Mar 2? 2009 14:00 MAR-2?-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 16-28 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case No. 2009000430 ve PACIFICA SUN CITY LP d/b/a SUN CITY RETIREMENT RESIDENCE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (the “Agency”) and files this Administrative Complaint against Pacifica Sun City LP d/b/a Sun City Retirement Residence (“Respondent” or “Respondent Facility”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of one thousand dollars ($1,000.00), based upon one cited State Class If deficiency pursuant to Sections 429.19(2) (b) and (3), Florida Statutes (2008), and to impose and a survey fee of five hundred dollars ($500.00) pursuant to Sections 429.19 and 429.28, Florida Statutes (2008), or such other relief as this tribunal may determine. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to Sections Mar 2? 2009 14:01 MAR-2?-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P.11/28 20.42, 120.60, and 429.07, and Chapter 408, Part II, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensing assisted living facilities and enforcing all applicable state statutes and rules governing assisted living facilities pursuant to Chapter 408, Part II, and Chapter 429, Part I, Florida Statutes, and Chapter 58A-5 Florida Administrative Code, 4. Respondent operates a one hundred and twenty (120) bed assisted living facility located at 3855 Upper Creek Drive, Ruskin, Florida 33573, and is licensed as an assisted living facility, license number 7290. 5. At all times material to the allegations of this complaint, Respondent was a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates above Paragraphs one (1) through five (5), as if fully set forth in this count, 7. Rule 58A-5.019(4) (b), Florida Administrative Code Mar 2? 2009 14:01 MAR-2?-2889 14:14 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 12/28 (2008), requires: (bo) Notwithstanding the minimum staffing requirements specified in paragraph (a), all facilities, including those composed of apartments, shall have enough qualified staff to provide resident supervision, and to provide or arrange for resident services in accordance with the residents scheduled and unscheduled service needs, resident contracts, and resident care standards as described in Rule 58A- 5.0182, F.A.C. 8. Rule 58A-5.0182, Florida Administrative Code (2008), requires: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, ineluding the following: (a) Moniter the quantity and quality of resident diets in accordance with Rule 59A-5.020, F.A.C. 9. On December 5, 2008, the Agency conducted a complaint investigation of Respondent Facility. 9.1. Based upon interviews with staff and family members as well as observation on December 5, 2008, the facility failed to provide sufficient staffing to meet the needs of 31 residents in the secure area of the facility. 9.2, Observations were made in the secure memory care unit. from approximately 5:00 p.m. until approximately 7:00 p.m. 9.3, Initially upon entering the secure memory unit, one staff person was visible in the large common area. Mar 2? 2009 14:01 MAR-2?-2889 14:14 AGENCY HEALTH CARE ADMIN 856 921 4158 P1328 Observed at this time were about 20 residents sitting in the common area. The TV was on at low volume, Christmas music was playing. The same song repeated itself over and over. Residents were not involved in any activity and there was no consistent staff interaction with the residents. Some residents appeared to be resting with eyes closed, others just staring into space. Other residents were observed wandering. Two female residents walked in from the patio aréa arti-in-arm; one of these residents was in bare feet. A member of Respondent’s staff came over to put sneakers on the shoeless resident and commented that the resident “will just pull them off again.” Members of Respondent’s staff were in and out of the common area, apparently taking residents who required care back to their room. A staff person was asked how many staff were on duty, and she responded there were three staff. One female resident was observed sitting in an armchair of the common area with a clothing protector already on. The clothing protector, which resembled a bib, was dingy looking and somewhat frayed. 9.4. At about 5:30 p.m. Respondent's staff started bringing the 31 residents into the dining area. Beverages for the evening meal were placed at some of the tables. Two members of Respondent ’s staff led residents into the MAR-27-2889 Mar 2? 2009 14:01 14:14 AGENCY HEALTH CARE ADMIN 856 921 @158 dining room, while another member of Respondent’s staff was involved in passing residents their medications. As staff sat residents down at tables and went to gather other residents, the residents who had been seated would get back up. Others who remained seated were observed attempting to drink beverages using spoons. 9.5, An unsupervised resident was observed walking around in the staff office and medication room, while staff members were out of the room passing medications. This resident walked over to the medication cart and fumbled with papers on top of the cart, then picked up the telephone as it rang. 9.6. Another female resident walked out to the dining area without pants on. Both members of Respondent's staff immediately approached this resident to bring her back to her room to dress. 9.7. At about 5:45 p.m. food service staff brought soup to the dining area. At this time the two direct care staff members were still engaged in getting residents to the table or were in rooms with residents. One resident was observed feeding another resident some fruit cocktail that had been brought out. The feeding resident would used one spoon to feed both residents. Staff being busy did not notice the sharing of the spoon. The resident continued to P.i4/28 Mar 2? 2009 14:02 MAR-27?-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P1528 feed the other resident the main entree until about 6:10 p.m., when the surveyor finally brought the sharing of a spoon to staff member’s attention. The resident who was feeding the other resident was not eating her own meal. Several other residents were not eating and were playing with their food or their neighbor’s food. One female resident asked the surveyor for help stating, “Ma'am, I need someone to help, eat". A family member of one of the residents, who was seated at a table with her father, was helping another female resident at the same table with her meal. A fourth staff person, the Wellness Director, came in to help out at about 5:45 p.m. 9.8. At 6:30 p.m, when the surveyor went to observe the rest of the medication pass, some of the residents were Still observed playing with their food. Meal-time assistance was not provided due to staff attempting to intervene and re-direct those residents they could. 9.9, Given the level of assistance the 31 residents in this secure area were observed to need, it was impossible for the three to four staff members available to provide the care required and ensure that residents received meal time assistance. 9.10. Agency surveyors concluded that the number of staff Respondent made available to the memory care unit Mar 2? 2009 14:02 MAR-27?-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 1628 were not enough to provide the level of care needed for the residents in the memory care unit. This lack of assistance with eating puts residents’ health at risk for unintended weight loss, malnutrition, and exposure to communicable illness. 10, The Agency determined that this deficient practice of Respondent Facility’s failure to adequately ensure that an adequate number of staff members were available to assist and care for residents was related to the personal care of the residents of Respondent Facility that directly threatened the health, safety, or security of the residents and cited Respondent for a State Class IT deficiency pursuant to § 429,19(2) (b), Florida Statutes (2008). 11. The Agency provided Respondent with a mandatory correction date of January 5, 2009, 12. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to §§ 429.19(2) (b) and (3), Florida Statutes (2008), or such further relief as this tribunal deems just. COUNT IT 13. The Agency re-alleges and incorporates above paragraphs one (1) through five (5) and Count I, as if fully set forth in this count. Mar 2? 2009 14:02 MAR-27-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 @158 P.i7/2e 14, Seetion 429.28(3) (¢), Florida Statutes (2008), requires: (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 JI violation, or more than three uncorrected class III violations. 15. Pursuant to § 429,19(7), Florida Statutes (2008): (7) 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 s. 429.28(3) (c) to verify the correction of the violations. 16. A fee for a monitoring visit must he assessed, even though the survey will occur in the future, See, Agency for Health Care Administration v. Luz Home for the Elderly, Inc., d/b/a/ Luz Home tor the Elderly, Case No. 02-263PH (Agency for Health Care Administration). 17. The above Count I results from an initial complaint investigation which found one or more Class II violations that were the subject of the complaint, or a monitoring visit will be conducted. 18. Respondent is therefore subject to a survey or monitoring fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2008). WHEREFORE, the Agency intends to impose an additional Mar 2? 2009 14:03 MAR-27?-2889 14:15 AGENCY HEALTH CARE ADMIN 856 921 4158 P. 18-28 survey or monitoring fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(7), Florida Statutes (2008). Aone mes H. Harris Fla. Bar. Na. 817775 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330H St. Petersburg, Florida 33701 727.552.1535 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. 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 Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No.7007 0220 0001 1589 3843 to Paracorp Incorporated, Registered Agent for Pacifica Sun City LP d/b/a Sun City Retirement Residence, 236 East 6* Avenue, Tallahassee, Florida 32303, and by U.S, Certified Mail, Return Receipt No. 7007 0220 0001 1589 32850 to Claudine Alexander-Leger, Administrator, Sun City Retirement Reson: 201 17° stre t, NW, Ruskin, Florida 33570, on February is _, 2009. es H. Harris, Esquire istant General Counsel MAR-2?-2089 14:16 Copies furnished to: AGENCY HEALTH CARE ADMIN Mar 2? 2009 14:03 856 921 4158 Claudine Alexander-Leger Administrator Sun City Retirement Residence 3855 Upper Creek Drive Ruskin, Florida 33573 (U.8,. Certified Mail) James H. Harris, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330H St. Petersburg, FL 33701 (Interoffice) Paracorp Incorporated Registered Agent for Pacifica Sun City LP d/b/a Sun City Retirement Residence 236 Bast 6° avenue, Tallahassee, Florida (U.S. Certified Mail) 32303 Kathleen Varga Facility Evaluator Supervisor 525 Mirror Lake Dr., 4°" Fl. St. Petersburg, Florida 33701 (Interoffice) 10 P.19/28 Mar 2? 2009 14:03 MAR-2?-2889 14°16 AGENCY HEALTH CARE ADMIN 854 921 @i5e P. 28/28 THIS SECTION COMPICTE THIS SEC TAN ON DELIVERY @ Completa itams 1, «ad 3, Also complete Item 4 if Restricted Dellvery Is desired. @ Print your name and address on the reverse go that we can return the card to you. @ Attach this card to the back of the mailplece, or on the front if space permits. A. Signature Dis celvery ad addres different from item 1? [1 Yes (f YES, enter delivery address below: [Ne 1. Article Addressed to: dong Lito oracec rarae ae eS Dac i Ca. a ane sf 3, Service Type fa! \b la, San Suk Cheri Mal] Express Mall 23 lo East Le r OO Ragtstered OO Ratum Racelpt for Merchandise Olreued Mal =O.00. Tallahassee. aft a Flaws: we 2, | 4, Resticted Dolivery? (Exim Fea) CO Yes 2. Article Number ele) 4 (ensfertomse = 7007 OF20 O00 1589 3843 oh _ 090004 30 PS Form 3811, February 2004 Domestic Return Recalpt 102805-02-M-1540 COMPLETE THIS SECY A xe ot n Agent : Ay | le) CO Addressee lacal vii) inted Ne G. Gat Ee KG (Te ” Gem ie D, Is delivery address different from item 17 a Yes HfYES, enter delivery address below; C1 No 1S SECTION SENDER: COMPLE| @ Complete Items 1, 2, wid 3. Also complete itern 4 If Restricted Delivery Is dasired, ® Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the maliplece, or on the front If space permits. 1. Article Addressed to: iAlexorder— AN NT cd Vas iva, ry CV Rotrement Rest BYSS Ut mr Core Fe RA wmin Flow da a ed 3. Serica Type CO Certiied Mal’ = Exprees Mall CO Registered 1 Ratum Recaipt for Merchandlse Banls Clinsurad Mal = €,0.0. 4, Restricted Dellvery? (Extra Fae) Ovs | i 3 ZOD NOOOL 3p 2, Articla Number 007 wueed oool 1584 3a50 am 9 (Transtar from s. _ ? —_——_-—— roy kf PS Form 3811, February 2004 Domestic Retumn Recelpt 10259502-MH1 540} TOTAL FP. 2a

Docket for Case No: 09-001612