- LTA OI $A STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005002321 Return Receipt Requested: v. 7002 2410 0001 4234 2277 7002 2410 0001 4234 2284 PALMS VILLA RETIREMENT HOME, INC. d/b/a PALMS VILLA RETIREMENT HOME, INC., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Palms Villa Retirement Home, Inc. d/b/a Palms Villa Retirement Home, Inc. (hereinafter “Palms Villa Retirement Home, Inc.”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administzative fine of $2,235.00 [$2,000.00 fine + $235.00 survey fee] pursuant to Sections 400.414 and 400.419, Florida Statutes for protection of public health, safety and welfare. Es Oe LORE RN JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 3. venue lies in Broward County pursuant to Section 120.57 Florida Statutes, 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 400, Part III, Florida Statutes (2005) and Chapter 58A-5 Florida Administrative Code. 5. Palms Villa Retirement Home, Inc. operates a 21-bed assisted living facility located at 2131 N. W. 28 Street, Oakland Park, Florida 33311. Palms Villa Retirement Home, Inc. is licensed as an assisted living facility under license number 4990. Palms Villa Retirement Home, 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. 2h TEL ee COUNT I PALMS VILLA RETIREMENT HOME, INC. FAILED TO ENSURE THAT AT LEAST ONE (1) STAFF MEMBER TRAINED IN FIRST AID AND CPR Is AT THE FACILITY AT ALL TIMES. RULE 58A-5.019 (4) (a), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Palms Villa Retirement Home, Inc. was cited with four (4) Class III deficiencies due to a re-licensure survey that was conducted on January 19, 2005. 8. A re-licensure survey was conducted on January 19, 2005. Based on record review and interview it was determined that the facility did not ensure that at least one staff member trained in CPR was at the facility at all times. The findings include the following: 9. During review of the facility personnel records, two of the four aides that work alone providing care and supervision had no current certification in CPR. During interview, the Administrator stated that he was not aware that the certifications had expired. 10. The mandated date of correction was designated as February 18, 2005. 11. A revisit survey was conducted on February 24, 2005. Based on record review and interview, it was determined that the facility did not ensure that at least one staff member trained in First Aid was at the facility at all times. The findings include the following: 12. During review of the facility personnel records, one of the four aides that works alone on the 8:00pm to 8:00am shift providing care and supervision had no documentation of current certification in First Aid. During interview, the Administrator confirmed this deficiency. This is an uncorrected deficiency from the survey of January 19, 2005. 13. Based on the foregoing facts, Palms Villa Retirement Home, Inc. violated Rule 58A-5.019(4) (a), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT II PALMS VILLA RETIREMENT HOME, INC. FAILED TO ENSURE THAT THE FACILITY WAS CLEAN, FUNCTIONAL AND IN GOOD REPAIR. RULE 58A-5.023(1) (b), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. AAS WE = re 15. A re-licensure survey was conducted on January 19, 2005. Based on observations made during tour of the facility it wag revealed that the facility did not ensure that it was clean, functional and in good repair. The findings include the following: 16. The wall outlet in the bathroom in resident's room #7 had exposed electrical wires and no switch plate. The ceiling in this room also had a hole with exposed wires that were left hanging and not connected to the smoke detector. 17. Based on observation at the time of the survey on 1/19/05, the facility was not providing furniture and furnishings that were functional, free of odors and in good repair for the residents. The findings include the following: 18. The patio furniture was soiled, stained and torn. The two fabric couches had large holes, no padding and were covered with cigarette burns. 19. The linens and blankets in room 4 on two of the residents' beds were not clean and in good repair. They were dirty and had large holes. 20. The mandated date of correction was designated as February 18, 2005. This is a repeat deficiency from the 09/26/03 survey report. 21. A revisit survey was conducted on February 24, 2005. Based on observations made during tour of the facility on 2/24/05, it was revealed that the facility aid not ensure that it was clean, functional and in good repair. The findings include the following: 22. The wall in the bathroom in resident's room #7 had a hole of approximately 4"x 4" with an exposed metal plate beneath the hole. The wall in resident's room #3 had a hole of approximately 3" x 3", The Administrator stated that the resident in this room had punched this hole in the wall. 23. Based on observation at the time of the survey on 2/24/05, the facility was not providing furniture and furnishings that are functional, free of odors and in good repair for the residents. The findings include the following: 24. The patio furniture was extremely soiled, stained and torn. The two fabric couches had large holes, no padding and were covered with cigarette burns. The Administrator stated he tried to throw out the furniture but the residents brought it back. The residents when interviewed, at the time of the survey, requested that the facility have comfortable furniture for them to sit outside on the covered patio. 25. This is a repeat deficiency from the 9/26/03 survey report and uncorrected from the 1/19/05 survey report. 26. Based on the foregoing facts, Palms Villa Retirement Home, Inc. violated Rule 58A-5.023(1) (b), Florida Administrative Aen ementa: TRS AEARS O Code, herein classified as an uncorrected and repeat Class IiI violation, which warrants an assessed fine of $1,000.00. COUNT IIL PALMS VILLA RETIREMENT HOME, INC. FAILED TO ENSURE THAT THE STAFF IN DIRECT CONTACT WITH MENTAL HEALTH RESIDENTS COMPLETE REQUIRED MENTAL HEALTH TRAINING. SECTION 400.4075(1), FLORIDA STATUTES RULE 58A-5.029(3) (da), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0191(8), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS III VIOLATION 27. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28. A re-licensure survey was conducted on January 19, 2005. Based on record review and interview, it was revealed that the facility did not ensure that the staff in direct contact with mental health residents had completed the required mental health training. The findings include the following: 29, Two of the five staff records reviewed did not contain evidence of staff members completing the required Limited Mental Health training. The owner confirmed that the two aides had not completed the required mental health training. These two employees were in direct contact with mental health residents and had been employed longer than six months. 30. The mandated date of correction was designated as February 18, 2005. 31. A revisit survey was conducted on February 24, 2005. Based on record review and interview, it was revealed that the facility did not ensure that the staff in direct contact with mental health residents had completed required mental health training. The findings include the following: 32. One of the five staff records reviewed did not contain evidence of staff members completing the required Limited Mental Health training. The owner confirmed that the one aide had not completed the required mental health training. This employee was in direct contact with mental health residents and had been employed longer than six months and was observed to be working alone at the facility on the day of the survey. The Administrator had no documentation that this employee was signed up for the required limited mental health training, 33. This is an uncorrected deficiency from the 1/19/05 survey report. 34. Based on the foregoing facts, Palms Villa Retirement Home, Inc. violated Section 400.4075(1), Florida Statutes, Rule 58A-5.029(3) (d), Florida Administrative Code, and Rule 58A- 5.0191(8), Florida Administrative Code herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $235.00 has been assessed in this case. 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 Palms Villa Retirement Home, Inc. on Counts I through III. 2. Assess an administrative fine of $2,0C0.00 against Palms Villa Retirement Home, Inc. on Counts I through III for the violations cited above. 3. Assess a survey fee of $235.00 against Palms Villa Retirement Home, Inc. pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. 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 (2004). Specific options for acministrative 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 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. bees ey Lourdes A. Naranjo, Es. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) 10 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (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 Jason G. Kissoonlal, Administrator, Palms Villa Retirement Home, Inc., 2131 N. W. 28 Street, Oakland Park, Florida 33311; Jason Kissoonlal, 2131 N. W. 28 Street, Oakland, Florida 33311 on this GT aay of SY __, 2005. 11

Docket for Case No: 05-002326