JUN-O7-2006 TUE 06:06 PH FAK NO. P, O06 pint (6s Wl NOLLYUIG« FISBORZSOCSOISO Z6USSNO.SUMSABRSXS-WAS oo WOME Wisses] We HL:CC-2 SU0ZIU9 LY OAD, Fit 204¢ , ote Res Ao! 11Oem. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004010819 Z, Return Receipt Requested¢’. i) ve 7002 2410 0001 4237 6715 ~ 7002 2410 0001 4237 6722 ENGRACIA’S RETIREMENT HOME, INC. d/b/a ENGRACIA‘’S RETIREMENT HOME, Ruspondent. es Os-adn ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Caxe Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Engracia’s Retirement Home, Inc, d/b/a Engracia’s Retirement Home (hereinafter ‘Engracia’s Retirement Home”), pursuant to Chapter 400, Part IIz, and Section 120.60, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION 1. This is an action to revoke the license or impose an administrative fine of $29,154.00 [$20,000.00 administrative fine + 6154.00 survey fee] pursuant to Sectiona 400.414 and 400.419, Florida Statutes (2004) for the protection of public health, safety and welfare. Ta 380d 3x0 NIL TTSeB2zSve EeiTa saez/Be/L8 JUM-07-2005 TUE 06:06 Plt FAR NO, P, Q7 pho [SS UL) NOLLYANGsLLS802ZG0C‘SD . J6ZU'SNO »SHABAMESK YZ WAS [eu HByheg twayse3] Wed PhG6:2 S00Z12/9 LY QAOU TC 30d JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Secticns 120.569 and 120.57 Florida Statutes (2004), Chapter 26-106, Florida Administrative Coda. 3. Venue lies in Dada 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 aesisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2004) and Chapter 58A-5 Florida Administrative Code. 5. Bngracia’s Retirement Home operates a 6-Ised assisted living faeility located at 10460 3S. W. 41 Terrace, Miami, Florida 33165. Engracia’s Retirement Home is licensed as an assisted living facility under license number 8136. Engracia’s Retirement Home wag 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. £Q@ Bove B20 NIL] T1S8AzZS aE €€:1B CZ /8G/28 JUN-07-2005 TUE 06:06 PH FAR NO. P, 08 ppt] HOLYNG }SR0ZCG0C‘CN89 . J6LL'SING eS ASAWESKNSSUAS ua, WS Waysed) id Fite'2 SOOCIU LY CADY #10 BOve counT = ENGRACTIA’S RETIRENENT HOME FAILED TO ENSURE THAT THE RESIDENTS WERE LIVING IN A SAFH ENVIRONMENT, FREE PROM ABUSE AND NEGLECT. SECTION 400.428(1), FLORIDA STATUTES CLASS I VIOLATION 6, AHCA re-allegee and incorporates paragraphs (1) through (5) as if fully eat forth herein. . 7. A complaint investigation survey was conducted on May 11, 2005. Based on observation, interview and record review the facility failed to ensure a safe and decent living environment, frae from abuse and neglect. The findings include the following: 8. Interview with administrator revealed that a fire ocnurred on $/10/05 as a result of a resident smoking in bed. Qbservation on 5/11/2005 ‘at 10:30 AM revealed that the bed on he left in bedroom #1 was severely burned. The bedroom window was broken and there was debria from the fire all through the bedroom and the hallway leading to the other resident living quarters. 9. Interview with the facility administrator on 5/11/2005 at 11:00 AM revealed that resident #1, who was blind, was Nalways emoking in bed." Interview with resident # 3 concurred that resident # 1 smoked in bed. The administrator stated that "the resident was irate” about being told not to smoke in his room and had been told on numerous occasions to stop smoking in 28 380d BavS NILW TtseazzZSee €€:19 Se@z/9a/28 JUH-O7- be 20 Q ol TUE 06:06 PM FAA NO. P, Og prt (6s-) NOLLYANG 1 }S8022S0C:0180 « J6ZL'SINO sSLUBAMBSKVESHAS «fot, Bj Aeg wansea] te f}e°2 $00 Ly OADM fit ated his room. The administrator also stated, “I am not a babysitter and cannot watch the residents 24/7." The administrator stated that during a prior survey the surveyor informed resident #1 that he ig not to smoke inside the bedroom, but no interventions were attempted by the administrator. The administrator stated that resident # 1 had a history of dropping his lit cigarettes and that he had holes in his clothing from these events. Despite tha dangerous amoking habitea cf residenc # 1, amd that he was blind, the administrator failed to make any attempt to supervise resident #1 while he smoked. 10. Racord review on 5/11/2605 at 10:45 AM revealed that chere is a policy in each resident file in regards to smoking in she facility. The policy estates that smoking 1s only allowed in designated areas and that it is not allowed inaide the bedrooms. The administrator stated that although he knew that reaident # 1 emoked in his badroom, telling the resident not to amoke in the ‘pedroom was hig only intervention. ll. As a result of this fire, resident #1 suffered 4th degree burns on 40% of his body and later expired. Resident #5 suffered smoke inhalation and was hospitalized. Home 12. Based on the foregoing facts, Engracia’s Retirement violated Section 400.428(1), Florida Statutes, herein classified as a Class I violation, which warrants an asseseed fine of $10,000.00. =oVd B00 NIL T1seazZSBe E€:1@ S@ae/aa/Ls8 JUN- 07-2005 TUE 06:06 PH FAK NO. ca fir ros (SS-UUl} NOLLYHNNC LIGGOCZS0E:CISO Z6L2:SINC s SVMBARESKVEUAS ; fa, yuSheq wiaysea] ig pLset2 SOCZIUG LY QADM #1 20¥e COUNT II ENGRACIA’S RETIREMENT HOME FAILED TO ENSURE THAT THE RESIDENTS WERE ABLE TO TRANSFER WITH ASSISTANCE. RULE 58A-5.0181(1) (d), FLORIDA ADMINISTRATION CLASS I VIOLATION 13. AHCA yxre-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14. A complaint investigaticn survey was conducted on May il, 2005. Based on interview and record review, the facility failed to ensure that resident was able to txansfer with assistance. The findings include the following: 15. The facility failed to ensure that resident #5 was able to transfer with assistance. 16. Interview and record review, conducted during the complaint survey of 5/11/05, revealed that resident #5 required total lifting to transfer, thereby placing her at greater risk ef injury and not appropriate to meet ALF residency criteria. 17. Record review at 11:00 AM on 5/11/05 revealed that the physician's health assessment for resident #5 indicated that she xequired total care with transfer. Administrator stated during interview with surveyor at 11:15 AM on 5/11/05, that resident #5 was "not able to walk." Interview with resident #3, roommate of resident #5, revealed that resident #5 was "not able to move! when the fire occurred. Interview with hospice social worker =OVd Sav NILOT TrSseazZSae E310 Seaz/aa/.s SUN-97-2005 TUE 06:08 Pit FAX NO. Pod hr (SSW) NOLNUNG FLSBOZ2SOC-CISD » L6ZZ'SINO s SHBAMBSXYS:UAS x faut, yuGeg wise] We p1:68:2 S0021U9 LY QACW BLL 3O¥e revealed that resident #5 required total care for transfer when she was under hospice care in the ALF from to 9/13/04 to 4/6/05. 18. Resident #5 suffered smoke inhalation and was taken to the hospital by fire rescue. The fire rescue report stated that "the resident was obviously in a fetal position” when found at the ALF, 20. Based on the forageing facts, Engracia’s Ratirement Eome violated Rule 58A-8.0181(1) (a), Florida Administrative Code, herein classified as a Clasa I violation, wh:ch warrants an assessed fine of $10,000.00. SURVEY PEE Pursuant to Section 400.419(10), Florida statutes, AHCA may agseas a gurvey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $154.00 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 Engracia’a Retirement Home on Counta I and If. 2@ 390d 3av0 NILVT TrgeazZ2sae EEt10 $@02/8G/49 ~~ JUN-07-2005 TUE 08:06 Pit FAK NO. P12 pr rOv(sS-WU) NOLLYUNG s bISROZZGOC-CISO «LEZU'SINGs SVMBARASHHSUAS {aw yybyfeg aise] wal b1:00°2 $0029 LY GAOY P18 39¥e 2. Revoke the facilities license pursuant to Section 400.414 (1) (e)1, Florida Stazutes. 3. In the alternative to paragraph 2 above, assess an administrative fine of $20,000.00 against Engracia’s Retirement Home on Count I and Count II for the violations cited above. 4, Assess a survey fee of $154.00 against Engracia’s Retirement Home pursuant to Section 400.419(10), Florida atatutes. 5. Assesa costs related to the investigation and prosecution of this matter, if the Court Finds costs applicable. 6. Grant such other relief as this Court deems is just and proper. Respondent ia notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Plorida Statutes (2004). Specific options for administrative 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, Ageney for Health Care Administration, 2727. Mahan ODrive, MS #3, Tallahassee, Florida 32308. 8A Bd 3sV0 NILV) TYSB@ZZSaE BE:1G $eG2/8a/28 JUN-97-2005 TUE 06:08 Pit FAR NO, P, 12 str (S- Wl] NOLLYUN HS80Z2SNE“CI8D JBLU'SING s SHABAMSKYSUAS «UAL yabiyhea uuayseg) Wd pU°C5:2 S00z/U9 LY GADY 7H 30¥d 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 ALLEGHD IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Nelson Redney, Esq. Assistant General Counsel Agency for Health Care Administration 6350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6802 Copies furnished to: Diane Castillo Field office Manager Agency for Health Care Administration 8350 N.W. 53 Street Miami, Florida 33166 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Agaisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 60 3dvc! 320 NILV1 TTSSaZzZSBe fE:18 S@aZ/8G/24 oe JUN-07-2005 TUE 06:06 Pit Fak NO, PL 14 pyrpss-Wul) OnLy « HSRO22EOC:OISD« /ELU'SNO s SHAAN NY'EAS [Ly }Aeg waysel id #1°£6°2 $0029 LY CADE PLIG 30d 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 Julio Lh. Romero, Administratoz, Engracia‘s Retirement Home, 10460 S.W. 41 Terrace, Miami, Florida 33165; Rita Cardose, 13371 S. W. 34 Street, Miami, Florida 33175 on ~~ thie \W_ day of No 4 , 2005. Nelson’ Rodney, Esq. Gt 2ovd 33V2 NIV TTSee@2zS2e EE:7B S@@Z/8A/Le8 JUN-10-2885 11:55 AHCA LEGAL DEPARTMENT BENDER: COMMLETE THIS SLO HON 8 Cormplate Heme 1, 2, and 3. Also complete ttem 4 If Reatricted Delivery |e desired. nm Print your name and addreas on the reverse $0 that we can return the card to you. @ Attach this.card to the back of the malipiece, of on the Yront If spaca permits. D. ie ooltvery address cifierent from tem 12 L) You It YES, enter delivery address below: 0 No |, Article Addressed to: 1040'S At Tonnies Kiam’. Filoicdar 33165 9. Service Type CO cenied Mat 0) Exproae Moll CD Realstered 1D Retum Receipt for Merchandlaa D insured Mail =§0 6.0.0. 102595-02-M-1540_ P. fal j1-81 TOTAL P.G1

Docket for Case No: 05-002417