STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2012013691 v. Return Receipt Requested: 7009 0080 0000 0586 6140 PIONEER ADULT RESIDENTIAL FACILITY, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Pioneer Adult Residential facility (hereinafter “Pioneer Adult Residential Facility”), pursuant to Chapter 429, Part I, 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 Section 429.19(2)(b), Florida Statutes (2012), for the protection of the public health, safety and welfare and $500.00 survey fee pursuant to Section 429.19(7), Florida Statutes (2012). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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, Florida Statutes (2012), and Chapter 58A-5, Florida Administrative Code. 5. Pioneer Adult Residential Facility operates a 111-bed assisted living facility located at 2166 S.w. 14° Terrace, Miami, Florida 33145. Pioneer Adult Residential Facility is licensed as an assisted living facility license number AL3868, with an expiration date of 6/05/2014. Pioneer Adult Residential Facility 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 PIONEER ADULT RESIDENTIAL FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION SECTION 429.28, Florida Statutes, and/or Rule 58A-5.0182(1) (6), Florida Administrative Code (RESIDENT CARE-RIGHTS & FACILITY PROCEDURES -SUPERVISION) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 9/24/2012 and based on observation, interview and record review, it was determined that the facility failed to provide adequate 2 staffing for supervision of 4 out of 7 (SR#1, SR#2, SRH#3, & SR#4) sampled residents. 8. A record review of the facility's adverse incident reports, revealed a full adverse incident report (15-days) on SR#1. It's recorded in the report that on 04/30/2012 at 9:30 PM, staff #1 heard a scream coming from the side patio area. Staff #1 went to the side patio where she discovered that SR#1 was urinating in the side bushes when SR#4 attacked and attempted to rape her. Further review of the facility's adverse incident reports revealed a 1 day electronic incident report on SR#2. It's recorded in the report that on 09/18/2012 at 3 AM, staff #2 found SR#2 outside in the back of the building bleeding. According to the report, SR#6 told staff #2 that he saw SR#3 having sex with SR#2. The police was called, SR#2 was taken to the emergency room and SR#3 admitted to having sex with SR#2 and he was arrested. 9. On 09/24/2012 at 11:33 AM, an interview was conducted with the Administrator. When asked to provide a description of the incident that occurred on 04/30/12 at 9:30 PM, the Administrator said: "We have been talking to her a couple of times about urinating on the patio. I think when she had her panties off, he was trying to help her pull them up and get up." The Administrator said that SR#1 has a history of urinating outside. "She sits outside a lot and holds it at the last minute and constantly goes outside." When asked to provide a description of the incident that occurred on 09/18/2012 at 3:00 AM, the Administrator reiterated what was in the incident report and stated that SR#2 "did have some bites, human, on her body. I think one of the bites were on one of her breast." 10. A review of the facility's staffing scheduled revealed that 13 out of the 18 employees work the day shift and 3 out of the 18 employees are scheduled to work three separate night shifts: staff #1 works Mondays - Thursdays from 4 PM - 12 midnight, staff#2 works Tuesdays - Fridays from 12 midnight to 9 AM, & staff#3 works Fridays - Sundays from 4 PM - 9 AM. 11. An interview with staff#2 on 09/24/2012 at 2:52 PM, revealed that on 09/18/2012 at 1 AM, two hours prior to the sexual assault committed against SR#2 by SR#3, staff#2 had observed SR#3 in the facility's activity room screaming and making noise. Staff #2 said SR#3 had communicated to him that he was hearing voices and that he had a headache. In response, staff #2 talked with SR#3 and gave him an aspirin. Two hours later on 09/18/2012 at 3 AM, staff#2 said that SR#6 came to the office door and told him that SR#2 was lying in the back bleeding and needed help, that he saw SR#3 having sex with SR#2. At that moment, staff #2 said that he went to the location and saw SR#2 lying on the floor with her head against the wall, he then called 911. Staff #2 said that SR#3 have gotten irritated a couple of times before and that SR#3 has "an angry side to him." 12. A record review of SR#3's file revealed that he was admitted to the facility on 01/23/2012 with a diagnosis of SCPT/CAD/GERD/HTN/DM/Colitis. A review of the progress notes in SR#3's file revealed that on 07/09/2012, SR#3 "was aggressive with 4 the home health nurse, refused services from her". SR#3 was later Baker Act on 07/09/2012 and returned to the facility on 07/10/2012. A review of the Certificate of Professional Initiating Involuntary Examination document dated 07/09/2012, revealed the psychiatrist's observation of SR#3 as "psychomotor agitation/delusional/paranoia, patient requires hospitalization for protection of self and others ...bizarre and unpredictable " A review of SR#3's Mental Health Annual Community Living Support Plan dated 04/10/2012 revealed that the facility will monitor SR#3's mental health status and will notify the physician of any changes in behavior. A review of SR#3's Resident Service Plan for Assistive Care Services dated 01/26/2012 revealed in the section title ‘Observing Resident's Appearance and Well-being' that, "staff will be aware of resident normal base line in order to respond appropriate when devastation occurs." 13. An interview was conducted with the Administrator and the Assistant Administrator on 09/24/2012 at 3:10 PM. When questioned about the written statement in SR#3's Mental Health Annual Community Living Support Plan regarding the monitoring of SR#3's mental health status, The Assistant Administrator said "Every day he would come to the office, we would see him, he has a nurse for the insulin ...He never had an incident where anyone came to complain." The administrator response was, "Never notice any change in behavior ...once we see there is a change we log it in the progress notes. We call the psychiatrist right away." 14. On 09/24/2012 at 3:26 PM, when question about the written statement recorded in SR#3's Resident Service Plan regarding SR#3's base line, the assistant administrator said SR#3's base is quiet, tranquil and peaceful. The administrator response was, "we immediately goes to the progress notes and will call the doctors (psychiatrist & medical)." 15. A record review of SR#3's file did not reveal any documentation that showed that on 09/18/2012 at 1 PM, that the facility had responded appropriately "when devastation occurs" as recorded in SR#3's Resident Service Plan for Assistive Care Services or documentation that showed SR#3's physician was immediately notified when staff #2 observed him in the activity room screaming and making noise, and hearing voices two hours before SR#3 had beaten and sexually assaulted SR#2. 16. Based on the foregoing, The Pioneer Adult Residential Facility violated Section 429-28, Florida Statutes, and/or Rule 58A-5.0182(1) (6), Florida Administrative Code, a Class I deficiency, which carries, in this case, an assessed fine of $10,000.00. SURVEY FEE Pursuant to Section 429.19(7), Florida Statutes, AHCA may assess a survey fee of $500.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $10,000.00 against Pioneer Adult Residential Facility ALF on Count I, for the violation cited above. c. Assess a survey fee of $500.00 against Pioneer Adult Residential Facility ALF, pursuant to Sections 429.19(7), and 429.19(2) (a), Florida Statutes (2012). D. 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 and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 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. ria Lawton-Russell Assistant General Counsel Agency for Health Care Administration 8333 NW 53%? Street Suite 300 Miami, Florida 33166 (305) 718-5907 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 N.W. 53°? Street, Room 300 (Inter-office 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 Ada C. Leyva Administrator, Pioneer Adult Residential were 2166 S.W. 14% Terrace, Miami, Florida 33145 by Mall Tria Lawton-Russell on y 2013. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Pioneer Adult Residential Facility AHCA No. 2012013691 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed 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 must be returned by mail or by fax within 21 days of the day you receive the attached Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed 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 (2008) and Rule 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. Phone: 850-412-3630 Fax: 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 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 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 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 Administrative Complaint, and I request a formal hearing (pursuant to Subsection 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 administrative 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. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC 7009 o080 0000 O54b b140 13. Also complete COMPLETE THIS SECTION ON: DELIVERY. A. Signature ‘ery is desired. x © Agent lress on the reverse O Addressee > card to you. B. Received by (Printed Name, G, Date of Deli ack of the mailpiece, (D vi ; O me 74 a postage Loren) ermits. LE Certified Fee Postmark Return Receipt Fee Here (Endorsement Required) Restricted Delivery Fee (Endorsement Required) K 0 [0229 ite D. Is delivery address different fram item 12 Yes If YES, enter delivery address below: No . Service Type EX ortiioa Mail OC Express Mail 7 3 3 A AL, a Oo Registered &Retum Receipt for Merchandise , ‘O Insured Mail (1 6.0.0. 4, Restricted Delivery? (Extra Fee) roo9 ooo OOOO 0586 nag PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 !

Docket for Case No: 14-000153

Orders for Case No: 14-000153