STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003001713 Return Receipt Requested: of Vv. 7000 1670 0011 4849 se6at! 7!” 7000 1670 0011 4849 5870 “WHelY NICOLAS & SHERRI CICCARELLO, 7000 1670 0011 4849 5887 “jill? (OWNERS) a/b/a SHARICK’S DECK RETIREMENT RANCH, Respondent. 0 Ds - o yb ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this administrative complaint against Nicolas & Sherri Ciccarello, Owners, d/b/a Sharick’s Deck Retirement Ranch (hereinafter “Sharick’s Deck Retirement Ranch” or the “facility”), pursuant to Chapter 400, Part III and Section 120.60, Florida Statutes, (2002), and alleges: NATURE OF THE ACTION 1. This is an action to impose and maintain the Agency’s administrative fine of $4,400.00 pursuant to Sactions 400.414, 400.419, Florida Statutes (2002), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes and Chapter 28-106, Florida Administrative Code. 3. venue lies in Hillsborough County pursuant to Section 120.57 Florida Statutes and 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 (2002) and Chapter 58A-5 Florida Administrative Code. 5. Sharick’s Deck Retirement Ranch operates a 25-bed assisted living facility located at 4508 Bruton Road, Plant city, Florida 33565. Sharick’s Deck Retirement Ranch is licensed as an assisted living facility under license number 5335. Sharick’s Deck Retirement Ranch was at all ~imes material hereto a licensed facility under the Licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE FINANCIAL RECORDS AVAILABLE FOR REVIEW BY THE AGENCY. RULES 58A-5.021(2), and/or 58A-5.024, FLORIDA ADMINISTRATIVE CODE, and/or SECTION 400.417(3), FLORIDA STATUTES. (RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Sharick’s Deck Retirement Ranch was cited with eight (8) uncorrected Class III violations pursuant to surveys conducted by the Agency on 1/28/03 and 2/27/03. 8. Based on the complaint investigation conducted by the Agency on January 28, 2003 and based staff interviews, the Agency found that the facility did not have fiscal records available for review by the Agency on the day of the survey. The findings include the following, to wit: 9. During an interview at approximately 12:56 p.m. on 01/28/03, the Administrator indicated the financial records were not at the facility, but were at his home. Given these records were not made available prior to the exit conference on 01/28/03, the facility did not have the following required financial records on the day of the survey: a. Written business records which accurately reflect the facility's assets and liabilities and income and expenses. b. Income from residents that had been identified by resident name in supporting documents, and income and expenses from other sources, such as from day care or interest on facility funds, shall be separately identified. 10. The mandated correction date was designated as February 27, 2003. 11. Based on a follow-up survey conducted on February 28, 2003 and based on staff interviews, the Agency again found that the facility did not have fiscal records available for review by the Agency on the day of the revisit survey of 2/28/03. The findings include the following, to wit: 12. During an interview at approximately 10:30a.m. on 02/28/03, the Administrator indicated the financial records were not at the facility, but were at his home. Given these records were not made available prior to the exit conference on 02/8/03, the facility did not have the following required financial records on the day of the survey: a. Written business records which accurately reflect the facility's assets and liabilities and income and expenses. b. Income from residents that had been identified by resident name in supporting documents, and income and expenses from other sources, such as from day care or interest on facility funds, shall be separately identified. 13. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rules 58A-5.021(2), and/or 58A-5.024, Florida Administrative Code, and/or Section 400.417(3), Florida Statutes, (2002), herein classified as an uncorrected Class II violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. COUNT ITI SHARICK’S DECK RETIREMENT RANCH FAILED TO MAINTAIN A WRITTEN GRIEVANCE PROCEDURE. RULES 58A-5.024(1) (k), and/or 58A-5.0182(6) (b), FLORIDA ADMINISTRATIVE CODE, and/or SECTION 400.428, FLORIDA STATUTES. (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 15. Based on the complaint investigation conducted on January 28, 2003 and based on record reviews and an interview with the staff, the Agency found that the facility/Administrator failed to maintain a written grievance procedure for receiving and responding to resident complaints and recommendations. The findings include the following, to wit: 16. During a review of the facility's records and an interview with the Administrator, indicated there was no documentation of the facility's complaint procedure, complaints received, and how the facility responded to complaints they had received. During an interview at approximately 1:18 p.m. on 01/28/03, the Owner/Administrator stated, "It's with our log book, I have a new log book now." 17. The mandated correction date was designated as February 27, 2003. 18. Based on the follow-up survey conducted on February 28, 2003 and based on an interview with the staff on the day of this re-visit (2/28/03), the Agency again found that the facility/Administrator failed to maintain a written grievance procedure for receiving and responding to resident complaints and recommendations. The findings -nclude the following, to wit: 19, There was no documentation of the facility's complaint procedure, complaints received, and how the facility responded to complaints they had received. During an interview with the facility manager at approximately 11:00 am on 2/28/03 she indicated there was not a written procedure available for review. 20. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rules 58A-5.024(1) (k), and/or 5S8A- 5.0182(6) (b), Florida Administrative Code, and/or Section 400.428, Florida Statutes, herein classified as an uncorrected Class III violation pursuant to Section 400.419(1) (cj), Florida Statutes, (2002), which carries an assessed fine of $500.00. COUNT III SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE A CURRENT FIRE INSPECTION REPORT. SECTION 400.441, FLORIDA STATUTES, and/or RULES 58A-5.015(1) (a) (3), and/or 58A-5.024(1) (m), FLORIDA ADMINISTRATIVE CODE. (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 21. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 22. Based on the complaint investigation conducted on January 28, 2003 and based on record review and an interview, the facility did not maintain and/or provide satisfactory fire safety inspection reports issued by the local authority having jurisdiction or the State Fire Marshal within the last year. The findings include the following. 23. During a xreview of the ALF's fire inspection reports and an interview with the Administrator/Owner, revealed the last Fire Department's inspection was conducted on 06/28/01 or more than a year and a half ago. During an interview at approximately 10:42 a.m. on 01/28/03, the Administrator/Owner stated, "We had one done last year, i= not, I can send one to you." 24, The mandated correction date was designated as February 27, 2003. 25, Based on the follow-up survey conducted = on February 28, 2003 and based on an interview, the facility did not maintain and/or provide satisfactory fire safety inspection reports issued by the local authority having jurisdiction or the State Fire Marshal within the last year. The findings include the following. 26. During the re-visit of 2/28/03, the facility manager indicated that the local fire department had been contacted and requested to conduct an annual inspection but they had not come to the facility as yet. The fire inspection report available for review was dated 6/28/01. 27. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Section 400.441, Florida Statutes and Rule 58A-5.015(1) (a) Florida Administrative Code, herein classified as n uncorrected Class III violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. COUNT IV SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE RESIDENT CONTRACTS AVAILABLE FOR REVIEW. RULE 58A-5.024(3) (i), FLORIDA ADMINISTRATIVE CODE (RESIDENT RECORD STANDARDS) UNCORRECTED CLASS III VIOLATION 28. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29, Based on the complaint investigation conducted on January 28, 2003 and based on_ record review and an interview with the Administrator, the Agency found that the facility failed to have resident contracts available for review by the Agency. The Agency determined that two of three records did not include the required information regarding the signed contract between the resident and the facility. The findings include the following, to wit: 30. Resident #2’s and resident #3's clinical records were reviewed and the Administrator interviewed at 11:00 a.m. It revealed that the resident files did not contain signed contracts between the facility and the residents. 31. The mandated correction date was designated as February 27, 2003. 32. Based on the follow-up survey conducted on February 28, 2003 and based on an interview with the Administrator during the re-visit of 2/28/03 at approximately 10:30 AM, the Agency again found that the facility failed to have resident contracts available for review by the Agency. The Administrator stated that the contracts for the residents (#2 6 3) were not at the facility but were at his home. The administrator stated that he does not keep this information at the facility, and that this is a recurring issue, at every survey. During conversation, the administrator stated he could fax the information the following day, but could not bring or fax the contracts to the facility at the time of this visit. 33. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.024(3) (i), Florida Administrative Code, herein classified as an uncorrected Class IIl violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. 10 COUNT V SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE STAFF TRAINING IN THE IMPLEMENTATION OF EMERGENCY PROCEDURES. RULE 58A-5.0191(2) (b), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 35. Based on the complaint investigation conducted on January 28, 2003 and based on record reviews and interview, the Agency found that the facility failed to have staff training in the implementation of emergency procedures. The administrator did not ensure that staff who provide direct care to residents had received the training required by the Rule or Florida Administrative Code, for two out of four Employee's sampled. The findings include the following, to wit: 36. Employee #2 hired 11/15/01 and Employee #3 hired 07/28/02, did not have documented evidence in his/her personnel files of having received a minimum of 1 hour in- service training within 30 days of employment on _ the facility emergency procedures including chain of command and staff roles relating to emergency evacuation. During an interview at approximately 1:01 p.m. on 01/28/03, the Administrator stated, “I did it, but does it have to be documented?" 37. The mandated correction date was designated as February 27, 2003. 38. Based on the follow-up survey conducted on February 28, 2003 and based on record reviews and interview at the time of this re-visit of 2/28/03, the Agency again found that the facility failed to have staff training in the implementation of emergency procedures. The administrator did not ensure that staff who provide direct care to residents had received the training required by the Rule or Florida Administrative Code, for one employee sampled. The findings include the following, to wit: 39. One employee did not have documented evidence in his/her personnel files of having received a minimum of 1 hour in-service training within 30 days of employment on the facility emergency procedures including chain of command and staff roles relating to emergency evacuation. 40. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0191(2) (b), Florida Administrative Code, herein classified as an uncorrected Class III violation pursuant to Section 400.419(1)(c), Florida Statutes, (2002), which carries an assessed fine of $500.00. 12 COUNT VI SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE STAFF TRAINED IN REPORTING ABUSE AND RESIDENT RIGHTS. RULE 58A-5.0191(2) (c), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 41. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 42. Based on the complaint investigation conducted on January 28, 2003 and based on record reviews and interview, the Agency found that the facility failed to have staff trained in reporting abuse and resident rights. The Administrator did not ensure that staff who provide care to residents, who have not taken the core training program, had received the required training per the Rule or Florida Administrative Code, for two out of four Employee records sampled. The findings include the following, to wit: 43. Two employees (#2 and #3) who did not take the Core training did not have documented evidence in his/her personnel file of having received a minimum of 1 hour in- service training within 30 days of employment in the following required areas: a. Resident rights in an assisted living facility. b. Recognizing and reporting resident abuse, neglect, and exploitation. 44. The mandated correction date is designated as February 27, 2003. 45. Based on the follow-up survey conducted on February 28, 2003 and based on record reviews on the day of tais re-visit and interview with the facility manager, the Agency again found that the facility failed to have staff trained in reporting abuse and resident rights. The Administrator did not ensure that staff who provide care to residents, who have not taken the core training program, had received the required training per the Rule or Florida Administrative Code. The findings include the following, to wit: 46. Two employees who did not take the Core training did not have documented evidence in his/her personnel file ef having received a minimum of 1 hour in-service training within 30 cays of employment in the following required areas: a. Resident rights in an assisted living facility. b. Recognizing and reporting resident abuse, neglect, and exploitation. 14 47. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0191(2) (c), Florida Administrative Code, herein classified as an uncorrected Class III violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. COUNT VII SHARICK’S DECK RETIREMENT RANCH FAILED TO TRAIN STAFF IN RESIDENT BEHAVIOR AND NEEDS. RULE 58A-5.0191(2) (d), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 48. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 49. Based on the complaint investigation conducted on January 28, 2003 and based on record reviews and interview, the Agency found that the Administrator failed to ensure that staff who provide direct care to residents, other than rurses, CNAs, or home health aides, had received the required training in resident behavior and needs, per the Rule or Florida Administrative Code, for two out of four Employee records sampled. The findings include the following, to wit: 50. Two (#2 and #3) staff members did not have documented evidence in their personnel files of having received training in accordance with Rule 59A-8.0095 by receiving 3 nours of in-service training within 30 days of employment in the following areas: a. resident behavior and needs. b. providing assistance with activities of daily living. 51. During an interview at approximately 11:44 a.m. on 011/28/03, the Administrator indicated he would have to ask another staff member which staff had the training. 52. During an interview at approximately 12:00 p.m. on 011/28/03, the Administrator further indicated none of his employees were RNs, LPN,s or C.N.A.'S. 53. The mandated correction date was designated as February 27, 2003. 54, Based on the follow-up survey conducted = on February 28, 2003 and based on record reviews and interview with the facility manager on the day of this re-visit, the Agency found that the Administrator failed to ensure that staff who provide direct care to residents, other than nurses, CNAs, or home health aides, had received the required training in resident behavior and needs, per the 16 Rule or Florida Administrative Code. The Administrator did not ensure staff who provide care to residents' received the training as required within 30 days of employment. The findings include the following, to wit: 55. Two staff members did not have documented evidence in their personnel files of having received training in accordance with Rule 58A-5.0191(2) and Rule 59A-8.0095, in resident behavior and needs. 56. Based on the foregoing, Sharick’s Deck Retirement Ranch viclated Rule 58A-5.0191(2) (d), Florida Administrative Code, herein classified as an uncorrected Class III violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. COUNT VIII SHARICK’S DECK RETIREMENT RANCH FAILED TO MAINTAIN THE FACILITY’S PHYSICAL STRUCTURE IN GOOD REPAIR. RULE 58A-5.023(1) (b), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) UNCORRECTED CLASS III VIOLATION 57. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 58. Based on the complaint investigation conducted on January 28, 2003 and based on observation and an interview, 7 the Agency found that Sharick’s Deck Retirement Ranch failed to maintain the facility's physical structure, including the interior walls, in good repair. The findings include the following, to wit: 59. During the tour of the facility at approximately 10:40 a.m., it was discovered that the bathroom nearest the working kitchen was missing the interior molding on the inside of the bathroom door. The Administrator's interview at approximately 2:50 p.m. revealed that one of the residents in a wheel chair probably tore it off. 60. The mandated correction date was designated as February 27, 2003. 61. Based on the follow-up survey conducted = on February 28, 2003 and based on observation and an interview on the day of this re-visit of 2/28/03, the Agency found that Sharick’s Deck Retirement Ranch failed to maintain the facility's physical structure, including the interior walls, in good repair. The findings include the following: 62. During the tour of the facility at approximately 11:00 a.m., it was learned the bathroom nearest the working kitchen was missing the interior molding on the inside of the bathroom door had still not been repaired, although cited during the annual survey of 1/28/03, and had been assigned a mandated correction date of February 27, 2003. 18 63. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.023(1){(b) Florida Administrative Code, herein classified as an uncorrected Class III violation pursuant to Section 400.419(1) (c), Florida Statutes, (2002), which carries an assessed fine of $500.00. SURVEY FEE 64. Pursuant to Section 400.419(9), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of initial complaint investigations. A survey fee of $400.00 was assessed in this instance. 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 Sharick’s Deck Retirement Ranch on Counts I, II, III, IV, V, VI, VII and VIII. 2. Assess and maintain the Agency’s administrative fine totaling $4,000.00 against Sharick’s Deck Retirement Ranch on Counts I through VIII, for the violations cited above. 3. Assess and maintain the Agency’s survey fee of $400.00 against Sharick’s Deck Retirement Ranch pursuant to Section 400.419(9), 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 (2002). 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, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE BR 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. 20 Respectfully submitted, (f~ Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 N. W. 53 Street Miami, Florida 33166 Copies furnished to: Patricia Reid Caufman Field Office Manager Agency for Health Care Administration 525 Mirror Lake Drive Sebring Building - 4" Floor St. Petersburg, Florida 33701 (U.S. Mail) 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) 21 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 Nicolas Antonio Ciccarello, Administrator, Sharick’s Deck Retirement Ranch, 4506 Bruton Road, Plant City, Florida 33565; Sharick’s Deck Retirement Ranch, Inc., 107 N. Alexander Street, Plant City, Florida 33567; Nicolas A. Ciccarello, 107 N. Alexander Street, lag Plant City, i 33567 on this SD } day of i Cpe , 2003. Kathryn F. Fenske, Esq. 22

Docket for Case No: 03-002250