STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION q;, NAR 18 PH i: Ol AGENCY FOR HEALTH CARE VIS ADMINISTRATION, ADMINISTRAI YE HEARINGS Petitioner, AHCA No.: 2003009252 Return Receipt Requested: v. 7002 2410 0001 4237 4209 7002 2410 0001 4237 4216 PALMS VILLA RETIREMENT HOME, INC. d/b/a PALMS VILLA 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 Palms Villa Retirement Home, Inc. d/b/a Palms Villa Retirement Home, Inc. (hereinafter “Palms Villa Retirement Home, iInc.”), 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 an administrative fine of $1,000.00 pursuant to Sections 400.414 and 400.419, Florida Statutes 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, Chapter 28-106, Florida Administrative Code. 3. Venue lies in Broward 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 assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2003) and Chapter 58A-5 Florida Administrative Code. 5. Palms Villa Retirement Home, Inc. operates a 21-bed assisted living facility located at 2131 N. W. 28 Street, Oakland Park, Florida 33311. Palms Villa Retirement Home, Inc. is licensed as an assisted living facility under license number 4990. Palms Villa Retirement Home, Inc. 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 PALMS VILLA RETIREMENT HOME, INC. FAILED TO ENSURE THAT ALL FURNITURE AND FURNISHINGS BE FUNCTIONAL AND IN GOOD REPAIR. RULE 58A-5.023(1) (b), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Palms Villa Retirement Home, Inc. was cited with two (2) Class III deficiencies due to safety appraisal visit surveys conducted on September 26, 2003 and November 24, 2003. 8. Based on a survey conducted on September 26, 2003 and based on observation and interview, the facility failed to ensure all furniture and furnishings be functional and in good repair. The findings include the following. 9. During the tour of the facility, it was noted that the dresser drawer in room 2 was broken and that there were many drawer pulls missing from the dresser in room 4. The aide on the tour was interviewed and after investigation, confirmed the findings. 10. The mandated date of correction was designated as October 26, 2003. 11. Based on a survey conducted on November 24, 2003 and based on observation and interview, the facility failed to ensure all furniture and furnishings be functional and in good repair. The findings include the following. 12. During the revisit of the facility on 11/24/03, it was noted that there were still many drawer pulls missing or broken from the dresser in room 4. There were 5 pulls missing and 3 pulls broken. The "pulls" were not decorative, but necessary for the resident to open (pull-out) the dresser drawers. The residents had to leave the drawers partially open in order to operate the dresser to access their clothes. The dresser was not in good repair and _ the functionality of the dresser was compromised. The aide on the revisit-tour was interviewed and after investigation, confirmed the findings. The deficiency remains uncorrected. 14, Based on the foregoing, Palms Villa Retirement Home violated Rule 58A-5.023(1) (b), Florida Administrative Code, herein classified as a Class III violation pursuant to Section 400.419 (2) (c) Florida Statutes, which warrants an assessed fine of $500.00. COUNT IT PALMS VILLA RETIREMENT HOME, INC. FAILED TO ENSURE THAT THERE IS AT LEAST 1 BATHROOM WITH 1 TOILET AND 1 SINK PER SIX PERSONS AND 1 BATHTUB OR SHOWER PER EIGHT PERSONS. RULE 58A-5.023(5) (a), FLORIDA ADMINISTRATIVE CODE (PHYSICAL PLANT STANDARDS) CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. Based on a survey conducted on September 26, 2003 and pased on observation and interview, the facility failed to ensure that there be at least one bathroom with a one toilet and sink per six persons and one bathtub or shower per eight persons. The findings include the following. 16. During the tour of the facility, it was observed that the main building had only 1 operational toilet, sink and bathtub/shower for 10 residents. The second bathroom was not operational. The aide on the tour was interviewed and after investigation, confirmed the findings. 17. The mandated date of correction was designated as October 26, 2003 18. Based on a survey conducted on November 24, 2003 and based on observation and interview, the facility failed to ensure that there be at least one bathroom with one toilet and one sink per six persons and one bathtub and/or one shower per eight persons. The findings include the following. 19. During the revisit of the facility on 11/24/03, it was observed that the main building had only 1 operational toilet, sink and bathtub/shower for use by 10 residents. The second bathroom remains not operational. The aide on the revisit-tour was interviewed and after investigation, confirmed the findings. The owner was interviewed via the phone and he/she stated that there were other bathrooms in the facility that the residents could use to be in compliance with the numbers discussed above, but it was explained to the owner that the other bathrooms were located in residents! rooms and not in common areas which would be a deficiency if the bathrooms are used by residents not assigned to the rooms in which the bathrooms are located. The deficiency remains uncorrected. 20. Based on the foregoing, Palms Villa Retirement Home violated Rule 58A-5.023(5) (a), Florida Administrative Code, herein classified as a Class III violation, pursuant to Section 400.419 (2)(c) Florida Statutes, 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 Palms Villa Retirement Home, Inc. on Count I and Count II. 2. Assess an administrative fine of $1,000.00 against Palms Villa Retirement Home, Inc. on Count I and Count II 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 (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 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 FIWAL ORDER BY THE AGENCY. Géorge D. Shirejian, Esq. Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 BE. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (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) 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 Jason Kissoonlal, Administrator, Palms Villa Retirement Home, Inc. 2131 N. W. 28 Street, Oakland Park, Florida 33311; Jason Kissoonlal, 2131 N. W. 28 Street, Oakland park, Florida 33311 on this @ day of SQnvstd , 2003. George D. Shirejian, Esq.

Docket for Case No: 04-000995