STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ( \ - \ SOY vs. Case No. 2004011067 NICOLAS & SHERRI CICCARELLO, d/b/a SHARICK’S DECK RETIREMENT RANCH, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against NICOLAS & SHERRI CICCARELLO, d/b/a SHARICK’S DECK RETIREMENT RANCH, (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Fla. Stat., (2004), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $1,000.00 based upon Respondent being cited with two repeat State Class III deficiencies, pursuant to §400.41 9(2)(c) Fla. Stat. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, Fla. Stat. 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes, and rules governing assisted living facilities pursuant to the Chapter 400, Part Il, Florida Statutes, and; Chapter S8A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 25-bed assisted living facility located at 4506 Bruton Road, Plant City, Florida 33565, and is licensed as an assisted living facility, license number 5335. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT 1 6. The Agency re-alleges and incorporates paragraphs (1) throu gh (5) as if fully set forth herein. 7. That pursuant to Florida Jaw, no resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to, inter alia, be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Section 400.428(1)(b), Fla. Stat. (2004). 8. That on January 28, 2003, the Agency conducted a Biennial Licensure Survey of the Respondent. 9. That based upon observations, the Respondent facility failed to ensure that the facility complied with the Resident Bill of Rights in being treated with due recognition of personal dignity and the need for privacy for a facility resident in violation of law. 10. That the Petitioner’s representative toured the Respondent facility on January 28, 2003 at approximately 10:40 AM. 11. That one of the resident rooms had no window treatment in order to provide the resident privacy from the outside. 12. That the Petitioner’s representative viewed the resident’s room with the Respondent facility's administrator at approximately 2:50 PM on the same day. 13. That the resident was resting on the resident’s bed. 14. That the window in the resident’s room opened to the front of the facility and residents gathered at a sitting area directly outside the window. 15. That a sheet had been placed to cover the window, though the same was somewhat rolled up with its placement. 16. That the resident’s room was not equipped to provide a means for the resident’s privacy from persons outside the window or a means for the resident to shield light from the room. 17. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a State Class II deficiency. 18. That the Agency provided the Respondent with a mandatory correction date of February 27, 2003. 19. That during a re-visit survey conducted February 28, 2003, the Agency determined that the Respondent had corrected the deficiency. 20. That on November 4, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 21. That based upon observation, the Respondent facility did not ensure the facility complied with the Resident Bill of Rights in being treated with due recognition of personal dignity and the need for privacy for the residents in two out of nine resident bedrooms in violation of law. 22. That the Petitioner’s representative reviewed the Respondent facility via a tour. 23. That the following was observed in the seventh bedroom: a. That the aluminum type window blinds were bent or otherwise damaged such that the window could not be completely covered; b. That the side door to the room contained a large window which lacked any means of coverage. 24, That in the eighth bedroom, the aluminum type window blinds hanging from one of two windows were bent or otherwise damaged such that the window could not be completely covered. 25. That the failure of the Respondent to provide a means of adequate and complete coverage of windows in resident rooms resulted in the exposure of the residents to persons outside the facility and failed to provide the residents with privacy in the resident’s room. 26. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class [II deficiency. 27. That the Agency provided the Respondent with a mandatory correction date of December 4, 2004. 28. That the same constitutes a repeat offense as defined in Florida Statute 400.419(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida. pursuant to § 400.419(2)(c), Fla. Stat. (2004). COUNT II 29. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 30. Pursuant to Florida law, menus to be served shall be dated and planned at least one week in advance for both regular and therapeutic diets. Residents shall be encouraged to participate in menu planning. Planned menus shall be conspicuously posted or easily available to residents. Regular and therapeutic menus as served, with substitutions noted before or when the meal is served, shall be kept on file in the facility for 6 months. Fla. Admin. Code R. 58A-5.020(2)(d). 31. That on December 31, 2003, the Agency conducted a Complaint Survey of the Respondent. 32. That based upon observation, interviews with residents, and the review of available documentation, the facility has failed to note menu substitutions before or when the meal is served for two of two observed meals in violation of law. 33. That the Petitioner’s representatives reviewed the evening meal menu posted on the bulletin board in the facility “office” on December 31, 2003 at approximately 1:45 PM. 34. That the posted menu provided for a chicken patty on a bun, cole slaw, potato chips, peach cobbler, milk and tea or juice. 35. That in fact the meal served by the Respondent facility consisted of a tuna fish sandwich, pasta salad, lime gelatin and water. 36. That the Petitioner’s representatives reviewed the noon meal menu posted on the bulletin board in the facility “office” on January 1, 2004 at approximately 9:30 AM. 37. That the posted menu provided for meatloaf with ketchup, mashed potatoes, broccoli, rolls, margarine, ice cream and coffee or tea. 38. That in fact the meal served by the Respondent facility was roast beef, rice, gravy, green beans, bread and water. 39. That the Petitioner’s representative reviewed the Respondent facility’s substitution list, which was on the facility office desk. 40. That though some substitutions appeared to be listed, none of the substitutions were dated and none of the listed substitutions reflected the substitutions from the menus and meals observed by the Petitioner’s representatives. 41. That the Petitioner’s representatives interviewed five residents of the Respondent facility. 42. That each of the five residents interviewed expressed that the facility consistently failed to serve meals as reflected on the menu and that substitution lists were not being kept. 43. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class III deficiency. 44. That the Agency provided the Respondent with a mandatory correction date of January 1, 2004. 45. That during a re-visit survey conducted April 7, 2004, the Agency determined that the Respondent had corrected the deficiency. 46. That on November 4, 2004, the Agency conducted a Biennial Licensure Survey of the Respondent. 47. That based upon review of records, observation, and an interview, the Respondent facility failed to ensure that regular and therapeutic menus that were served with substitutions were noted before or when the meal was served and further did not ensure that menu items (vegetables, protein and milk) which had been substituted were substituted with items of comparable nutritional value based on seasonal availability of fresh produce or the preferences of the residents in violation of law. 48, That the Petitioner’s representatives reviewed the menu for the noon meal served on November 4, 2004. 49. That the meal served contained a total of four substitutions that included a half of a turkey sandwich, an extra % boiled egg, pink Kool-aid and home made vegetable soup. 50. That the menu substitutions were not noted on the facility’s substitution list or on the menu before or when the meal was served. 51. That the Petitioner’s representative interviewed the Respondent’s direct care staff member on November 4, 2004 at approximately 2:25 PM. 52. That the staff member indicated, “When I finish (serving the meal) I will put it (substitutions) down.” 53. That the Petitioner’s representatives reviewed the menu and substitution list before the meal, when the meal was served (approximately 2:20 PM to approximately 2:40 PM), at approximately 3:00 PM, and at approximately 5:05 PM. 54. That the menu substitutions had not been documented by the Respondent as required. 55. That the Petitioner’s representative reviewed the facility’s approved (week 3 — Thursday, as stated by the staff) menu for the day of the survey. 56. That the menu provided as follows: Chef salad Lettuce/tomato — Ic (one cup) Assorted Veggies — 2 Ham and cheese — 2 02 Hardboiled Egg — '% French Onion Soup — lc With crackers (8 small) Peaches — ‘Ac Milk — lc Tea or juice — | 57. That the Petitioner’s representative observed the meal served by the Respondent facility. 58. That the residents were served approximately 2 to % cup of home made soup that consisted of a great quantity of broth with a bit of vegetables, noodles, and approximately 1/8 oz. or less of turkey. 59. That the same was served in substitution of the vegetables in the Chef salad that was to consist of 1 cup of Lettuce/tomato and 1 cup of assorted vegetable. 60. That as such the residents did not receive the nutritional equivalent for at least one and '4 cup of vegetables. 61. That the residents were served an extra 2 hardboiled egg, % turkey sandwich that had a thin layer of turkey salad approximately 1/8 or less than the width of a piece of ham, and home made soup that consisted of a bit of turkey meat approximately 1/8 ounce of turkey in substitution for the protein which the menu would have provided in the Chef salad: two ounces of ham and cheese and a half of a hardboiled egg. 62. That two large eggs are a nutritional equivalent of one protein serving. 63. That the residents did not receive the nutritional equivalent for approximately one and 4 ounces of protein as planned on the Respondent's approved menu. 64. That the residents were served Pink Kool-aid in substitution for the 1 cup or 8 ounces of milk. 65. That the residents did not receive the nutritional equivalent for one serving or 8 ounces of milk. 66. That the Petitioner's representative interviewed the Respondent’s direct care staff member regarding the meal, preparations thereof, and the substitutions on November 4, 2004. 67. That the Respondent’s direct care staff member indicated the following: a. That she had not served the chef salad or assorted veggies as “I had the lettuce and veggies; I was with you and I did not do it;” b. That she did not take the time to ask the residents exactly what they wanted and served all residents the same thing; c. That when questioned regarding her method of measuring and/or weighing the food items (i.e. turkey spread, salad, soup), the direct care staff member stated, “I just looked at it.” 68. That the Agency determined that this deficient practice was related to the personal care of the residents that indirectly or potentially threatened the health, safety, or security of the resident and cited the Respondent for a repeat State Class III deficiency. 69. That the Agency provided the Respondent with a mandatory correction date of December 4, 2004. 70. That the same constitutes a repeat offense as defined in Florida Statute 400.419(2)(c). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(c), Fla. Stat. (2004). 2 Respectfully submitted this _© / day of February, 2005. yas J. Walsh, IL Fla. Bar. No. 566365 Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). 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, Bldg #3,MS #3, Tallahassee, FL 32308; Telephone (850) 922-5873. 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003-1010-0003 0279 4423 on February ZY, 2005 to: Nicolas & Sherri Ciccarello, Owners, Sharick’s Deck Retirement Ranch, 4506 Bruton Road, Plant City, FL 33565. fy} A yj Thoms J. Walsh, IT, Esq. Copies furnished to: Nicolas & Sherri Ciccarello Thomas J. Walsh, II, Esq. Owners/Administrator Agency for Health Care Admin. Sharick’s Deck Retirement Ranch 525 Mirror Lake Drive, 330G 4506 Bruton Road St. Petersburg, FL 33701 Plant City, FL 33565 (Interoffice) (U.S. Certified Mail) PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. SHARICK’S DECK RETIREMENT RANCH 2004011067 Facility Name AHCA No.

Docket for Case No: 05-001309