STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2014001439 Return Receipt Requested: v. 7009 0080 0000 0586 0322 ALL AMERICA ADULT CONGREGATE LIVING FACILITY INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (““AHCA”), by and through the undersigned counsel, and files this administrative complaint against All America Adult Congregate Living Facility Inc. (hereinafter “All America Adult Congregate Living Facility Inc.”), pursuant to Chapter 429, Part I, Chapter 408, Part II, and Section 120.60, Florida Statutes (2013), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $$5,500.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2013), 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 (2013), and Chapter 28-106, Florida Administrative Code (2013). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2013). 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 (2013), and Chapter 58A-5 Florida Administrative Code (2013). 5. All America Adult Congregate Living Facility Inc. operates a 100-bed assisted living facility located at 808 West 1 Avenue, Miami, Florida 33010. All America Adult Congregate Living Facility Inc. is licensed as an assisted living facility under license number 7890. All America Adult Congregate Living Facility Inc. 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 ALL AMERICA ADULT CONGREGATE LIVING FACILITY INC. FAILED TO ENSURE THAT THERE WAS PERSONAL SUPERVISION OF PREVENT RESIDENTS FROM HARMING THEMSELVES. THE RESIDENT WAS LEFT ALONE AFTER VERBALIZING HIS INTENT TO HARM HIMSELF, WAS FOUND WITH A RAZOR BLADE, AND SUBSEQUENTLY CUT HIMSELF REQUIRING HOSPITALIZATION. RULE 58A-5.0182(1), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE AND STANDARDS) CLASS IT VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. All America Adult Congregate Living Facility Inc. was cited deficient practice as the result of a complaint investigation that was conducted on November 21, 2013. 8. A complaint investigation survey was conducted from November 21, 2013. Based on observation, interview, and record review, it was determined that the facility failed to ensure there was personal supervision to prevent 1 of 8 sampled residents (resident #2) from harming themselves. The resident was left alone after verbalizing his intent to harm himself and being found with a razor blade and subsequently accessed another razor blade and cut himself requiring hospitalization. The findings include the following. 9. Record review of the facility's policy titled "Accidents and Incidents" with an effective date of 4/1/2002 revealed "Employees witnessing an accident or incident involving a resident, employee, or visitor must report such occurrence to his or her immediate supervisor as soon as practical. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance." 10. Interview with resident #2 on 11/19 at 9:40 revealed he reported feeling like this place was just a drop off point for handicapped people and that makes him depressed. He said he has no family and no friends to come visit him. He began crying during the interview. He said sometimes he just doesn't want to wake up but he doesn't believe in suicide because, "that is against the law of god." 11. He had an approximately 6 inch long stitched up wound running from the wrist up his left forearm. He reported he was trying to cut cardboard with a razorblade and accidentally cut himself. He said they sent him to the hospital and while he was there, he was put him on suicide watch. 12. Record review of resident #2's chart revealed he was admitted to the facility on 5/15/13. His health assessment included diagnoses of Schizophrenia Chronic Paranoid Type (SCPT) and history of alcohol abuse. 13. Interview with the administrator on 11/19/13 at 12:17 pm revealed the resident sees the doctor once a month. She said that one night the resident came to the office and told staff #2, "Call 911, I'm going to kill myself." The staff member called 911. When resident #2 left the office, he went to his room and locked the door. She is unsure if the resident's roommates were in the room. Rescue did not take long to arrive and when they arrived, the resident had cut his arm and was bleeding significantly. 14. She denied that staff #2 followed the resident back to the room. She said the other staff member, staff #3, followed him to the room and the room was locked. Staff #2 stood by the gate and yelled at her that rescue was here. They cleaned the room and wrapped the wound and rescue took resident #2 to the nearest hospital. 15. Interview with the administrator on 11/19/13 at 1:00 pm revealed she denied seeing signs or symptoms of depression in resident #2 immediately preceding the incident. She reported the resident drinks and then cries and thinks life is pointless. She reported that when he has not been drinking he is happy and full of life. She reported he has been to the hospital more than 10 times since admission for being depressed when he is drunk. 16. Interview with the administrator on 11/19/13 at 2:36 pm revealed rounds are conducted at night every hour. When asked whether she had implemented any extra supervision for resident #2 post incident, she said "what do you mean by extra supervision?" She could not provide examples of any additional supervision put in place after the resident's suicide attempt. 17. Interview was conducted with staff B and staff C on 11/21/13 at 5:16 am. Staff B reported he was making rounds when saw resident #2 in his room breaking the razor open with his mouth. He entered the room and took the razor from resident #2. He came back to the office to call the ambulance and do the transfer paperwork. When he went back to the room, the resident had obtained another blade, he thinks out of his closet, and had already cut himself and was bleeding. 18. Staff B reported he was the one who bandaged the resident. He said rescue arrived quickly. After he got done doing basic first aid, about 5 to 10 minutes later, rescue arrived. He reported that he and Staff C are the only staff members present at night. Staff C denied working on the night of the incident. Staff B reported he was the only one working on that night. He said he usually works with Staff C but that night in particular, he was alone. 19. He said currently they have 100 residents. Staff B reported they make 3-4 rounds every hour and he is always looking at the TV camera monitors. When they make rounds, they check through the windows. They also check the gates to make sure nobody is coming in at night. In regards to whether they check inside the rooms, he said it depends, because sometimes the residents lock their doors. They do not have a master key but can use a tool to get into the room if they need to. 20. Daniel said he always checks on resident #2 because he spends most of the night awake watching movies. He re-iterated that on the night of the incident, he was doing rounds and looked into the room from outside of it and saw the resident breaking open the razor with his teeth. He knocked on the door and the resident let him in. Initially, the resident didn't want to give him the razor, but eventually he did so. After the resident gave him the razor, he left the room to complete the paperwork for the discharge. 21. He said approximately 10 minutes elapsed between then and when he went back to the room. He said he thinks wherever the resident was before he had tried to do the same thing, because he cut himself over an existing scar. When rescue arrived, staff B reported he went back to the office. 22. Interview with staff D on 11/21/13 at 7:05 am revealed that was the first time resident #2 tried to commit suicide at the facility. He denied the resident had a history of suicide attempts. He reported the resident was admitted in May 2013 and had not tried to commit suicide prior to that incident. He reported when they find out that someone is having a crisis, the first thing they do is call the doctor. If the person is a danger to himself, they call the police. When asked why staff B was working alone on October 20th, he said "That's impossible" and indicated two people always work at night. He said staff C worked with staff B that night. He was then informed that both staff B and staff C confirmed staff C was not there that night and that staff B had confirmed he was alone. 23. Interview with staff D on 11/21/13 at 7:15 revealed he said staff B did what he was supposed to do by coming back to the office and calling rescue. He said that now staff has cellular phones so they can call from anywhere and don't have to rely on the cordless phone which only reaches to just past the dining room. 24, Interview with staff B on 11/21/13 at 7:30 am revealed he stated his father came in and was working on 10/20 but was in the bathroom when the incident occurred. 25. Based on the foregoing facts, All America Adult Congregate Living Facility Inc. violated Rule 58A-5.0182(1), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $5,500.00. 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 All America Adult Congregate Living Facility Inc. on Count I. 2. Assess an administrative fine against All America Adult Congregate Living Facility Inc. based on Count I for the violation cited above. 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 (2013). 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 Pircee Gece Lourdes A. Naranjo, Esq. Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53" Street Suite 300 Miami, Florida 33166 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 8333 N. W. 53” Street — Suite 300 (Interoffice 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 Mildrey Galindo, Administrator, All America Adult Congregate Living Facility Inc., P. O. Box 452434, Miami, Florida 33245 on this [38 ~ day of eeopes vf, 2014. C Seri LY ler asp Lourdes A. Naranjo, Esq. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: All America Adult Congregate Living Facility AHCA No.: 2014001439 Inc. 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 Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or 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 Chapter 120, Florida Statutes (2006) 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 Notice of Intent to Impose a Late Fine or Fee, 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 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, the 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)_____—S—sI. dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or 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 ru mu m oa oa ag wm i "3 pols = Return Receipt Fee o (Endorsement Required) Restricted Delivery Fee ( (Endorsement Required) ro 3 Total Postage & Fees yy Wil dna, Alerts | om | Seat To i Sa hewn. ant CI | Sieet, ~ or PO ‘ox No. (£0: Pax... Salto, (SENDER: COMPLETE THIS:SECTION 1 Complete Items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ' gl 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 mailpiece, or on the front if space permits. 1. Article Addressed to: Oe America, Aaws Conguyate 0 Bm 452434 Woon . F Coda IS Lag, 7009 a060 ooo “058 O3eec COMPLETE THIS:SECTION ON DELIVERY. A. Signature & fe” is ae, B. Received by (Printed re . -~ ; O Agent Cl Addressee C. Date of Delivery D. Is delivery addi ferent fromytem 1? CI Yes If YES, enter. delivery meas CNo F f 3. Service Type oe | C1 Certified Mail d Bp abs Mail D Registered 1 Return Recelpt for Merchandise Cl tnsured Mall 1.0.0. 4, Restricted Delivery? (Extra Fee) oy oy OTT TO PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 i Comach Gaoun

Docket for Case No: 15-004844