STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2017008737 Petitioner, Return Receipt Requested: 7013 2250 0001 4950 2793 Vv. 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 $1,000.00 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). 8. 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 AZ814) RESPONDENT FAILED TO MAINTAIN AN ACCURATE ROSTER OF ITS EMPLOYEES IN THE BACKGROUND SCREENING CLEARINGHOUSE DATABASE . SECTION 435.12(2)(b), (c) & (d), FLORIDA STATUTES (BACKGROUND SCREENING CLEARINGHOUSE) UNCLASSIFIED VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) and (5) as if fully set forth herein. kL Respondent was cited with deficient practice as the result of an Extended Congregate Care monitoring visit conducted on June 29, 2016. 8. Based on record reviews and interview the facility did not maintain an employee roster on the Agency’s Background Screening Clearing House that listed all the facility employees subject to a background screening for 2 of 4 sampled staff (B) and (C). 9. Background Screening Clearing House roster on 6/29/16 revealed facility’s employee roster did not list staff C, an Advanced Registered Nurse Practitioner hired by contract on 5/20/15 and staff B a Licensed Practical Nurse (LPN) hired by contract on 2/1/16. The facility secretary stated on 6/29/16 at 12:15 PM that staff B and C were not facility staff, but contracted staff. 10. Based on the foregoing, Respondent violated Section 435.12(2)(b), (c), and (d), Florida Statutes, an unclassified deficiency that carries, in this case, an assessed fine of $500.00. COUNT II (TAG Z815 RESPONDENT FAILED TO PROVIDE EVIDENCE OF A LEVEL II BACKGROUND RE-SCREENING FOR ONE STAFF PERSON SECTION 408.809, FLORIDA STATUTES SECTION 435.02(2), FLORIDA STATUTES SECTION 435.06, FLORIDA STATUTES (BACKGROUND SCREENING - PROHIBITED OFFENSES) UNCLASSIFIED VIOLATION 11. AHCA re-alleges and incorporates paragraphs (1) and (5) as if fully set forth herein. 12. Respondent was cited with deficient practice as the result of a monitoring visit for Extended Congregate Care conducted on 6/29/16. 13. Based on personnel record review and interview the facility failed to ensure 1 of 4 staff (C), whom was in a role that required a background screening (BGS) did not have any disqualifying offenses and was allowed work without a background screening. 14. Personnel record review revealed that staff C, was an Advanced Registered Nurse Practitioner (ARNP) hired by contract on 5/20/15. The BGS available for review indicated Agency review required and was printed on 5/20/15. The Agency BGS site indicated on 6/29/16 at 11:30 AM “awaiting privacy policy". The facility secretary stated on 6/29/16 at 12:15 PM that staff B and C were not facility staff, but contracted staff. 15. Based on the foregoing Respondent violated Sections 408.809, 435.02(2), and 435.06, Florida Statutes (2016), an unclassified 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 | and II. 2. Assess an administrative fine in the amount of $1,000.00 against Respondent based on Counts | and II. 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 ‘nce Garou) 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, Pinew: v4 Estates Assisted Living Facility, 4055 Pinewood Read, ‘ae (1 934, on this y/ Yy of January, 2018. des A. Naranjo, Esq. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: Pinewood Estates Living Facility AHCA No. 2017008737 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. | 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: 70132250000149502793 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

Docket for Case No: 18-001591

Orders for Case No: 18-001591