STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2017006442 Petitioner, Return Receipt Requested: 7013 2250 0001 4950 2809 v. PINEWOOD ESTATES ASSISTED LIVING FACILITY, LLC d/b/a PINEWOOD ESTATES LIVING FACILITY Respondent ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA” or “Agency” or “Petitioner”), by and through the undersigned counsel, and files this administrative complaint against Pinewood Estates Assisted Living Facility, LLC d/b/a Pinewood Estates Assisted Living Facility (hereinafter Pinewood or Respondent or facility), pursuant to Chapter 429, Part I, Chapter 408, Part Il, Chapter 58A-5, Florida Administrative Code, and Section 120.60, Florida Statutes (2015), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,500.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2016), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2016), 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 (2016), and Chapter 58A-5 Florida Administrative Code (2012). 5, Respondent operates a 6-bed assisted living facility located at 4055 Pinewood Road, Melbourne, Florida 32934. Respondent is licensed as an assisted living facility under license number 12678. Respondent 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 (TAG 081) RESPONDENT FAILED TO PROVIDE OR ARRANGE FOR ONE OUT OF FOUR SAMPLED STAFF (C) TO RECEIVE THE MANDATED IN-SERVICE TRAINING RULE 58A-5.0191(2), FLORIDA ADMINISTRATIVE CODE (STAFF IN-SERVICE TRAINING ) UNCORRECTED CLASS III 6. AHCA re-alleges and incorporates paragraphs (1) and (5) as if fully set forth herein. 7. Respondent was cited with deficient practice as a result of a monitoring visit conducted on June 29, 2016. 8. Based on interview and personnel record review the facility did not provide or arrange for 3 of 4 sampled staff (# B and #C) to receive the mandated in-service trainings. 9. Personnel record review for staff # B revealed she was hired 2/01/2016 and was a Licensed Practical Nurse. Continued review revealed no evidence to confirm the staff attended: 1 -hour in-service training regarding Resident Rights in an assisted living facility and Recognizing abuse/neglect and exploitation; 1- hour in -service training regarding nutrition and safe food handling. An in-service training regarding the facility’s resident elopement response policies and procedures; 1 hour in -service training regarding 1. Reporting major incidents. 2. Reporting adverse incidents. and 3. Facility emergency procedures including chain-of-command and staff roles relating to emergency evacuation. 10. Personnel record review for staff # C revealed she was hired 5/20/15 and was an Advanced Registered Nurse Practitioner. Continued review revealed no evidence to confirm the staff attended: 1-hour in-service training regarding Resident Rights in an assisted living facility and Recognizing abuse/neglect and exploitation, a 1 hour in -service training regarding 1. Reporting major incidents. 2. Reporting adverse incidents. and 3. Facility emergency procedures including chain-of-command and staff roles relating to emergency evacuation. 11. Respondent was cited with deficient practice as the result of a follow up to a monitoring visit for an Extended Congregate Care survey which survey was conducted on September 27, 2016. The Agency found that this deficiency remained uncorrected. 12. Based on interview and personnel record review the facility did not provide or arrange for 1 of 4 sampled staff (C) to receive the mandated in-service trainings. 13. During the entrance interview on 9/27/16 at 10 AM the assistant to the facility owner stated that nothing previously cited for staff C, the Advanced Registered Nurse Practitioner (ARNP) was corrected because nothing really needed correcting. She placed a call to the Agency office in Tallahassee as it was her understanding that the Tallassee office was in agreement with her The Agency representative placed a phone call to the local Area office 7, was instructed to return later during the day. 14.‘ During the entrance interview on 9/27/16 at 2 PM the assistant to the facility owner said that staff C who had a PHD (doctorate degree) in nursing and was not doing any of the in-services including Resident Rights in an assisted living facility and Recognizing abuse/neglect and exploitation as she was some type of trainer herself. An opportunity was provided to contact the ARNP and look into whether the ARNP had attended the ALF Core training (assisted living facility) core training and submit the ALF Core training certificate by closing of business on 9/27/16 by e mail. An email was received on 9/27/16 at 8:44 PM, however there was no evidence staff C had attended the Assisted Living Core training or was exempt from the 1-hour in-service training regarding Resident Rights in an assisted living facility and Recognizing abuse/neglect and exploitation. 15. Based on the foregoing, Respondent violated Rule 58A-5.0191(2), Florida Administrative Code, an uncorrected class III, that carries, in this case, an assessed fine of $500.00. COUNT II (TAG A083 RESPONDENT FAILED TO ENSURE THAT A STAFF WHO HAD COMPLETED COURSES IN FIRST AID AND CPR BE IN THE FACILITTY AT ALL TIMES RULE 58A-5.0191(4), FLORIDA ADMINISTRATIVE CODE (TRAINING — FIRST AID AND CPR ) UNCORRECTED CLASS III 16. | AHCA tre-alleges and incorporates paragraphs (1) and (5) as if fully set forth herein. 17. Respondent was cited with deficient practice as the result of a monitoring visit for Extended Congregate Care conducted on 6/29/16. 18. Based on personnel record review and interview the facility failed to ensure that 2 of 4 sample staff had First Aid certification offered by an accredited college, university or vocational school; a licensed hospital; the American Red Cross, American Heart Association, or National Safety Council; or a provider approved by the Department of Health (#A and D). 19, Personnel records review revealed that : Staff A had a certificate dated 5/23/15 with an expiration date of 5/23/15. The certificate was for CPR. The training was done from an Internet provider. It was not done by an accredited college, university or vocational school; a licensed hospital; the American Red Cross, American Heart Association, or National Safety Council; or a provider approved by the Department of Health. There was no evidence she had current CPR certification. 20. Staff D, a caregiver, had a CPR certificate that expired on 1/2017. The card indicated Basic Life Support (BLS). There was no evidence she had current First Aid training. On 6/29/16 at 11:45 AM the facility secretary called the training school and, she said that she was told that BLS included First Aid. On 7/01/206 at 9AM the training school representative stated that BLS did not include First Aid training and BLS was Basic Life Support for lay people. The card would have indicated the training attended. 21. Respondent was cited with deficient practice as the result of a follow up to a monitoring visit for an Extended Congregate Care survey which survey was conducted on September 27, 2016. The Agency found that this deficiency remained uncorrected. 22. Based on personnel record review and interview the facility failed to ensure that a staff who has completed courses in First Aid and CPR and held a currently valid card documenting completion of such courses be in the facility at all times. 23. | Observations on 9/27/16 at 10 AM noted that staff A was the sole caregiver in the facility with the residents. During the entrance interview on 9/27/16 at 10 AM the assistant to the facility owner stated that nothing previously cited for staff A was corrected because nothing really needed correcting. She placed a call to the Agency office in Tallahassee as it was her understanding that the Tallassee office was in agreement with her. The Agency representative placed a phone call to the local Area office 7, and was instructed to return later during the day. 24. During the entrance interview on 9/27/16 at 2 PM the assistant to the facility owner said that staff A had current CPR and First Aid certifications. She provided a Heart Saver First Aid training card. She added that the Heart Saver First Aid card meant the staff had both, First Aid and CPR training The Agency representative explained the card must indicate First Aid and CPR training. She voiced disagreement. The assistant to the facility owner was informed that the trainer would be called for clarification. 25. On 9/30/16 at 10:45 a call was placed to the issuer of the Heart Saver First Aid card. According to the continuing education manager, when a card read Heart Saver First Aid and it indicated First Aid training only, it meant that the person had only received First Aid Training. When the card read CPR/First Aid, them both trainings were taken. If it read BLS CPR and or First Aid this was training for medical personnel only. 26. Based on the foregoing Respondent violated Rule 58A-5.0191(4), Florida Administrative Code, an uncorrected class III deficiency that carries, in this case, an assessed fine of $500.00. COUNT III (TAG A090) RESPONDENT FAILED TO ENSURE THAT ONE OUT OF FOUR SAMPLED STAFF (C) RECEIVED AN IN-SERVICE TRAINING REGARDING THE FACILITY’S DO NOT RESUSCITATE ORDERS (DNRO) POLICIES AND PROCEDURES RULE 58A-5.0191(11), FLORIDA ADMINISTRATIVE CODE (TRAINING — DO NOT RESUSCITATE ORDERS ) UNCORRECTED CLASS III 27 AHCA re-alleges and incorporates paragraphs (1) and (5) as if fully set forth herein. 28. | Respondent was cited with deficient practice as the result of a monitoring Extended Congregate Care visit that was conducted on 6/29/16. 29. Based on interview and record review the facility failed to ensure 3 of 4 sampled staff (#B, #C and #D ) received an in-service training regarding the facility’s Do Not Resuscitate Orders (DNRO) that included all the information in Rule 58A-5.0186, F.A.C. 30. Individual personnel record review revealed that Staff B hired was 2/01/2016 and was a Licensed Practical Nurse. There was no evidence to confirm she received an in-service training regarding the facility’s Do Not Resuscitate Orders (DNRO) policies and procedures. 31. Staff C was hired on 5/20/15 and was the Extended Congregate Care nurse. There was no evidence to confirm she received an in-service training regarding the facility’s Do Not Resuscitate Orders (DNRO) policies and procedures. 32. Staff D was hired on 10/30/15 and was a caregiver. There was no evidence to confirm she received an in-service training regarding the facility’ s Do Not Resuscitate Orders (DNRO) policies and procedures. The facility secretary stated on 6/29/16 at 12:15 PM that her regulation set indicated that only staff that was counted towards the staffing hours needed to be trained. She did not have her regulation set with her. 33. | Respondent was cited with deficient practice as the result of a follow up to a monitoring visit to an Extended Congregate Care survey which survey was conducted on 9/27/16. The Agency found that the deficiency remained uncorrected. 34. Based on interview and record review the facility failed to ensure 1 of 4 sampled staff (C) received an in-service training regarding the facility’s Do Not Resuscitate Orders (DNRO) policies and procedures. 35; During the entrance interview on 9/27/16 at 10 AM the assistant to the facility owner stated that nothing previously cited for staff C, the Advanced Registered Nurse Practitioner (ARNP) was corrected because nothing really needed correcting. She placed a call to the Agency office in Tallahassee as it was her understanding that the Tallassee office was in agreement with her. The Agency representative placed a phone call to the local Area office 7, was instructed to return later during the day. 36. During the entrance interview on 9/27/16 at 2 PM, the assistant to the facility owner said that staff C who had a PHD (doctorate degree) in nursing and was not doing any of the in-services including the Do Not Resuscitate Orders (DNRO) policies and procedures. She added that it had something to do with her liability insurance and too much time spent on these in-services. 37. Based on the foregoing Respondent violated Rule 58A-5.0191(11), Florida Administrative Code, an uncorrected class III deficiency that carries, in this case, an assessed fine of $500.00. 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 Respondent on Counts I and II and III. 2. Assess an administrative fine in the amount of $1,500.00 against Respondent based on Counts I and II and III. 3. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 4. 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 (2016). 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 Ne-v@as Cf. Lacon Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North, suite 330 St. Petersburg, Florida 33702 727-552-1944 Copies furnished to: Theresa DeCanio Field Office Manager Agency for Health Care Administration Hurston South Tower 400 Robinson, Suite $309 Orlando, Fla. 32801 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 Peter Fellows, Administrator, Pine Estates Assisted Living Facility, 4055 Pinewood Road, Melbourne, Fla. 7. 34, on this Tey of January, 2018. (~vile Gee es A. Naranjo, Esq. 10 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Pinewood Estates Living Facility AHCA No. 2017006442 ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (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 form 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 fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but 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 agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and 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: Contac 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 form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: USPS Tracking® Tracking FAQs Track Another Package + Remove Tracking Number: 70132250000149502809 Expected Delivery on: Saturday13 January 2018 Expected delivery on the date provided is the latest information on when the Postal Service™ expects to deliver your package. by 8:00pm Status: Delivered January 13, 2018 at 2:57 pm Delivered, Left with Individual MELBOURNE, FL 32934 Get Updates

Docket for Case No: 18-001588

Orders for Case No: 18-001588