STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 20020¥45089 4 Return Receipt Requested: an Vv. 7000 1670 0011 4849 32654! 7000 1670 0011 4849 3272 NICOLAS & SHERRI CICCARELLO (OWNERS) d/b/a SHARICK’S DECK RETIREMENT mee CU-Y970 Respondent. Petitioner, / 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 of 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, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose and maintain the Agency’s administrative fine of $8,000.00, pursuant to Section 400.419, Florida Statutes (2001), 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 28-166, Florida Administrative Code. 3. Venue lies in Hillsborough County, pursuant to Section 120.57, Fla. Stat. 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 (2001), and Chapter 58A-5, Florida Administrative Code. 5. Sharick‘s Deck Retirement Ranch operates a 25-bed assisted living facility located at 4506 Bruton Road, Plant City, Florida 33565. Sharick‘s Deck Retirement Ranch is licensed as an assisted living facility license number AL5335, with an expiration date of September 3, 2003. Sharick’s Deck Retirement Ranch was at all times material hereto a licensed under the licensing authority of AHCA and was facility required to comply with all applicable rules and statutes. COUNT I SHARICK’S DECK RETIREMENT RANCH WAS PROVIDING SERVICES AT A LOCATION THAT IS NOT LICENSED/NOT INCLUDED IN IT’S LICENSE. Rule 58A-5.016(3),(4),(5), Florida Administrative Code, and/or 400.407(1), Fla. Stat. (GENERAL LICENSE STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on May 3, 2002 and based on a tour of the facility, on a review of available documentation and on interview with two employees, the Agency found that Sharick’s Deck Retirement Ranch was providing services at a location that is not licensed/not included in it’s license. The facility is providing personal care services for one individual who is living in an unlicensed building on the facility grounds. A review of the facility's Medication Observation Record (MOR) indicated that 28 residents are receiving supervision with their medications; however, the facility is only licensed for 25 residents. When the whereabouts of these 28 individuals was discussed with two facility employees on 05/03/02 at 1:20 p.m., it was revealed that one individual for whom the facility is supervising medications lives in a "shed" or "apartment" on the facility grounds. This building is not a licensed portion of the ALF, however. Time given for correction: 05/13/02. Loe) 8. During a follow-up survey conducted on 6/14/02 and based on a tour of the facility, on interview with two employees and on interview with one resident, the Agency again found that Sharick’s Deck Retirement Ranch was providing services at a location that is not licensed/not included in it’s license. The facility is providing personal care services for one individual who is living in an unlicensed building on the facility grounds. During a review of medications in the medication cart on 06/14/2002, medications prescribed for one resident were noted to be in the medication cart but no corresponding pages were in the Medication Observation Record. An employee stated that the medications were kept there for one individual who lives in an unlicensed "apartment" on the facility grounds. During an interview with the resident, SB, on 06/14/2002 at 8:30 a.m., the resident stated that when it is time for his medications, he goes to the main building where staff take the medications out of the medication cart and "give them to (him.)" Because a personal care service is being provided to this individual, he must reside in a licensed portion of the facility. This is an uncorrected violation. 9. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.016(3), (4), (5), F.A.C., and/or Section 400.407(1), Fla. Stat, an uncorrected Class III violation pursuant to Section 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT II SHARICK’S DECK RETIREMENT RANCH EXCEEDED THE LICENSED CAPACITY 400.407(3), Fla. Stat. and /or 58A-5.0181(2)(g), F.A.C. (GENERAL LICENSE STANDARDS) UNCORRECTED CLASS III VIOLATION 10. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. During the complaint investigation conducted by the Agency on 5/03/02 and based on a review of resident records and on interviews with two facility staff, the Agency found that the number of residents at the facility exceeded its licensed capacity. A review of the pages in the facility Medication Observation Record indicated that medications were being supervised by facility staff for 29 residents. However, the facility is licensed for only 25 residents. This was discussed at length with the two staff members on 05/03/02 at 1:30 p.m.; the names of the residents were discussed individually to determine if the residents were, in fact, residents of the facility or if personal services (such as supervision of medications) were being performed by facility staff. It was indicated that one resident had been in the hospital since 04/20/02, but that he had not been given a discharge notice and was expected to return; and that one a resident did not live in the licensed ALF but on the grounds and that he received no services except for his supervision of medication. The other 27 residents were confirmed by the two employees as currently residing within the licensed facility. Time given for correction: 05/03/02. 12. When a follow-up visit was conducted on 6/14/02 and based on a tour of the facility, on interview with two employees and on interview with one resident, the Agency again found that the number of residents at the facility exceeded its licensed capacity. The facility is providing personal care services for one individual who is living in an unlicensed building on the facility’s grounds. During a review of medications in the medication cart on 06/14/2002 medications prescribed for one resident were noted to be in the medication cart but no corresponding pages were in the Medication Observation Record. An employee stated that the medications were kept there for one individual who lives in an unlicensed "apartment" on the facility grounds. During an interview with the resident, SB, on 06/14/2002 at 8:30 a.m., the resident stated that when it is time for his medications, he goes to the main building where staff take the medications out of the medication cart and "give them to (him.)" Because a personal care service is being provided to this individual, he must reside in a licensed portion of the facility, and be counted as a resident. Including this resident, the facility exceeded its licensed capacity of 25 residents. This is an uncorrected violation. 13. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Chapter 400.407(3), Fla. Stat, and/or Rule 58A- 5.0181(2) (g), Florida Administrative Code, an uncorrected III violation pursuant to Section 400.419(1)(c), Fla. Class Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT III SHARICK’S DECK RETIREMENT RANCH FAILED TO MAINTAIN AND/OR DOCUMENT LIABILITY INSURANCE COVERAGE. 400.4275(3), Fla. Stat. and/or 58A-5.021(8) and 58A- 5.024(1) (g), F.A.C. (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. During the complaint investigation conducted by the Agency on 5/03/02 and based on a review of available documentation, the Agency found that the facility failed to maintain and/or document liability insurance coverage, as the facility does not currently have a liability insurance policy in place. A review of the most recent policy available indicated that the insurance coverage expired 05/02/02, the day preceding the visit to the facility. Time given for correction: 06/03/02. 16. When the follow-up visit was conducted on 6/14/02 and based on a review of available documentation, the Agency again found that the facility failed to maintain and/or document liability insurance coverage, as the facility does not currently have a liability insurance policy in place and/or does not have documentation of liability insurance. A review of the most recent policy available indicated that the insurance coverage expired 05/02/02. Despite a diligent search by one employee, no replacement policy was located. In telephone conversation with the Administrator on 06/19, he indicated that liability insurance had been obtained and As of the indicated he would fax a copy to the surveyor. writing (of the form 3020), no such insurance verification has been received. This is an uncorrected violation. 17. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Chapter 400.4275(3), Fla. Stat, and/or Rules 58A-5.021(8), and 58A~-5.024(1) (gq), Florida Administrative Code, an uncorrected Class III violation pursuant to Section 400.419(1)(c), Fla. Stat.,, which carries, in this case, an assessed fine of $1,000.00. COUNT IV SHARICK’S DECK RETIREMENT RANCH FAILED TO MAINTAIN A DAILY UP- TO-DATE MEDICATION OBSERVATION RECORD (MOR) FOR EACH RESIDENT. 58A-5.0185(5) (b), F.A.C. (MEDICATION STANDARDS) UNCORRECTED CLASS III VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. During the complaint investigation conducted by the Agency on 5/03/02 and based on a review of the Medication Observation Record for 29 residents, the Agency found that the facility failed to maintain a daily up-to-date Medication Observation Record (MOR) for each resident. The MOR was not up-to-date for one resident. One resident had been admitted to the hospital on 04/20/02, according to staff members; however, his chart had been marked through 05/04/02, the day after the survey, to indicate he was still in the hospital. When asked why such a "future entry" had been made, the employee in charge of the daily med pass stated, on 05/03/02 at 11:15 a.m., that she had made the entry "so that the other staff wouldn't write anything there." Time given for Correction: 5/13/02. 24. When the follow-up visit was conducted on 6/14/02 and based on a review of the Medication Observation Record for 26 residents, the Agency again found that the facility failed to maintain a daily up-to-date Medication Observation Record (MOR) for each resident. The MOR was not up-to-date for 25 residents. A review of the MOR on 06/14/02 at 11:00 a.m. revealed that no entries were made for any resident for any administration of morning meds. When asked why the MOR was left blank for these entries, one employee stated that she didn't know, that the meds were administered before she arrived at work that morning. Interviews with three residents indicated that the morning medications had, in fact, been given to the residents. This is an uncorrected violation. 25. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0185(5)(b), Florida Administrative Code, an uncorrected Class III violation pursuant to Section 400.419(1)(c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT V SHARICK’S DECK RETIREMENT RANCH FAILED TO KEEP CENTRALLY STORED MEDICATIONS IN A LOCKED AREA 58A-5.0185(6) (b)2., F.A.C. (MEDICATION STANDARDS) UNCORRECTED CLASS III VIOLATION 26. BHCA re-alleges and incorporates paragraphs (1) through (5) as of fully set forth herein. 27. During a complaint investigation conducted by the Agency on 5/03/02 and based on a tour of the facility, the Agency found that the facility failed to keep centrally stored medications in a locked area, locked away from residents at all times. Upon entry to the facility on 05/03/02 at 10:45 a.m., a review was made of the facility's med cart, where the residents' medications are kept. The cart was locked; however, placed on top of the med cart, within reach of any passing individual, was a pill organizer; this pill organizer contained medications for two residents. Time given for correction: 5/03/02. 28. When the follow-up visit was conducted on 6/14/02 and based on a tour of the facility, the Agency again found that the facility failed to keep centrally stored medications in a locked area, locked away from residents at all times. Upon entry to the facility on 06/14/02 at 10:45 a.m., a review was made of the facility's med cart, where the residents' medications are kept. The cart was not locked, and a cabinet in which extra medications are kept had an open lock hanging from the door-- the lock was not "locked." This is an uncorrected violation. 29. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0185(6) (b)2., Florida Administrative Code, an uncorrected Class III violation pursuant to Section 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT VI SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE SCHEDULED ACTIVITIES FOR RESIDENTS 58A-5.0182(2) (c), F.A.C. (RESIDENT CARE STANDARDS) UNCORRECTED CLASS III VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. During the complaint investigation conducted on 5/03/02 and based on observation and on interviews with a facility employee and with two residents, the agency found that the facility failed to have scheduled activities for the residents. During the survey, residents were observed to be sleeping, watching television or outside smoking; there were no "activities" observed. When asked what was available for residents to do, two residents replied, "nothing" and "watching TV". When asked on 05/03/02 at 12:35 p.m. whether the facility had any scheduled activities for the residents, " Time given for correction: one employee stated, no. 5/13/02. 32. During the follow-up visit conducted on 6/14/02 and based on observation and on interviews with a facility employee and with two residents, the Agency again found that the facility does not have scheduled activities for the residents. During the survey, residents were observed to be sleeping, watching television or outside smoking; there were no "activities" observed. When asked what was available for residents to do, two residents replied "nothing" and "watch Tv". When asked on 06/14/02 at 10:00 a.m. whether the facility had any scheduled activities for the residents, one employee stated replied in the negative. The employee stated that she had recently purchased and brought to the facility some games and puzzles for the residents, that a volunteer was helping with activities and that "a couple" of the residents did handicrafts, but she acknowledged that there were no scheduled activities. This is an uncorrected violation. 33, Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0182(2) (c), Florida Administrative Code, an uncorrected Class III violation pursuant to Section 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT VII SHARICK’S DECK RETIREMENT RANCH FAILED TO POST AN ACTIVITIES CALENDAR IN COMMON AREAS WHERE RESIDENTS NORMALLY CONGREGATE. 58A-5.0182(2) (c), F.A.C. (RESIDENT CARE STANDARDS) UNCORRECTED CLASS III VIOLATION 34. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. During the complaint investigation conducted on 5/03/02 and based on a tour of the facility and on interview with one employee, the Agency found that the facility failed to post an activities calendar in common areas where residents normally congregate. When asked whether the facility had any scheduled activities for the residents, on 05/03/02 at 12:35 p.m., or if there was an activities calendar somewhere showing what activities the facility had scheduled for the residents, one staff member stated, "no." Time given for correction: 05/13/02. 37. When a follow up was conducted on 6/14/02 and based on a tour of the facility and on interview with one employee, the Agency again found that the facility failed to post an activities calendar in common areas where residents normally congregate. When asked whether the facility had any scheduled activities for the residents, on 06/14/02 at 10:00 a.m., or if there was an activities calendar somewhere showing what activities the facility had scheduled for the residents, one staff member stated, "no," but that she had intended to make one that morning, prior to the survey. This is an uncorrected violation. 38. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0182(2) (c), Florida Administrative Code, an uncorrected Class III violation pursuant to Section 4 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT VIII SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE /DOCUMENT ANNUAL TUBERCULOSIS TESTS FOR ALL EMPLOYEES. 58A-5.019(2) (a), F.A.C. (STAFF RECORDS STANDARDS) UNCORRECTED CLASS IIT VIOLATION 39. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 40. During the complaint investigation conducted on 5/03/02 and based on a review of two employee files, the Agency found that the facility failed to have/document annual tuberculosis test for all employees. Neither file contained documentation of the employee's freedom from tuberculosis, obtained on an annual basis. The file of one long-time employee contained a TB statement dated 08/22/00; the file of one other employee, date of application 12/04/01, did not contain any documentation to ensure that the employee was free from Tuberculosis. Time given for correction: 06/03/02. 41. During the follow-up visit conducted on 6/14/02 and based on a review of two employee files, the Agency again found that the facility failed to have/document annual tuberculosis test for all employees. Neither file contained documentation of the employee's freedom from tuberculosis, Cc. Grant such other relief as this Court deems is just and proper. is notified that it has a right to request an Respondent administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 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, Manchester Building, First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Kathryn F. Fenske. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. Respectfully submitted, Le Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar # 0142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 17 obtained on an annual basis. The file of one long-time employee contained a TB statement dated 08/22/00; the file of one other employee, date of application 12/04/01, did not contain any documentation to ensure that the employee was free from Tuberculosis. In an interview conducted on 06/14/02 at 12:00 p.m., one employee stated that a home health agency had been contacted by the facility and was scheduled to come to the facility and perform TB tests on the staff on 06/26/02. This is an uncorrected violation. 42. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.019(2) (a), Florida Administrative Code, an uncorrected Class III violation pursuant to Section 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through VII. B. Assess and maintain the Agency’s administrative fine totaling $8,000.00 against Sharick’s Deck Retirement Ranch on Counts I through VIII for the uncorrected Class III violations, pursuant to 400.419(1)(c), Fla. Stat. 16 Copies furnished to: Patricia Reid Caufman Field office Manager Agency for Health Care Administration 525 Mirror Lake Drive St. Petersburg, FL 33701 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Inter-office Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #30 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 Nicolas Antonio Ciccarello, Administrator, Sharick’s Deck Retirement Ranch, 4506 Bruton Road, Plant City, Florida 33565, and to Nicolas & Sherri Ciccarello, 4806 Lonesome Dove Court, Plant City, Florida f° Far 33565 on Ciped 3 , 2003. Kathryn F. Fenske, Esq. 18

Docket for Case No: 04-004270