STATE OF FLORIDA dp ff AGENCY FOR HEALTH CARE ADMINISTRATION yp *e &y PM — od STATE OF FLORIDA, O77: AYGS Vopr, 6 Loe AGENCY FOR HEALTH CARE Mpls 2 ADMINISTRATION pl Ot % AHCA No.: 2006009177 “%i Wy Petitioner, Return Receipt Requested: v. 7002 2410 0001 4235 4454 7002 2410 0001 4235 4461 RICHLAND RETIREMENT HOME #2, INC., d/b/a RICHLAND RETIREMENT SENIOR HOME ITI, 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 $5,000.00 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 PROOF OF AN UP-TO-DATE ADMISSION AND DISCHARGE LOG FOR EACH RESIDENT Section 429.41(1) (e), Florida Statutes and/or Rule 58A-5.015(1) (a)3, Florida Administrative Code (FACILITY RECORDS STANDARDS) REPEATED CLASS III VIOLATION ty 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide proof of an up-to- date admission and discharge log for each resident. 8. The facility's record review that took place on 8/10/05 at 10:15am revealed that the facility failed to keep an up-to-date admission and discharge. log. The log indicated that there were 9 residents in the facility when the current census is 11 residents. 9. An interview with the facility's staff that took place on 8/10/05 at approximately 10:30 am revealed this is an oversight. 10. This deficiency was found to be repeated when the Biennial Licensure survey was conducted on 9/13/06 and based on record review of the admission and discharge log at approximately 11:45 am it was determined that the log was not current. Residents #4, #5 and #6, have not been discharged on the log. 11. An interview with the caregiver on 9/13/06 at approximately 12:15pm confirmed the findings. This is a repeat deficiency from the 8/10/05 survey 12. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.41(1)(e), Florida Statutes, and/or Rule 58A-5.024(1)(b), Florida Administrative Code, herein classified as a repeated Class IIt violation, which warrants an assessed fine of $500.00. COUNT II RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE A CURRENT SATISFACTORY ANNUAL FIRE INSPECTION Section 429.41(1)(a)l.m, Florida Statutes, and/or Rule 58A-5.015(1) (a)3, Florida Administrative Code (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 a complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide evidence of satisfactory annual fire inspection. 15. A tour of the facility was conducted at 9:30am and it was determined that the facility failed to provide evidence of a satisfactory annual fire inspection conducted by the local fire Marshall or authority having jurisdiction. 16. A review of the facility’s records that took place on 8/10/05 at 11:05am revealed that the facility lacked evidence of satisfactory annual fire inspection conducted by the local fire Marshall or authority having jurisdiction. 17. An interview with the facility’s staff& that took place on 8/10/05 at 11:30am revealed that the facility had a fire inspection conducted, but there was not evidence of a fire inspection on file during the time of the survey. 18. During the Biennial Licensure survey conducted on 9/13/06 and based on interview and record review, the facility failed again to provide a current satisfactory annual fire inspection. 19. A review of the facility’s record that took place on 9/13/06 at 11:00 am revealed that the most recent fire inspection expired on 7/25/05. 20. An interview with the caregiver that took place on 9/13/06 at 12:30 pm revealed that the facility had a current fire inspection but she/he was unable to provide during the survey process. This is a repeat deficiency from the 8/10/05 survey. 21. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.41(1)(a)1.m, Florida Statutes, and/or Rule 58A-5.015(1)(a)3, Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of 5500.00. COUNT III RICHLAND RETIREMENT SENIOR HOME IIT FAILED TO PROVIDE EVIDENCE OF MOST RECENT SATISFACTORY SANITATION INSPECTION Rule 58A-5.015(1) (a)4, Florida Administrative Code (FACILITY RECORDS STANDARDS) REPEATED CLASS III VIOLATION 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. During a complaint investigation conducted on 8/10/05 and based on observation, interview and record review the facility failed to provide evidence of most recent satisfactory sanitation inspection. 24. A tour of the facility was conducted at 9:30am and it determined that the facility failed to provide evidence of most recent satisfactory sanitation inspection conducted by the county’s health department. 25. A review of the facility’s records that took place at 9:45am revealed that the facility lacked evidence of most recent satisfactory sanitation inspection conducted by the county's health department. 26. An interview with the staff that took place on 8/10/05 at 10:00 am revealed that there was no evidence of a most recent health inspection in the facility at the time of the survey. a7. During the biennial licensure survey conducted on 9/13/06 and during a review of the facility’s records that took place at approximately 11:00 am revealed that the most recent sanitation inspection expired on 7/19/05. 28. The caregiver was interviewed at approximately 11:30am and he/she revealed that the facility had the annual sanitation inspection done as required but was not able to provide evidence during the survey date. This is a repeat deficiency from the 8/10/05 survey. 29. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.015 (1) (a) 4, Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT IV RICHLAND RETIREMENT SENIOR HOME II FAILED TO MAINTAIN A COMPLETED CONTRACT FOR SOME RESIDENTS Sections 429.24(1), and 429.24(5), Florida Statutes, and/or Rules 58A-5.024(3) (i), and 58A-5.025(1), Florida Administrative Code (RESIDENT RECORDS STANDARDS) REPEATED CLASS III VIOLATION 30. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31. During a complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to maintain a completed contract for one of the five residents. 32. A tour of the facility was conducted at 9:30am and it was revealed that the facility did not maintain a signed contract for one of the five residents. 33. A review of the facility’s record that took place at 9:45am revealed that the contract for resident #4 was missing the signature of the resident. 34. An interview with the facility’s staff that took place at 10:00am revealed that this is an oversight. 35. During the biennial licensure survey conducted on 9/13/06 and based on record review and interview, the facility failed to maintain a complete resident contract of file for two of three sampled resident records (Residents #1 and #3). 36. A record review for sampled resident #3 on 9/13/06 at approximately 11:00am revealed that the facility failed to include the Administrator’s signature in the resident contract. Resident #3 was admitted on 11/10/05. . 37. A record review of sampled resident #1 revealed that the facility failed to include resident’s signature in the resident's contract. Resident #1, was admitted on 6/01/04. 38. During an interview conducted with the caregiver on 9/13/06 at approximately 1:00pm confirmed the findings. This is a repeat deficiency from the 8/10/05 survey. 39. Based on the foregoing, Richland Retirement Senior Home II violated Sections 429.24(1), and 429-25(5), Florida Statutes, and/or Rules 58A-5.024(3) (i), amd 58A-5.025(1), Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT V RICHLAND RETIREMENT SENIOR HOME IIT FAILED TO PROVIDE PROOF OF HIGH SCHOOL DIPLOMA OR GED FOR THE FACILITY’S ACTIVE ADMINISTRATOR Rule 58A-5.019(1) (a)2, Florida Administrative Code (STAFFING STANDARDS) . REPEATED CLASS III VIOLATION 40. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 41. During the compliant investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide proof of High School Diploma or GED for the facility’s active Administrator. 42. A review of the facility’s. records revealed that the Administrator failed to show documentation that he/she is a High School Graduate. , 43. An interview with the facility’s staff that took place at 11:00am revealed that the staff did not know where the administrator's proof of High School Diploma or GED was. This is a repeat deficiency from the 8/10/05 survey. 44. During the biennial licensure survey conducted on 9/13/06 and based on interview, the facility failed to provide documentation regarding administrator’s High School Diploma or GED. 45. An Interview was conducted with the caregiver on 9/13/06 at approximately 11:30am. 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. This is a repeat deficiency from the 8/10/05 survey. 46. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.019(1) (a)2, Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT VI RICHLAND RETIREMENT SENIOR HOME IZ FAILED TO PROVIDE EVIDENCE OF FDLE LEVEL BACKGROUND SCREENING FOR ONE OF TWO STAFF Section 429.174(2), Florida Statutes, and/or Rule 58A-5.019(3), Florida Administrative Code (STAFFING STANDARDS) REPEATED CLASS IIIT VIOLATION 47. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. During a complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide evidence of FDLE Level background screening for 1 of 2 staff. 49. A tour of the facility was conducted on 8/10/05 at 9:30am and it was revealed that the facility failed to provide evidence of FDLE Level background screening for 1 of 2 staff. 10 50. An interview wit the facility’s staff took place at 11:25am and it revealed that there was no information on file for FDLE Level 1 background screening for staff #1. 51. During the Biennial licensure survey conducted on 9/13/06 and based on interview it was determined that the facility failed to ensure the direct care staff obtained a Level 1 background screening for 3 of 3 staff (#1, #2, and #3). 52. An interview was conducted with the caregiver on 09/13/06 at approximately 11:30 am. She verified that the staff records were in another facility and she was unable to provide them during the inspection. 53. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.174(2), Florida Statutes, and/or Rule 58A-5.019(3), Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT VII RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE PROOF OF CURRENT FIRST AID AND CPR TRAINING FOR SOME STAFF MEMBERS Rule 58A-5.019(4) (a)4, Florida Administrative Code (STAFFING. STANDARDS) , REPEATED CLASS III VIOLATION 54. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. During a complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide proof of current First Aid and CPR training for two out of two staff members. 56. A review of the facility’s records that took place at 10:25am revealed that the First Aid and CPR training for staff #1 and staff #2 had expired. 57. During an interview with the facility’s staff that took place at 10:30am it was revealed that the First Aid and CPR training for staff #1 and staff #2 had expired. 58. During the biennial licensure survey that took place on 9/13/06 and based on observation and interview the facility failed to have an employee in the facility at all timed that is trained in First Aid and CPR. 59. During the entrance conference on 09/13/06 at approximately 9:35am was known that the staff #3 (caregiver) was in charged of the facility during the survey date. 60. During an interview with the caregiver on 09/13/06 approximately at 11:30am he/she stated that the employees’ records were in another facility and he/she was unable to provide them during survey. This is a repeat deficiency from the 8/10/05 survey. 61. Based on the foregoing, Richland Retirement Senior Home II violated Rule 58A-5.019(4) (a) 4, Florida 12 Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT VIII RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE EVIDENCE OF AN EMPLOYMENT APPLICATION WITH REFERENCES FOR ONE OUT OF TWO STAFF : Section 429.275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code (STAFF RECORDS STANDARDS) REPEATED CLASS III VIOLATION 62. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 63. During the complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide evidence of an employment application with references for one out of 2 staff. 64. A tour of the facility was conducted at 9:30am and it was revealed that the facility failed to provide evidence of an employment application with references for one out of 2 staff. 65. A review of the facility’s records took place at 10:30 am and revealed that there was no application on file for staff #1. 66. An interview with the facility’s staff that took place at 10:35am revealed that he/she is in the process of organizing the employees’ files. 67. During the biennial licensure survey conducted on 9/13/06 and based on interview the facility failed to provide personnel record for 3 of 3 employees (Staff #1, #2 and #3). 68. During an interview with the caregiver on 09/13/06 revealed that the staff records were in another facility and the staff was unable to provide them during the date of the survey. 69. Based on the foregoing, Richland Retirement Senior Home II violated .Section 429.275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code, herein.classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT IX RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE EVIDENCE THAT PERSONNEL RECORDS CONTAIN VERIFICATION OF FREEDOM FROM COMMUNICABLE DISEASE, INCLUDING TUBERCULOSIS Section 429.275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code (STAFF RECORDS S'TANDARDS) REPEATED CLASS IIT VIOLATION 70. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 71. During a complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide evidence that personnel records contained verification of freedom from 14 communicable diseases including tuberculosis for 1 of 2 staff. 72. A tour of the facility was conducted at 9:30am and revealed that the facility failed to provide evidence of personnel containing verification of freedom from communicable diseases including tuberculosis for 1 of 2 staff. 73. During an interview with facility’s staff that took place at 11:30am it was revealed that there was no information on file for personnel records that contain verification of freedom from communicable diseases including tuberculosis for staff #1. 74. During the biennial licensure survey conducted on 9/13/06 and based on interview, the facility failed to have verification for freedom from communicable disease including tuberculosis for 3 of 3 staff (#1, #2 and #3). 75. Interview with the caregiver on 09/13/06 at approximately 11:00am revealed that the staff records were in another facility and he/she was unable to provide them during the survey date. This is a repeat deficiency from the 8/10/05 survey. 76. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.275(4), Florida Statutes, and/or Rule 58A-5.024(2) (a), Florida Administrative Code, herein classified as a repeated Class III violation, which warrants an assessed fine of $500.00. COUNT X RICHLAND RETIREMENT SENIOR HOME II FAILED TO PROVIDE PROOF OF BIENNIAL CONTINUING EDUCATION CURSE TRAINING ON HIV AND AIDS FOR ONE STAFF Section 429.275(2), Florida Statutes, and/or Rules 58A- 5.0191(3); 58A-5.024(2) (a)1, and 58A-5.0191(11), Florida Administrative Code (STAFF RECORDS STANDARDS) REPEATED CLASS III VIOLATION 77. AHCA ‘re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 78. During the complaint investigation conducted on 8/10/05 and based on observation, interview and record review, the facility failed to provide proof of biennial continuing education course on HIV and AIDS for 1 out of 2 staff. 79. During a review of the employees’ records that took place on 8/10/05 at 11:45am it was revealed that there was no information on file for HIV and AIDS training for staff #1. 80. During an interview with the facility’s staff that took place around 11:50am it was revealed that there was no information on file for biennial continuing education course training on HIV and AIDS for staff #1. 81. During the biennial survey conducted on 9/13/06 and based on interview the facility failed to have staff 16 training in HIV/AIDS for 3 out of 3 employees (Staff #1, #2 and #3). 82. During an interview with the caregiver at approximately 11:30am, he/she stated that the employees’ records were in another facility and he/she was unable to provide tem during the survey. This is a repeat deficiency from the 8/10/05 survey. 83. Based on the foregoing, Richland Retirement Senior Home II violated Section 429.275(2), Florida Statutes, and/or Rules 58A-5.0191(3), 58A-5.024 (2) (a)1, and 58A- 5.0191(11), Florida Administrative Code, herein classified as a repeated 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 xX. 2. Assess an administrative fine of $5,000.00 against Richland Retirement Senior Home II on Counts I through X for the violations cited above. 3. Grant such other relief as this Court deems is just and proper. 17 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. elson E. Rodney, Esq Assistant General Co Agency for Health Care Administration Spokane Bldg., Suite 103 8350 N. W. 52"? Terrace Miami, Florida 33166 sel Copies furnished to: 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) 18 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. l.:th Avenue, Miami, Florida 33125,and to Marisela Delgado, Registered Agent, 721 tw Nw 13° avenue, Miami, Florida 33142 on this xX day of \ ) ee ee , 2006. an Nelson E. Rodney } 19

Docket for Case No: 07-003495