STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2002038131 Return Receipt Requested: (> v. 7000 1670 0011 4849 32894!" 64 7000 1670 0011 4849 3296 ‘\2 NICOLAS & SHERRI CICCARELLO (OWNERS) d/b/a SHARICK’S DECK RETIREMENT . RANCH, CY _ U is) | | Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), 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”), 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 $7,300.50 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 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 EXCEEDED THE CAPACITY LICENSE 400.407(3), Fla. Stat. and/or 58A-5.0181(2)(g), F.A.C. (GENERAL LICENSE STANDARDS) REPEATED CLASS III VIOLATION 6. BHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted by the Agency on April 2, 2001 and based on review of the Medication Observation Record, observation, staff interview, and interview with the Administrator, the Agency found that the facility exceeded its licensed capacity. 8. The licensed capacity of the facility is 25. Review of the Medication Observation Records revealed 26 residents receiving assistance with medications. 9. Observation in the facility revealed 27 resident beds and staff interview revealed 26 beds were occupied by residents. 10. Interview with the Administrator revealed that the facility had 26 residents including his aunt. Interview and observation of the Medication Observation revealed that the aunt occupies an ALF bed and received assistance with medications. Immediate correction required. 11. During a complaint investigation conducted by the Agency on May 3, 2002 and based on a review of resident ive) records and on interviews with two facility staff, the Agency again 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 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. 12. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Chapter 400.407(3), Fla. Stat, and/or Rule 58A- 5.0182(2)(g) Florida Administrative Code, a repeated Class III violation pursuant to 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT ITI SHARICK’S DECK RETIREMENT RANCH FAILED TO MAINTAIN/DOCUMENT LIABILITY INSURANCE. 400.4275(3), Fla. Stat. and /or 58A-5.021(8), and/or 58A-5.024(1)(g), F.A.C. (FACILITY RECORDS STANDARDS) REPEATED CLASS III VIOLATION 13. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14. During the biennial survey conducted on 11/06/00 and based on a review of the information board and interview with the manager, the Agency found that the facility failed to maintain/document liability insurance. The Agency found that there was no evidence that the facility had current liability insurance in force at the time of the survey. Time given for correction: 12/06/00. 15. During a complaint investigation conducted on 4/02/01 and based on interview with the Administrator, the Agency again found that the facility failed to maintain/document liability insurance. The Agency found that the facility did not have liability insurance. This was an uncorrected deficiency from the survey of 11/06/00. 16. During another complaint investigation conducted on 5/03/02 and based on a review of available documentation, the Agency again found that the facility failed to maintain/document liability insurance. The facility does not Ww 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. 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, a repeated Class III violation pursuant to 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. COUNT III SHARICK’S DECK RETIREMENT RANCH FAILED TO HAVE AN ANNUAL FIRE INSPECTION CONDUCTED BY THE LOCAL FIRE MARSHALL OR AUTHORITY HAVING JURISDICTION. 400.441(1) (a), Fla. Stat. and/or 58A-5.015(1) (a) (3), and/or 58A-5.024(1) (m), F.A.C. (FACILITY RECORDS STANDARDS) REPEATED CLASS III VIOLATION 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. During the biennial survey conducted on 11/06/00 and based on information provided by the facility’s manager, the Agency found that the facility did not have a current fire inspection that had been conducted within the last 365 days. Time give for correction: 12/06/00. 20. During a complaint investigation conducted by the Agency on 5/03/02 and based on a review of available documentation, the Agency found that the facility does not have record of a fire inspection having been conducted in the last 365 days. Although a diligent search of facility records was performed by two facility employees, the most recent fire inspection that had been conducted by the local fire Marshall was dated 12/08/98, more than 365 days ago. This is a repeat and uncorrected violation. 21. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Chapter 400.441(1) (a), Fla. Stat, and/or Rules 58A-5.015(1) (a) (3), Florida Administrative Code, a repeated and uncorrected Class IIlI violation pursuant to 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) REPEATED CLASS III VIOLATION 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. During the complaint investigation conducted on 4/02/01 and based on review of the Medication Observation Record, the Agency found that the facility did not maintain a daily up-to-date medication observation record (MOR) for each resident. 24, Review of the MOR at 10:45 am on April 2, 2001 revealed that the 8:00 am medications for April 2, 2001 had not been initialed as having been given. Staff interview revealed that the medications had been given but staff did not have time to initial the record. Time given for correction: 5/02/01. 25. During another complaint investigation conducted on 5/03/02 and based on a review of the Medication Observation Record for 29 residents, the Agency again found that 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.” 26. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0185(5) (b), Florida Administrative Code, a repeated and uncorrected Class III violation pursuant to 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), F.A.C. (MEDICATION STANDARDS) REPEATED CLASS III VIOLATION 27. AHCA re-alleges and incorporates paragraphs (1) through (5) as of fully set forth herein. 28. During the complaint investigation conducted on 4/02/01 and based on observation at 10:30 am revealed 4 loose pills laying on a napkin on the kitchen counter, 14 pill organizers on the kitchen counter, and an unlocked medication cart. Time given for correction: 5/02/01. 29. During a complaint investigation conducted on 5/03/02 and based on a tour of the facility, centrally stored medications were not kept 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. 30. Based on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.0185(6) {b) (2), Florida Administrative Code, a repeated and uncorrected Class III violation pursuant to 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 ALL REGULAR AND THERAPEUTIC MENUS REVIEWED ANNUALLY BY A REGISTERED DIETITIAN, LICENSED DIETITIAN/NUTRITIONIST, OR BY A DIETETIC TECHNICIAN, TO ENSURE THE MEALS ARE COMMENSURATE WITH THE NUTRITIONAL STANDARDS . 58A-5.020(2) (c), F.A.C. (NUTRITION AND DIETARY STANDARDS) REPEATED CLASS III VIOLATION 31. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 32. During the biennial survey conducted by the Agency on 11/06/00 and based on review of the posted menus and an interview with the manager, the Agency found that Sharick’s Deck Retirement Ranch failed to have all regular and therapeutic menus reviewed annually by a registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician, to ensure the meals are commensurate with the nutritional standards. The last menu review was completed on 11/16/98. 33. During a complaint investigation conducted = on 5/03/02 and based on observation and on review of available documentation, the Agency found that Sharick’s Deck Retirement 10 Ranch failed to have all regular and therapeutic menus reviewed annually by a_ registered dietitian, licensed dietitian/nutritionist, or by a dietetic technician, to ensure the meals are commensurate with the nutritional standards. The sole menu available for review, and according to two staff members interviewed, the most recent menu, was dated 11/00. This is a repeat violation from the survey of 11/06/00. 34. Based» on the foregoing, Sharick’s Deck Retirement Ranch violated Rule 58A-5.020(2)(c), Florida Administrative Code, repeated Class III violation pursuant to 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 HAVE/DOCUMENT LEVEL ONE BACKGROUND SCREENINGS COMPLETED FOR ALL DIRECT CARE STAFF. 400.4275(2), Fla. Stat., and/or 58A-5.019(3), and 58A- 5.024 (2) (a) (3), F.A.C. (STAFF RECORDS STANDARDS) REPEATED CLASS III VIOLATION 35. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. During the biennial survey conducted on 11/06/00 and based on review of personnel records and interview with the manager, the Agency found that Sharick’s Deck Retirement Ranch failed to have/document level one background screenings completed for all direct care staff. The Agency found that ll staff members #3, #4, and #5 did not have the necessary level 1 background screening in their files. Time given for correction: 12/06/00. 37. During a complaint investigation conducted on 5/03/02 and based on a review of two employee files, the Agency again found that Sharick’s Deck Retirement Ranch failed to have/document level one background screenings completed for all direct care staff. The file of one direct-care employee did aot contain any documentation of compliance with level 1 background screening. The file of one currently scheduled employee, date of application 12/04/01, did not contain any documentation of any kind, except for her application. This is a repeat violation from the 11/06/00 survey. 38. Based on the foregoing, Sharick’s Deck Retirement Ranch violated 400.4275(2), Fla. Stat., and/or Rules 58A- 5.019(3), and/or 58A-5.024(2) (a) (3), Florida Administrative Code, a repeated Class III violation pursuant to 400.419(1) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. SURVEY FEE 39, Pursuant to Section 400.419(9), Florida statutes, AHCA may assess a survey fee of $300.50 to cover the cost of 12 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 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 $7,000.00 against Sharick’s Deck Retirement Ranch on Counts I through VII for the repeated Class III violations, pursuant to 400.419(1)(c), Fla. Stat. Cc. Assess and maintain the Agency’s survey fee of $300.50 against Sharick’s Deck Retirement Ranch, pursuant to Section 400.419(9), Florida Statutes. 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 (2001). Specific options for administrative action are set out in the attached Election of 13 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, 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 Copies furnished to: Patricia Reid Caufman Field Office Manager Agency for Health Care Administration 525 Mirror Lake Drive, 4°" Floor 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 ~ fa” 33565 on ipurf Fo _, 2003. Ln (ij, ——— Sf as KatKryn F. Fenske, Esq.

Docket for Case No: 04-004271