STATE OF FLORIDA ip f fs AGENCY FOR HEALTH CARE ADMINISTRATION 7 * 2 STATE OF FLORIDA, OT: 3YqL, obit, "6 3 AGENCY FOR HEALTH CARE HUSH 9, "2s ADMINISTRATION Ah nape AHCA No.: 2007000833 “ed “he Petitioner, Return Receipt Requested: v. 7002 2410 0001 4235 5130 7002 2410 0001 4235 5147 RICHLAND RETIREMENT HOME #2, INC., d/b/a RICHLAND RETIREMENT SENIOR HOME II, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Richland Retirement Home #2, Inc., d/b/a Richland Retirement Senior Home II (hereinafter “Richland Retirement Senior Home II”), pursuant to Chapter 429, Part I and Section 120.60, Florida Statutes (2006), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $3,700.00 pursuant to Sections 429.14 and 429.19(2)(c), Florida Statutes for the protection of the public health, safety and welfare pursuant to 429.28 (3) (c) , Florida Statutes. 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 Miami-Dade 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 429, Part I, Florida Statutes (2006), and Chapter 58A-5 Florida Administrative Code. 5. Richland Retirement Senior Home II operates a 14- bed assisted living facility located at 721 N.w. 13% Avenue, Miami, Florida 33125. Richland Retirement Senior Home II is licensed as an assisted living facility under license number 9964. Richland Retirement Senior Home II 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 RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE A CURRENT SATISFACTORY ANNUAL FIRE INSPECTION CONDUCTED BY THE LOCAL FIRE MARSHALL OR AUTHORITY HAVING JURISDICTION Section 429.41(1) (a), Florida Statutes and/or Rule 58A-5.015(1) (a)l.m., Florida Administrative Code (FACILITY RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the Biennial State Licensure Survey conducted on 9/13/06 and based on interview and record review, the facility failed to provide a current satisfactory annual fire inspection conducted by the local fire marshal or authority having jurisdiction. 8. During a facility's record review that took place on 09/13/2006 at approximately 11:00 a.m. revealed that the most recent fire inspection expired on 07/25/05. 9. An interview with the caregiver that took place on 09/13/2006 at approximately 12:30 p.m. revealed that the facility had a current fire inspection but she/he was unable to provide during the survey process. Correction Date: 10/13/06. . 10. During the follow up conducted on 10/30/06 a facility’s record review took place at approximately 11:00 a.m. and it was revealed that the most recent fire inspection expired on 7/25/05. 11. It was revealed that on 10/20/06 the facility had fire inspection conducted by Miami-Dade Fire Department and eight (8) fire violations were discovered. . 12. An interview with the new Administrator on 10/30/06, at approximately 11:30 a.m. confirmed the findings. This is an uncorrected deficiency from the 9/13/06 survey. 13. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.41(1) (a)1l.m., Florida Statutes, and/or Rule 58A-5.024(1) (a)3, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT IT RICHLAND RETIREMENT SENIOR HOME II FAILED TO HAVE AN ANNUAL SATISFACTORY SANITATION INSPECTION Rule 58A-5.015(1) (a)4, Florida Administrative Code (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 Biennial State Licensure Survey conducted on 9/13/06 and based on record review and interview the facility failed to have an annual satisfactory sanitation inspection. 16. During a facility's record review that took place on 9/13/06 at approximately 11:00 a.m. it was revealed that the most recent sanitation inspection expired on 7/19/05. 17. The caregiver that was interviewed on 9/13/06 at approximately 11:30 a.m. revealed that the facility had the annual sanitation inspection done as required but was unable to provide it during the survey date. Correction date given: 10/13/06. 18. During the follow-up visit conducted on 10/30/06 it was determined that the facility did not have an annual satisfactory sanitation inspection. An interview with the Administrator at about 11:45 a.m. revealed that he/she was not aware of such inspection. This is an uncorrected deficiency from the 9/13/06 survey. 19. Based on the foregoing, Richland Retirement Senior Home Ir violated Rule 58A-5.015(1) (a) 4, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT III ' RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE DOCUMENTATION REGARDING THE ADMINISTRATOR’S HIGH SCHOOL DIPLOMA OR G.E.D. Rule 58A-5.019(1) (a)2, Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS IV VIOLATION 20. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 21. During Biennial State Licensure Survey conducted on 9/13/06 and Based on interview the facility failed to provide documentation regarding administrator high school diploma or G.E.D. 22. An Interview was conducted with the caregiver on 09/13/06 at approximately 11:30 am. He/she verified that the record of the administrator was in another facility and he/she was unable to produce the required file on day of the survey. Correction Date: 10/13/06 23. During the follow-up visit conducted on 10/30/06 and review of the personnel record for the new Administrator it was determined that the record lacked the administrator's high school diploma or G.E.D. 24. The Administrator stated that he/she kept her diploma at home. He/she was going to file it in his/her personnel record at the facility. This is an uncorrected deficiency from the 9/13/06 survey. 25. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.019(1) (a)2, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $200.00. COUNT IV RICHLAND RETIREMENT SENIOR HOME II FAILED TO MAINTAIN DOCUMENTATION VERIFYING THAT THE ADMINISTRATOR HAD COMPLE'TED THE ASSISTED LIVING FACILITY CORE TRAINING REQUIREMENTS INCLUDING THE PASSING OF THE COMPETENCY TEST Rule 58A-5.0191(1) (b), Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 26. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 27. During the Biennial State Licensure Survey conduced on 9/13/06 and based on interview the facility administrator failed to successfully complete the administrator core training requirement within 3 months from the date of becoming a facility administrator or manager. 28. An interview with the caregiver on 09/13/06 approximately at 11:30 a.m. stated that the employee files were in another facility and the staff was unable to provide it during the day of the survey. Correction Date: 10/13/06. 29. During the follow-up survey conducted on 10/30/06 and based on personnel records review it was revealed that. the new Administrator had attended the assisted living facility CORE training on may 26, 2006. ‘There was no proof indicating that the Administrator had taken and passed the competency test. 30, An interview with the Administrator on 10/30/06 at about 1:00 p.m. revealed that in fact she had taken the test but could not provide documentation at the time of the survey. This is an uncorrected deficiency from the 9/13/06 survey. 31. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.0191(1) (b, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT V RICHLAND RETIREMENT SENIOR HOME II FAILED TO ENSURE THAT 3 OF 3 DIRECT CARE STAFF OBTAIN A LEVEL 1 BACKGROUND SCREENING Section 429.174(2), Florida Statutes and/or Rule 58A-5.019(3), Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 32... AHCA....re-alleges....and...incorporates---paragraphs-—-(4.)——--—--___—_ - through (5) as if fully set forth herein. 33. During the Biennial State Licensure survey conducted on 9/13/06 and based on interview the facility failed to ensure the direct care staff obtained a Level 1 background screening for 3 of 3 staff (#1, 2, and 3). 34. An interview was conducted with the caregiver on 09/13/06 at approximately 11:30 am. He/she verified that the staff records were in another facility she was unable to provide during the inspection. Correction Date: 10/13/06. 35. During the follow-up conducted on 10/30/06 and based on review of the facility’s personnel records for 2 new staff (staff #1, Administrator and staff #2, caregiver/cook) it was determined that none of them has Level 1 background screening information in the records. 36. Staff #1 was hired 10/23/06; Staff #2 was hired 6/05/06 and staff #3 was hired 6/05/06. 37. An interview with the new Administrator at about 1:00 p.m. confirmed the findings. This is an uncorrected deficiency from the 9/13/06 survey. 38. Based on the foregoing, Richland Retirement Senior Home Ir violated Rule 58A-5.019(2) (b), Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. COUNT VI RICHLAND RETIREMENT SENIOR HOME II FAILED TO HAVE AN EMPLOYEE WHO IS IN THE FACILITY AT ALL TIME TRAINED IN FIRST AID AND CPR Rule 58A-5.019(4) (a)4, Florida Administrative Code (STAFFING STANDARDS) UNCORRECTED CLASS III VIOLATION 39. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 40. During the Biennial State Licensure Survey conducted on 9/13/06 and based on observation and interview the facility failed to have employee in the facility all time: that is trained in Fist Aid and CPR. 41. During the entrance conference on 09/13/06 at approximately 9:35 a.m. it was known that the staff #3 (caregiver) was in charged of the facility during the survey date. 42. An interview with the caregiver on 09/13/06 approximately at 11:30 a.m. stated that the employees’ records were in another facility and he/she was unable to provide during survey. Correction Date: 10/13/06. 43. During the course of the follow-up conducted on 10/30/06 and based on observation at about 9:30 a.m. it was revealed that Staff #3 was only staff who was in the facility at all times. 44. A record review revealed that staff #3 still did not have proof of First Aid Training. 45. An interview with the Administrator at about 1:50 p-m. confirmed the findings. This is an uncorrected deficiency from the 9/13/06 survey. 46. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.019(4) (a) 4, Florida Administrative Code, herein classified as an uncorrected Class III violation, which warrants an assessed fine of $500.00. ) COUNT VIL RICHLAND RETIREMENT SENIOR HOME II FAILED TO HAVE VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE INCLUDING TUBERCULOSIS FOR 1 OF 3 STAFF Rule 58A-5.024(2) (a), Florida Administrative Code (STAFF RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 47. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. During the Biennial State Licensure Survey conducted on 9/13/06 and based on interview the facility 10 failed to have verification for freedom from communicable disease including tuberculosis for 3 of 3 staff (#1, 2 and 3). 49. An interview with the caregiver on 09/13/06, at approximately 11:00 a.m. revealed that the staff records were in another facility and he/she was unable to provide them during the survey date. Correction Date: 10/13/06. 50. During the follow-up conducted on 10/30/06 and based on record review and interview, the facility failed to have verification of freedom from communicabie disease, including tuberculosis for o1 of 3 Staff (Staff #1, Administrator) 51. A review of personnel records conducted on 10/30/06 reveled that the new Administrator's File lacked verification of freedom from communicable disease including tuberculosis. 52. An interview with the new Administrator on 10/30/06 at about 3:00 p.m. confirmed the findings. The Administrator further stated that he/she had just started the job and was in the process of updating all necessary documents. This is an uncorrected deficiency from the 9/13/06 survey. 53. Based on the foregoing, Richland Retirement Senior Home II violated - Rule 58A-~5.024 (2) (a), Florida Administrative Code, herein classified as an uncorrected 11 Class III violation, which warrants an assessed fine of $500.00. COUNT VIII RICHLAND RETIREMENT SENIOR HOME II FAILED TO ENSURE THAT STAFF #3 RECEIVE A MINIMUM OF 1 HOUR IN-SERVICE TRAINING WITHIN 30 DAYS OF EMPLOYMENT IN SAFE FOOD HANDLING PRACTICES Rules 58A-5.0191(2) (e); 58A-5.020(1) (d), and 58A- 5.024(2) (a)1, Florida Administrative Code (STAFF RECORDS STANDARDS) UNCORRECTED CLASS III VIOLATION 54. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. During the Biennial State licensure Survey conducted on 9/13/06 and based on observation and interview the facility did not had any staff training in safe food handling practices within 30 days of employment for 3 of 3 staff (#1,2 and 3). 56. Observation while conducting the tour of the facility on 09/13/06 at approximately 09:45 am revealed that the staff #3 prepared the food for residents. 57. An interview with the caregiver on 09/13/06 approxSimately at 11:30 am revealed that the employee records were in another facility and he/she was unable to provide them during survey date. Correction Date: 10/13/06. 58. During the follow-up conducted on 10/30/06 and based on observation, record review and interview it was revealed that facility failed to ensure that Staff #3 received a minimum of 1-hour in-service training within 30 days of employment in safe food handling practices. 59. An observation while conducting the tour of the facility at approximately 9:45 a.m. revealed that Staff #3 was preparing food for residents. 60. A review of facility's records revealed that staff #3 had not yet received a minimum of 1l-hour in-service training within 30 days of employment in safe food handling practices. Staff #3 was hired 6/05/06. 61. An interview with the Administrator at about 3:00 p.m. confirmed the findings. This is an uncorrected deficiency from the 9/13/06 survey. 62. Based on the foregding, Richland Retirement Senior Home II violated Rules 58A-5.0191(2) (e), 58A-5.020(1) (d), and, 58A-5.024(2) (a)1, Florida Administrative Code, herein ‘classified as an uncorrected Class III violation, 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 Richland Retirement Senior Home II on Counts I through VIII 13 2. Assess an administrative fine of $3,700.00 against Richland Retirement Senior Home II on Counts I through VIII for the violations cited above. 3. 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 (2006). Specific options for administrative action are set out in the attached Election of Rights form. 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 FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THE MATTER Lhe fe Nelson E. Rodney, Esq. Assistant General Counsel Agency for Health Care Administration Spokane Bldg., Suite 103 8350 N. W. 52"? Terrace Miami, Florida 33166 Copies furnished to: 14 Harold Williams Field Office Manager Agency for Health Care Administration 8355 N.W. 53°? Street, First Floor Miami, Florida 33166 (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 Julio Romero, Administrator, Richland Retirement Senior Home II, 721 N.W. irth Avenue, Florida 33125,and to Marisela Delgado, Registered Agent, 721 ’ - Nw 13°" avenue, Miami, Florida 33142 on’this old day of f VWI , 2007. elson E. Rodney 15

Docket for Case No: 07-003494