STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF F LORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2014005674 . Return Receipt Requested: v. 7002 2410 0001 4240 1042 VILLA SERENA III, 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 Villa Serena Tl (hereinafter “Villa Serena III”), pursuant to Chapter 429, Part I, Chapter 408, Part Il, and Section 120.60, Florida Statutes (2013), 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 (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. Villa Serena III operates a 13-bed assisted living facility located at 1777 N. W. 30 Street, Miami, Florida 33142, Villa Serena III is licensed as an assisted living ‘facility under license number 10792. Villa Serena III 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 VILLA SERENA II FAILED TO HONOR RESIDENTS’ RIGHTS AS EVIDENCED BY FAILING TO MAINTAIN A SAFE AND DECENT ENVIRONMENT FREE OF BED BUG INFESTATION. SECTION 429.28 FLORIDA STATUTES RULE 58A-5.0182(6), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE, RIGHTS, AND FACILITY PROCEDURES STANDARDS) CLASS If VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein, 7. Villa Serena III was cited. deficient . practice as the result of a complaint investigation survey that was conducted on February 4, 2014, 8, A complaint investigation survey was conducted on February 4, 2014. Based on record review, interview, and observations, it was determined that the assisted living facility failed to honor resident rights. The facility failed to maintain a safe and decent environment, free of bed bug infestation. 9. On 2/3/2014 at 9:05 a.m. met with the Department of Health (DOH) inspector at the facility and she said that the facility had bed bugs in rooms #1, #2, #4, and #8, And that there was evidence of bed bugs in room #7. 10. Tour with one of the facility's assistant administrator on 2/3/2014 at 9:10 a.m. Room #1 two beds both. with lifts. There were two male residents in this room. Room #2 two beds both male residents sleeping. Room #4 two beds, both male residents were not at the facility at the time of survey. Room #7 there were three beds, all three beds were occupied by male residents. Room #8 two beds, both male residents were lying on their beds during the tour. 11. After the tour, the assistant administrator confirmed that rooms #1, #2, #4, and #8 had bed bugs based on the Department of Health's inspection. She said she knows. She said that the facility had a census of 13 residents. 12. In an interview with resident #2 on 02/03/2014 at 9:25 a.m. sitting on the back porch. He stated he has been living at the facility for one year. He stated the facility had a problem with bed bugs last winter. He stated someone came out and sprayed the facility at that time. He stated he has not seen any bed bugs since. 13. — In an interview with resident #3 on 02/03/2014 at 9:35 a.m. in his room #3. He stated he has been living at the facility for one year. He stated has seen bugs on the walls and ceiling in his room. He stated he do not know what kind of bugs they are. . 14. ‘In an interview with resident #4 on 02/03/2014 at 9:40 a.m. in the TV room. He stated he has been living at the facility for two years. He stated he has never had bed bugs problems. He stated his roommate complained to him something was biting him over his entire body and did not know what it was. 15. Interview with resident #9 (resident #4's roommate) at 9:42 am. He was asked if he has any issues with bed bugs or anything biting him. He said yes in my bed at night and they bite me all over. He said he had bumps and had to go to the VA (Véterans Administration) hospital to get a cream. The cream was in his dresser called Ketoconazole. He says this was happening for 1 to 2 months. He told them to change his mattress. He said that he does not have any bumps or bites right now. He said that this did not happen during the day only at night. 16. Phone interview with the facility's administrator on 2/3/2014 at 9:45 a.m. She was told that the Department of Health was at the facility and they confirmed that there were bed bugs. She said that they were spraying and a company came out to spray also. We requested the receipt to show that a company was out there spraying. She was told which rooms where affected. She was weighing her options to tent the home or purchase new mattress. She said that there were mattresses that were changed and the old one thrown away. She said that she would be tenting the house. 17. Interview with assistant administrator on 2/3/2014 at 10 am. revealed that administrator will tent the house. She said that mattresses are being removed and that they threw out five mattresses but the mattresses were observed on the side of the house next to a resident room window. 18. In an interview with DOH inspector on 02/03/2014 at 10:30 AM. She stated she observed bed bugs in rooms #1, #2, #4, and #8 in the mattress. She stated room #7's mattresses had evidence of bed bugs. She stated in room #8 one of the mattress had bed bug eggs. She stated she will return to the facility on 02/04/2014", 19. Phone conversations at 12:12 p.m. and 12:26 p.m. with the administrator. She said that she spoke to a company and that they would need to be out of the facility for 20 hours. She is looking to tent the house tomorrow. She said she had 7 beds available at her other facilities plus has a friend with an ALF that can take a couple of the residents. She is also in the process of calling family members to help for one night. She says that this is the initial plan but it may change and she will put everything in writing to us. 20. She called again and she said AVE pest control were out there on December 3. - She says that her maintenance person has been spraying and no company has come out to spray for the bed bugs. 21, Phone interview with the administrator on 2/3/2014 at 3:52 p.m. She stated that they are tenting the house tomorrow 2/4/14 and that the residents will be out of the facility for two days. One day to exterminate and another day to air out the house. She was told that residents in the affected area needed to be removed from room #1, #2, #4, and #8. She said that she will be moving them out today and that the rest will go out tomorrow at her other facilities, family homes, or another ALF. She said that all the information will be faxed to the office including the list of where residents are going. . 22. — Record review found that the Department to Health's report dated 2/4/2014 found that the facility had bed bugs in the mattresses throughout. During the inspection, bed bugs were found in resident rooms #1, #2, #4, and #8, There was evidence of bed bugs in resident room #7. The health department also observed blood stained and damage linens. DOH also had photo © graphic evidence of the infestation of bed bugs. . 23. Arrived and entered the facility with DOH inspector on 02/04/2014 at 8:30 AM. The assistant administrator let us into the facility. DOH explained we wanted to inspect the rooms for bed bugs. 24. Inspection of rooms with DOH on 02/04/2014 at 8:35AM. Room #1 bed bugs found in the corner ceiling. Room #2 bed bugs noted in resident #9's mattress. Bed bugs were found in corner of wall base board. Room # 4 bed bugs noted in both mattresses. Room # 6 bloody spots noted on bed sheet. Room #8 bed bugs noted in both mattresses. 25. 02/04/2014 at 10:15 am. staff member from the Miami office translated via telephone an interview with the maintenance man from the facility. He stated he sprayed the facility for bed bugs four to five times using a spray named Talstar, 26. — Inan interview with a staff member from Darn Quick Termite and Fumigation via telephone on 02/04/2014 at 10:30 a.m, She stated the administrator did not tell them of the bed bug problems at the facility. She stated the revised proposal in the amount of $1,500 dollars was e-mailed 02/03/2014. She stated the company was planning to tent the facility 02/06/2014. No signed contract between the facility and Darn Quick was on file at the time of my visit. 27. 2/5/2014 the agency received a fax from Villa Serena 3. The first page was an action plan for the next few days. 2/4/14 transfer residents (with items examples medications, clothing, efc.). Disposed compromised furniture. Wash linens at high temperature. 2/5/14 Property is tented. 2/6/14 tent is removed from property and staff begins cleaning. 2/7/14 pending Department of Health approval to readmit residents. | 28. The facility faxed the maintenance log to the agency on 2/5/2014 which stated that on 12/4/13 "presence of bed bugs in Resident s room". The log says that the area was sprayed with special chemical] solution. Mattresses were disposed and clothing cleaned, The log says that on 12/11/13" bed bugs in resident room”. The facility documents that they sprayed and special covers for beds were purchased. 29. ‘The facility does not document that the mattresses were disposed. The facility writes on 12/23/13" all rooms sprayed for bed bugs". The facility writes on 1/10/2014" pest control-bed bug sprayed". The facility does not have any additional documentation regarding spraying for bed bugs after 1/20/2014. The facility does not have any documentation that a licensed pest control company came out from 12/4/2013 to complete an inspection to see if the spray was actually helping eliminate the bed bugs. 30. Based on the foregoing facts, Villa Serena III violated Section 429.28, Florida Statutes, and Rule 58A-5.0182(6)(f), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. 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 Villa Serena III on Count I. 2. Assess an administrative fine against Villa Serena III 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 Lourdes A. Naranjo, Esq. 7 Fla, Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53” Street Suite 300 Miami, Florida 33166 305-718-5906 Copies furnished to: Arlene Mayo-Davis Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. — Suite 500 Delray Beach, Florida 33484 (U.S. Mail)(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 Roxana Solano, Administrator, Villa Serena 4 . “ Ill, 1777 N. W. 30 Street, Miami, Florida 33142-on this V, en of ; 2014. ews eee fo Lourdes A. Naranjo, Esq. } o } . STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Villa Serena HI , AHCA No.: 2014005674 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 J] 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)___—I 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 : 7 . } . received by the Agency Clerk at the address above within 21 days of your ..¢eipt 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. Astatement 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. 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Docket for Case No: 14-003679