STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2008008282 Return Receipt Requested: v. 7004 2890 0000 5525 9945 7004 2890 0000 5525 9952 SOUTH MIAMI HEIGHTS ALF, INC. d/b/a SOUTH MIAMI HEIGHTS ALF, 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 South Miami Heights ALF, Inc. d/b/a South Miami Heights ALF (hereinafter “South Miami Heights ALF”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2007), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,500.00 pursuant to Sections 429.14 and 429.19, Florida Statutes (2007), 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 (2007), and Chapter 28-106, Florida Administrative Code (2007). 3. Venue lies in Miami-Dade County pursuant to Section 120.57, Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code (2007). 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 1, Florida Statutes (2007), and Chapter 58A-5 Florida Administrative Code (2007). 5. South Miami Heights ALF operates a 4-bed assisted living facility located at 11720 s. W. 181 Terrace, Miami, Florida 33177. South Miami Heights ALF is licensed as an assisted living facility under license number 10904. South Miami Heights ALF 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 SOUTH MIAMI HEIGHTS ALF FAILED TO ENSURE THAT MEDICATION CABINET WAS LOCKED AT ALL TIMES. RULE 58A-5.0185(6) (b)2., FLORIDA ADMINISTRATIVE CODE (MEDICATION STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. South Miami Heights ALF was cited with three (3) Class III deficiencies as a result of a complaint investigation survey and a licensure survey that were conducted on June 18, 2007 and May 6, 2008. 8. A complaint investigation survey was conducted on June 18, 2007. Based on observation and staff interview, it was determined that the facility failed to ensure the medication cabinet was locked at all times. The findings include the following. 9. Facility tour conducted on 06/18/07 at 10:30 a.m. revealed the medication cabinet located in the kitchen was unlocked. An unsecured container of Lidocaine 5% ointment was observed in the medication cabinet. 10. An interview conducted with the administrator on 06/18/07 at 10:30 a.m. confirmed the medication cabinet in the kitchen area was unlocked and a container of Lidocaine 5% ointment was inside the cabinet. 11. The mandated date of correction was designated as July 18, 2007. 12. A licensure survey was conducted on May 6, 2008. Based on observation and staff interview, it was determined that the facility failed to ensure that its medications were locked up at all times. The findings include the following. 13. Observation of the inside of the facility's refrigerator on 5/6/08 at approximately 10 AM revealed that there was Insulin being stored inside the refrigerator in a Tupperware container. The Insulin was for Resident #3. 14. Staff interview with the facility's administrator on 5/6/08 at approximately confirmed these findings. He/she then moved the Insulin into a lockbox and placed it back into the refrigerator. This is a repeat violation from the survey of June 18, 2007. 15. Based on the foregoing facts, South Miami Heights ALF violated Rule 58A-5.0185(6) (b)2., Florida Administrative Code, herein classified as a repeat Class III violation, which warrants an assessed fine of $500.00. COUNT II SOUTH MIAMI HEIGHTS ALF FAILED TO ENSURE THAT THE FACILITY WAS FREE FROM HAZARDS THAT MAY THREATEN THE SAFETY OF THE RESIDENTS. RULE 58A-5.023(1) (a), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS III VIOLATION 16. AHCA yre-alleges and incorporates paragraphs (1) through (5) as. if fully set forth herein. 17. A complaint investigation survey was conducted on June 18, 2007. Based on observation and staff interview, it was determined that the facility failed to ensure the facility was free from hazards that may threaten the safety of the residents. The findings include the following. 18. Facility tour conducted on 06/18/07 at 10:30 a.m. revealed that resident room #1 had an extension cord which connected the television lying across the floor obstructing the pathway. 19. An interview conducted with the administrator on 06/18/07 at 10:30 a.m. revealed that she had connected the television to that extension due to a previous power outage. 20. The mandated date of correction was designated as July 18, 2007. 21. A licensure survey was conducted on May 6, 2008. Based on observation and staff interview, it was determined that the facility failed to provide a safe environment for residents. The findings include the following. 22. Observation of the facility's backyard on 5/6/08 at approximately 10:30 AM revealed that there was a structure currently under construction. There was a 3 foot piece of rebar on the ground and numerous wooden planks lying in and around the construction site (which was approximately 10 feet by 10 feet). Each plank had multiple nails sticking out of it. 23. Staff interview with the facility's administrator conducted on 5/6/08 at approximately 12 PM confirmed these findings. This is a repeat violation from the survey of June 18, 2007. 24. Based on the foregoing facts, South Miami Heights ALF violated Rule 58A-5.023(1) (a), Florida Administrative Code, herein classified as a repeat Class III violation, which warrants an assessed fine of $500.00. COUNT III SOUTH MIAMI HEIGHTS ALF FAILED TO ENSURE THAT PERSONNEL RECORDS CONTAINED VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE INCLUDING TUBERCULOSIS. SECTION 429.275(4), FLORIDA STATUTES ; RULE 58A-5.024(2) (a), FLORIDA ADMINISTRATIVE CODE (STAFF RECORDS STANDARDS) CLASS III VIOLATION 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. A complaint investigation survey was conducted on June 18, 2007. Based on record review and staff interview, it was determined that the facility failed to ensure that 2 of 2 (#1 and #2) sample employees maintain an annual physical exam that contained verification of freedom from communicable disease. The findings include the following. 27. Personnel record review revealed that the administrator and the caretaker staff #2 did not have a physical exam on file that contained verification of freedom from communicable disease. 28. An interview conducted with the administrator on 06/18/07 at 2:30 p.m. confirmed the findings. 29. The mandated date of correction was designated as July 18, 2007. 30. A licensure survey was conducted on May 6, 2008. Based on staff record review and staff interview, it was determined that the facility failed to provide verification that 2 of 3 sampled employees (#2 and #3) were free of communicable disease. The findings include the following. 31. Staff record review of staff #2's (hired 4/08). file revealed no statement of freedom from communicable disease. 32. Review of staff #3's file reveals no statement of freedom from communicable disease as well. 33. Staff interview with the facility's administrator on 5/6/08 at approximately 12 PM confirmed these findings. This is a repeat violation from the survey of June 18, 2007. 34. Based on the foregoing facts, South Miami Heights ALF violated Section 429.275(4), Florida Statutes and Rule 58A- 5.024(2) (a), Florida Administrative Code, herein classified as a repeat Class III violation, which warrants 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 South Miami Heights ALF on Counts I through III. 2. Assess an administrative fine of $1,500.00 against South Miami Heights ALF on Counts I through III for the violations 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. (2007). 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 RECE REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEI THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALL PT OF EGED 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 oe 4 Cobia +). Hedied Ly Alba M. aatige Z, oe £ Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace Miami, Copies furnished to: R. Steve Emling Field Office Manager Agency for Health Care Administration 8355 N. W. 537? Street Miami, Florida 33166 (Interoffice Mail) 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) 10 Florida 33166 #103 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 Anne Hamilton, Administrator, South Miami Heights ALF, 11720 S. W. 181 Terrace, Miami, Florida 33177; Anne M. Hamilton, Registered “en 11720 S. W. 181 Terrace, Miami, Florida 33177 on this gi “day of August, 2008. ~ Coiba: £xy). fjectis, i fn, Alba M. Rodeibient Esq. 4° il US. Postal Services CERTIFIED MAIL. REC senpeR: compLeTE THIS SECTION | (Domestic Mait Only: No insurance ¢ COMPLETE THIS SECTION ON DELIVERY A. Signatui 9 x thr ’ m Complete items 1, 2, and 3. Also complete i) For delivery information visit our website item 4 if Restricted Delivery is desired. cS a ca : ge | & {— ™ Print your name and address on the reverse a te @ #* fe go that we can return the card to you. m Attach this card to the back of the mailpiece, or on the front if space permits. 4 D. Is delivery address different from item If YES, enter delivery address below: 1. Article Addressed to: Conna, Pemat deni Saute Atom Height ALE Wide Sid 12L Toadies Hiami, FQaide 2074 Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Encorsement Required) 3. Service Type ; Ci Certified Mail 1 Express Mail CI Registered Ci Return Receipt for Merchandise insured Mail 1 C.0.D.} 4 Baeticted Delivery? (Extra Fee) O Yes Spain : Es 7004 2890 O000 5525 aq4s OL ( BS Form 3800, June 2002: 55 2 \- a ham sno abo ; -. ._— =< £ ie i int (Dru 402895-02-M-1540 PS Form 3811, February 2004 Domestic Return Receipt Com prt 7004 2890 o000 U.S. Postal Service: « SENDER: COMPLETE THIS. SECTION COMPLETE THIS SECTION ON DELIVERY He CERTIFIED MAIL a=! & Complete items 1, 2, and 3. Also complete Em (Domestic Mail Only; No Insurance Co . fom 4 if Restricted Delivery is desired. Tiny la For delivery information visit our website at so that we can return the cord to you verse : . ™ Attach this card to the b ailpi m je back of the mail a o ia Fe i c i A iL. -___ oron the front if space permits. pases, - ' 1. Article Addressed to: D. 6 Pener accress different from item 12 1 Yes : , enter delivery address below: 1] No a ane Cinna. H. Heemalldea) leturn: ee j “ a {Endorsement Required) i720 5w 1B) Tanne Restricted Delivery F: we . (endorsement Required) Miami, Fiend des AH mh - j 3 C. Return Receipt for Merchandise a O insured Mail ~(C1.C.0.D. 4 Reetricted Delivery? (Extra Fee) 7004 2890 OO00 5525 9952 , cies ET Oe WUOU S525 995e¢ | Ce (Transfer from service label) 5 . aad Z 8 Forit 9800, dune 2002. ath Ate

Docket for Case No: 08-004929