construction area due to safety concerns.

On 5/16/2013 at approximately 3:30 PM the

surveyor observed that a section of the metal

fence enclosure around the lake walkway, (next

to the front parking lot) was missing. The keypad

and gate remained intact but the lake area had

open access due to the missing fence section.

An interview was conducted with the

Administrator and Executive Director on 05/16/13

at 3:40 PM, inquiring about the enclosed lake

front area. They stated the fenced enclosure

provided safety for the residents. The

Administrator, Executive Director, Regional

Director of Operations and surveyor observed the

section of the fence that had been removed. The

Executive Director stated she was not aware that

the fencing had been removed and immediately

went to speak with the construction foreman. She

stated that the area was a construction site and

AHCA Form 3020-0001

STATE FORM 6899 8GJI11 If continuation sheet 3 of 4

PRINTED: 11/21/2013

FORM APPROVED

Aaencv for Health Care Administration

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: _ COMPLETED

AL11953616 B. WING 05/16/2013

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

FIVE STAR PREMIER RESIDENCES OF HOLLY 2480 HOLLYWOOD, NORTH PARK FL 33021 ROAD

(X4)ID (EACH SUMMARY DEFICIENCY STATEMENT MUST BE OF PRECEDED DEFICIENCIES BY FULL ID (EACH PROVIDER'S CORRECTIVE PLAN ACTION OF CORRECTION SHOULD BE COMPLETE (X5)

PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX CROSS-REFERENCED TO THE APPROPRIATE DATE

TAG TAG DEFICIENCy)

A 152 Continued From page 3 A 152

should be closed off to prevent injury. The ground

surrounding the open section of fence, was

observed to be uneven, rocks and construction

debris littered the pathway. Due to the fence

removal, the enclosure did not provide protection

for the vulnerable elderly residents since access

could be achieved to both the lakes edge and

construction site.

Class III

AHCA Form 3020-0001

STATE FORM 6899 8GJI11 If continuation sheet 4 of 4