STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2015005684 v. Return Receipt Requested: 7002 2410 0001 4240 2780 SWEET 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 Sweet Retirement Home, Inc. (hereinafter “Sweet Retirement Home”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes, (2014), and alleges: NATURE OF THE ACTION 1. This is an action to impose a revocation of license pursuant to Sections 408.815(1)(b), 408.815(1)(c), 429.14(1)(b), 429.14(1)(a), and 429.49(2), Florida Statutes, an administrative fine of $16,000.00 pursuant to Section 429.19(2)(b), Florida Statutes (2014), for the protection of the public health, safety and welfare and $440.00 survey fee pursuant to Section 429.19(2)(b), and 429.19(7), Florida Statutes (2014). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies pursuant to 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 429, Part I, Florida Statutes (2014), and Chapter 58A-5, Florida Administrative Code. 5. Sweet Retirement Home operates a 14-bed assisted living facility located at 1840- 42 NW 15% Street, Miami, Florida 33125. Sweet Retirement Home is licensed as an assisted living facility license number AL12510, with an expiration date of 5/22/2016. Sweet Retirement Home 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. COUNTI SWEET RETIREMENT HOME’S ADMINISTRATOR FAILED TO DEMONSTRATE THAT SHE WAS RESPONSIBLE FOR THE OPERATION AND MAINTENANCE OF THE FACILITY Section 429.176, Florida Statutes, and Rule 58A-5.019(1), Florida Administrative Code (STAFFING STANDARDS-ADMINISTRATORS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted from 5/01/201 and concluded on 5/29/2015, and based on observations, record reviews, and interviews, it was determined that the facility's Administrator failed to demonstrate that she was responsible for the operation and maintenance of the facility including that residents received three meals per day, that residents records were documented with incidents that were reported to law enforcement, that staff members had personnel records, that the facility had a Manager that completed CORE training, and that the facility was able to operate in a financially stable manner. 8. During the complaint survey process from 5/1/2015 to 5/29/2015, the Administrator listed did not participate in the survey process and was not available. The facility failed to have a Manager who completed CORE training to assist during the absence of the Administrator. 9. Record review found that Resident #1 went missing after a chemotherapy treatment on 4/29/2015. The facility did not have any documentation on the incident and did not follow its practice of sending a staff member with the resident. Resident #9 was admitted on 4/17/2015 and went missing on 4/18/2015, and the facility did not have any documentation on the incident and did not report it to the Agency for Health Care Administration. 10. During interview on 5/1/2015 at 11:56 AM with Staff F, it was stated that "when Resident #1 goes to her oncology appointments we send an employee with her, however other times she had gone by herself and we never had any problems. The day she went missing, Staff F had both employees at the home, she was picked up by the transporter about 8:00 in the morning, the oncology appointment is a whole day appointment, (she gets chemotherapy and returns in the afternoon) at about 4:00 PM, the staff at the doctor's office called to say she gotten up to get some paper work and when she returned to the desk, Resident #1 was gone. Within a few minutes of the incident, the doctor's office called us. The doctor's office then called the police, and they found her at about 2:00 AM. When Resident #1 returned back to the facility and she told the staff that, she had gone to the hospital cafeteria to get something to eat and was unable to find her way back to the office. She was found by the police sitting on a bench around the hospital area." 11. During an interview on 5/01/2015 at 11:34 AM with Staff F it was stated; "The hospital sent Resident #9 here on 4/17/2015, they said that as long as there was a fence around the property she wouldn't try to leave. On 4/18/2015 at about 2:15 PM she jumped over the fence and left. I didn't think it was possible for her to jump the fence. I then called the police and reported she was missing. The officer then called me and told me she (Resident #9) had done this before." 12. Observations and interviews on 5/1/2015 found that the residents were not receiving a balanced and variety meals three times a day at the facility. Resident interviews from 11:30 AM to 4:00 PM on 5/1/2015 revealed that Resident #2 and staff members bought the residents food. 13. Interview on 5/4/2015 at 1:35 PM with Staff D it was stated; "What I've seen here is that they are not keeping up with the food supplies, we ask for something and it takes them a while to get it, now after the inspection (5/1/2015) is when they are picking up the pace." 14. Interview on 5/4/2015 at 1:35 PM with Staff C it was stated; "When we ask for supplies or food it takes them a while to get them here, now we are seeing a better response, it is getting better with the new owners." 15. Record review on 5/29/2015 found that the facility had income and expense records for the month of April, no other financial documentation was found at the facility. 16. = On 5/29/2015 at 1:15 PM, the Administrator provided bank statements for the months of February, March, and April (2015). The March bank statement showed that the facility's account had insufficient funds fees on 3/19/2015 and 3/23/2015 for $34.00 each. The April bank statement showed the facility's account received $34.00 in fees for a total of $238.00 for insufficient funds on the following dates: 4/2/2015, three on 4/3/2015, 4/7/2015, 4/20/2015, 4/21/2015, and 4/30/2015. 17. Record review found the facility did not have personnel records for Staff E, F, and 18. Based on the foregoing, Sweet Retirement Home violated Section 429.176, Florida Statutes, and Rule 58A-5.019(1), Florida Administrative. Code, a Class II deficiency, which carries, in this case, an assessed fine of $5,000.00 and revocation of the license. COUNT II SWEET RETIREMENT HOME FAILED TO MAINTAIN ADEQUATE DIETARY STANDARDS FOR THE RESIDENTS Rule 58A-5.020(2), Florida Administrative Code (FOOD SERVICE-DIETARY STANDARDS) CLASS II VIOLATION 19. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 20. During the complaint investigation conducted from 5/01/2015 and concluded on 5/29/2015, and based on observation, interviews, and record review, it was determined that the facility failed to maintain adequate dietary standards for the residents. The facility failed to ensure that food was available for residents at all times. The facility failed to follow approved menus, failed to offer adequate portions, and did not offer meals adapted to the preferences of residents. The facility failed to follow diet orders for two of fourteen (Residents #1 and #8) sampled residents and the facility also failed to have diet orders for one of fourteen (Resident #11) sampled residents. 21. Record review showed that Resident #1's health assessment dated 10/17/2014 documented that the resident required a diabetic diet with no added salt. 22. Resident #11 did not have a diet order documented on the health assessment and the facility did not have any documentation regarding the resident's diet requirements. 23. During interview on 5/4/2015 at 10:45 AM, Resident #8 was asked about her health assessment dated 11/18/2014 with diet instructions that read, "Dental mechanical soft puree meals" she stated, "I've always been served regular food, it's sometimes hard for me to eat meat. It's just that at the end of the month sometimes there is little food left.” 24. On 5/01/2015, between 11:30 AM and 4:00 PM, six of seven sampled residents (Residents #2-7) stated that they had one piece of bread with a very small amount of cream cheese or jelly for breakfast. Resident # 6 stated; "usually we have two pieces." Resident #4 stated, "I asked for another piece, but they had run out." 25. On 5/1/2015, a review of the posted menu revealed that the day's breakfast menu was: 4 oz. juice, % cup hot or % cup cold cereal, 8 oz. milk, 1 slice toast, margarine, jelly. 26. On 5/1/2015 at 4:02 PM, Resident #6 stated that she is always hungry. She stated that she was drinking a lot of water so that she would feel less hungry until her doctor placed her on a water restriction because her blood potassium and sodium levels were found to be too low. 27. On 5/1/2015 at 12:00 PM, Resident # 2 stated that he had used his own money to buy food for residents because people were hungry. 28. On 5/1/2015 at 12:35 PM, Staff B stated that the residents had one piece of toast with cream cheese for breakfast on 4/30/2015. She stated that Staff C had also given each resident "a little piece of pizza" from the three frozen pizzas which the employee had bought. 29. On 5/1/2015 at 4:05 PM, Resident # 6 stated that she had hotdogs for dinner around four times during the past week, sometimes twice a day. 30. On 5/01/2015 at 1:35 PM, Resident #4 stated that hotdogs had been served at least three times for dinner in the past week. 31. © On 5/01/2015, a review of the posted menu revealed that there were no hotdogs on the dinner menu. 32. On 5/01/2015 at 1:35 PM, Resident #6 stated that she'd had black-beans and rice for dinner for the last 5 days and that she sometimes had it for lunch. She'd had it the night before, stating "it was supposed to be hotdogs and beans but there were really no hotdogs in it, mostly just beans and rice." 33. On 5/01/2015, a review of the menu revealed that dinner for the prior night should have been 3 oz. chicken and Spanish sausage, 1 cup yellow rice, % cup peas, 1 cup tossed salad, % cup dessert, 8 oz. milk 34. On 5/1/2015 at 1:32 PM, Resident #4 stated, Resident #2 " buys food for us to eat. He sees that we don't have what we're supposed to have to eat." 35. On 5/1/2015 at 12:35 PM, staff was observed serving one hotdog (approx. 1.5 oz.) to residents on a hamburger bun. 36. On 5/1/2015, a review of the menu revealed that 3 oz. of hotdogs on a bun were scheduled to be served. 37. Observations on 5/29/2015 at 9:30 AM found, two containers that contained what appeared to be urine in the facility's refrigerator on the top shell. The refrigerator contained food that was fed to the residents. 38. On 5/29/2015 at 9:30 AM, Staff B stated, the containers had urine for Residents #7 and another person. 39. Based on the foregoing, Sweet Retirement Home violated Rule 58A-5.020(2), Florida Administrative Code, a Class II deficiency, which carries, in this case, an assessed fine of $5,000.00 and revocation of the license. COUNT III SWEET RETIREMENT HOME FAILED TO ENSURE THAT ONE STAFF, WHO HAS ACCESS TO RESIDENTS’ PERSONAL PROPERTY OR LIVING AREAS HAD A LEVEL II BACKGROUND SCREENING AND BEEN DETERMINED ELIGIBLE Sections 408.809, 435.02(2), and 435.06, Florida Statutes (BACKGROUND SCREENING; PROHIBITED OFFENSES) UNCLASSIFIED VIOLATION 40. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 41. During the complaint investigation conducted from 5/01/2015, and concluded on 5/29/2015, and based on interview and record review, it was determined that the facility failed to ensure that one of seven sampled staff (Staff G) who has access to residents’ personal property or - living areas had completed a Level II Background Screening and been determined eligible. 42. On 5/1/2015 between 11:40 AM and 4:00 PM, Staff G was observed in several resident rooms, unaccompanied by any other facility staff, completing various repairs. 43. On 5/1/2015 at 1:30 PM, the Owner (Staff E) stated that Staff G is on staff as the maintenance man, and that he did not have a background screen because he only does repairs around the facility. 44. On 5/8/2015, a review of the AHCA Background Screening Database revealed that there was no current eligible Level II Background Screening for Staff G. 45, Based on the foregoing, Sweet Retirement Home violated Sections 408.809, 435.02(2), and 435.06, Florida Statutes, an unclassified deficiency, which carries, in this case, an assessed fine of $500.00 and revocation of the license. COUNT IV SWEET RETIREMENT HOME FAILED TO NOTIFY THE AGENCY IN WRITING, AT LEAST 60 DAYS BEFORE AN ANTICIPATED DATE OF THE CHANGE OF OWNERSHIP Sections 408.803(5), and 408.807, Florida Statutes (CHANGE OF OWNERSHIP) UNCLASSIFIED VIOLATION 46. | AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 47. During the complaint investigation conducted from 5/01/2015 and concludes on 5/29/2015, and based on record review and interviews, it was determined that the facility failed to notify the agency in writing at least 60 days before an anticipated date of the change of ownership. 48. . In an interview on 5/4/2015 at 10:55 AM, a friend of the owners (Staff E and F) stated; "the owner and her husband are buying the ALF, and they are working on bringing everything up to regulations. Currently we only have 3 months of financial records, the other manager here was fired, she was not keeping any records, we have been able to reconstruct only the past three months of records." 49. An interview with Staff E on 5/29/2015 at 10:05 AM revealed that she was trying to buy the ALF but need the zoning approval before she could submit the application to the * agency. 50. - The Florida Department of State, Division of Corporations website showed an event in which 51 percent or more of the ownership or controlling interest of a licensee is in any manner transferred or otherwise assigned to Staff E on 12/05/2014. 51. The agency was not notified in the change of ownership by the facility. 52. Based on the foregoing, Sweet Retirement Home violated Sections 408.803(5), and 408.807, Florida Statutes, an unclassified deficiency, which carries, in this case in accordance with Section 429.19(6), Florida Statutes, an assessed fine of $5,000.00 and revocation of the license. COUNT V SWEET RETIREMENT HOME FAILED TO SHOW EVIDENCE OF THE ABILITY TO OPERATE Sections 408.803(7), and 408.810, Florida Statutes, and Rule 58A-35.062(3)(e)&(7), Florida Administrative Code (PROOF OF FINANCIAL ABILITY TO OPERATE) UNCLASSIFIED VIOLATION 53. During the complaint investigation conducted from 5/01/2015 and concludes on 5/29/2015, and based on record review and interviews, it was determined that the facility failed to evidence to show the ability to operate. 54. Interview on 5/4/2015 at 1:35 PM with Staff D stated; "I started here on April 22, 2015 I just got paid on May 2, 2015. She (owner) said she was going to start paying us on the 1" and the 15" of the month. What I've seen here is they are not keeping up with the food supplies, we ask for something and it takes them a while to get it, now after the inspection (5/1/2015) is when they are picking up the pace." 55. Interview on 5/4/2015 at 1:35 PM with Staff C stated; “I started March 25, 2015, I was paid the first time on April 30, 2015. She (owner) said it was going to be on the 1“ and the 10 15" of the month from now on. When we ask for supplies or food it takes them a while to get them here, now we are seeing better, it is getting better with the new owners." 56. Interview on 5/4/2015 10:55 AM with a friend of the owners stated; "the owner and her husband are buying the ALF, and they are working on bringing everything up to regulations. Currently we only have 3 months of financial records, the other manager here was fired, she was not keeping any records, we have been able to reconstruct only the past three months of records." 57. Record review on 5/29/2015 found the facility had income and expense record for the month of April, no other financial documentation was found at the facility. 58. On 5/29/2015 at 1:15 PM, the Administrator provided bank statements for the months of February, March, and April (2015). The March bank statement showed the facility's account had insufficient funds fees on 3/19 and 3/23 for $34.00 each. The April bank statement showed the facility's account received $34.00 fees for a total of $238.00 for insufficient funds on the following dates: 4/2, three on 4/3, 4/7, 4/20, 4/21, and 4/30. 59. Based on the foregoing, Sweet Retirement Home violated Sections 408.803(7), and 408.810, Florida Statutes, and Rule 59A-35.062(3)(e)&(7), Florida Administrative Code, an unclassified deficiency, which carries, in this case, an assessed fine of $500.00 and revocation of the license. SURVEY FEE Pursuant to Section 429,19(7), Florida Statutes, AHCA may assess a survey fee of $440.00 to cover the cost of conducting complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits. PRAYER FOR RELIEF WHEREFORE, the Petitioner,.State of Florida Agency for Health Care Administration ll requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through V. B. Revoke the Respondent’s license and assess an administrative fine of $16,000.00 against Sweet Retirement Home ALF on Counts I through V, for the violation cited above. C. Assess a survey fee of $440.00 against Sweet Retirement Home ALF, pursuant to Sections 429.19(7), and 429.19(2)(a), Florida Statutes (2014). . D. 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 (2014). 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 for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 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. son E, Rodhey Assistant General Counsel Agency for Health Care Administration 8333 NW 53” Street, Suite 300 Miami, Florida 33166 (305) 718-5908 12 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 NW 53" Street, Suite 300 Miami, Florida 33166 (Cnter-office mail) CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Yadelkis Cruz, Administrator, Sweet Retirement Home, 1840-42 NW 15" Street, Miami, Florida 33125 ons \Weu 23 , 2015. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Sweet Retirement Home, Inc. AHCA No: 2015005684 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 Administrative Complaint. Tf 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 Chapter120, Florida Statutes (2008) 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 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the 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 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 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 received by the Agency Clerk at the address above within 21 days of your receipt 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. A statement 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) Thereby 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. Signed: Date: Print Name: Title: Late fee/fine/AC USPS.com® - USPS Tracking™ : Page 1 of 1 Engish Customer Service USPS Mobile Register/Sign in BaUSPSCOM: = Customer Service > : hd Have questions? We're here to help. i Get Easy Tracking Updates > Sign up for My USPS. USPS Tracking™ 7? 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Docket for Case No: 15-004326