STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos. 2010005191 vs. INGLESIDE RETIREMENT, 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 Ingleside Retirement (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2009), and alleges: . NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate an assisted living facility in the State of Florida pursuant to §§ 408.415 (1) (b) and (c) Florida Statutes, and 429.14(2), Florida Statutes (2009), to impose an administrative fine in the amount of two thousand dollars ($2,000.00) based upon two (2) uncorrected State Class III deficiencies pursuant to § 429.19(2)(c). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and Chapters 408, Part IJ, and 429, Part I, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed July 9, 2010 10:34 AM Division of Administrative Hearings. PARTIES 3, The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part 1, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates an 18-bed assisted living facility located at 1433 Ingleside Avenue, Jacksonville, Florida 32205, and is licensed as an assisted living facility, license number 5576. 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 I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, all applicants for renewal of a license shall submit the following: 3. A copy of the annual fire safety inspection conducted by the local authority having jurisdiction over fire safety or the State Fire Marshal. Documentation of a satisfactory fire safety inspection shall be provided at the time of the agency’s biennial survey. Fla. Admin. Code R. 58A-5.015(1)(a)3 8. That on January 25, 2010, the Agency conducted a biennial licensure survey of the Respondent’s facility. > 9. That based on facility record review and. an interview with the Administrator, the facility failed to ensure that an annual fire inspection was conducted by the local fire marshal for the last two of three years. 10. That a review of documents provided by the facility revealed the last fire inspection occurred on November 11, 2007. 11. That this was confirmed by the Administrator on January 25, 2010 at 1:30 P.M. 12. That the above reflects Respondent’s failure to obtain a satisfactory Fire Marshal’s report at the time of licensure renewal. 13. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in‘ this section for a ‘cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. 14.‘ That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). 15. That the Agency provided a mandatory correction date of February 25, 2010. 16. That an unannounced revisit survey was conducted at Respondent’s facility on March 8, 2010. 17. That based on a review of facility records and an interview with the Administrator, the facility failed to have a satisfactory fire safety inspection. 18. That a review of the fire marshal's review of February 22, 2010 revealed that the sprinkler system required inspection by a certified company. 19. That on February 24, 2010, the sprinkler system company came in and completed a report which required substantial work to make the system meet requirements. 20. That this had not been completed as of the day of the Agency's revisit. 21. That the Fire Marshal also found the Fire Panel had not been inspected and as of the day of the survey, this had not been done. 22. That the Fire Marshal also noted that the Smoke detectors in all resident rooms needed inspection and this had not been done as of the day of the revisit. 23. That this deficiency was previously written on January 25, 2010 and remained deficient practice as of March 8, 2010. 24. That this was confirmed in an interview with the Administrator on March 8, 2010 at 2:00 P.M. 25, ‘That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class ITI violation. A citation for a class mT violation must specify the time within which the violation is required to be corrected. If a class III violation is - corrected within the time specified, a fine may not be imposed. 26. That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). 27, That the Agency provided a mandatory correction date of April 8, 2010. 28. That that Agency conducted a second unannounced revisit to Respondent’s facility on April 30, 2010. 29. That based on facility record review and an interview with the Administrator, the facility failed to obtain a satisfactory Fire Marshal's report at the time of licensure renewal. 30. That the Fire Marshal's report of February 22, 2010 revealed major system problems and that the facility was out of compliance. 31. That the facility had not completed the work and was still out of compliance with fire safety standards. 32. That this was confirmed in an interview with the staff on April 30, 2010 at 11:30 AM. 33. That this was previously cited on March 8, 2010 and January 25, 2010. 34, That the Agency cited the Respondent for an uncorrected Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429,19(2)(c), Florida Statutes (2009). COUNT II 35. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. That pursuant to Florida law, the contract shall include a refund policy to be implemented at the time of a resident's transfer, discharge, or death. The refund policy shall provide that the resident or responsible party is entitled to a prorated refund based on the daily rate for any unused portion of payment beyond the termination date after all charges, including the cost of damages to the residential unit resulting from circumstances other than normal use, have been paid to the licensee. For the purpose of this paragraph, the termination date shall be the date the unit is vacated by the resident and cleared of all personal belongings. If the amount of belongings does not preclude renting the unit, the facility may clear the unit and charge the resident or his or her estate for moving and storing the items at a rate equal to the actual cost to the facility, not to exceed 20 percent of the regular rate for the unit, provided that 14 days’ advance written notification is given, If the resident's possessions are not claimed within 45 days after notification, the facility may dispose of them. The contract shall also specify any other conditions under which claims will be made against the refund due the resident. Except in the case of death or a discharge due to medical reasons, the refunds shall be computed in accordance with the notice of relocation requirements specified in the contract. However, a resident may not be required to provide the licensee with more than 30 days' notice of termination. If after a contract is terminated, the facility intends to make a claim against a refund due the resident, the facility shall notify the resident or responsible party in writing of the claim and shall provide said party with a reasonable time period of no less than 14 calendar days to respond. The facility shall provide a refund to the resident or responsible party within 45 days after the transfer, discharge, or death of the resident. The agency shall impose a fine upon a facility that fails to comply with the refund provisions of the paragraph, which fine shall be equal to three times the amount due to the resident. One-half of the fine shall be remitted to the resident or his or her estate, and the other half to the Health Care Trust Fund to be used for the purpose specified in s. 429.18. §429.24(3)(a), Florida Statutes (2009) 37, That an unannounced revisit to the biennial licensure survey was conducted at Respondent’s facility on March 8, 2010. 38. That based on resident record review and an interview with the Administrator, the facility failed to include the right for residents to give a thirty day notice when leaving the facility. 39, That a review of resident contracts revealed that the facility did not include a clause that the residents had the right to terminate the contract with thirty days written notice. 40. That this was confirmed in an interview with the Administrator on March 8, 2010 at 2:00 P.M. 41, That the Agency determined that this deficient practice was a condition or occurrence ~ related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class II violation. A citation for a class ITI violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. 42. That the Agency cited the Respondent for a Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). 43, That the Agency provided a mandatory correction date of April 8, 2010. 44, That that Agency conducted a second unannounced revisit to Respondent’s facility on April 30, 2010. 45. That based on resident record review and an intérview with the Administrator, the facility failed to provide contract language that allowed residents to provide a thirty day notice of termination for seven of seven records reviewed (#1, #2, #3, #4, #5, #6 and #7). 46. That a review of the records for Residents #1, #2, #3, #4, #5, #6, and #7 revealed that the contracts did not have language allowing residents to terminate their contract with a thirty day notice, 47. That this was confirmed in an interview with the staff on April 30, 2010 at 11:30 AM. - This was previously cited on March 8, 2010. 48. That the Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of clients, other than class I or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation. A citation for a class III violation must specify the time within which the violation is required to be corrected. If a class III violation is corrected within the time specified, a fine may not be imposed. 49, That the Agency cited the Respondent for an uncorrected ‘Class III violation in accordance with Section 429.19(2)(c), Florida Statutes (2009). WHEREFORE, the Agency intends to impose an administrative fine in the amount of one thousand dollars ($1,000.00), against Respondent, an assisted living facility in the State of Florida, pursuant to Section 429.19(2)(c), Florida Statutes (2009). COUNT Td 50. The Agency re-alleges and incorporates paragraphs (1) through (5), and Count J and II of this Complaint as if fully recited herein. 51, That pursuant to Florida law, upon notification by the local authority having jurisdiction or by the State Fire Marshal, the agency may deny or revoke the license of an assisted living facility that fails to correct cited fire code violations that affect or threaten the health, safety, or welfare of a resident of a facility. §429.14(2), Florida Statutes (2009) 52. That Respondent has violated the minimum requirements of law of Chapters 429, Part IJ, and Chapter 58A-5, Florida Administrative Code as described with particularity within this complaint. 53. That Respondent has a duty to maintain its operations in accord with the minimum requirements of law and to provide care and services at mandated minimum standards. 54, That the above reflect grounds for which the Agency may revoke Respondent’s licensure to operate an assisted living facility in the State of Florida. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an assisted living facility in the State of Florida, pursuant to §§ 408.815 and 429.14, Florida Statutes (2009). CLAIM FOR RELYEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: ) (A) Make factual and legal findings in favor of the Agency on Counts I through IIT (B) Recommend administrative fines against Respondent in the amount of $2,000; (C) Revoke the Respondent’s assisted living facility license #5576. (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (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. Respectfully submitted this ¢ 5 day of June, 2010. ~~) Carlton Enfinger F Fla. Bar,0793450 U/ . Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412.3640 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by | U.S. Certified Mail, Retum Receipt No. 7004 2890 0000 5526 9753 to Facility Administrator Stacy Wilson, Ingleside Retirement, 1433 Ingleside Avenue, Jacksonville, Florida 32205; and by USS. Certified Mail, Return Receipt No. 7004 2890 0000 5526 Rm to Owner Wajad Alli, 8945 Shindler Crossing Drive, Jacksonville, Florida 3222 on rane 26 , 2010: Ge on Copy furnished to: Robert Dickson, FOM 7753 Postmark Roturn Recelpt Fee Here (Endorsement Required) Restricted Delivery Fae {Endorsement Required) Total Postage & Fees 7004 2890 o000 Sse, S SENDER: COMPLETE THIS: SECTION LIVERY A. Regelved by (Please int Clearly) | B. Date of, ene : “Mel [chad | gah” | CASI ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery Is desired. @ Print your name and address On the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front if space permits. TI Agent CI Addressee D. Is delivery gfidress different from item 1?__L Yes IT YES, enter delivery address below: + GYNo . 1 Article Addressed to: Vrccty Nodame a het Irgre.g BO_ Ret erate Sa \ SNe Atala AOL 3 wee Certifled Mail ©] Express Mail 102595-00-M-0952 3 Oo Registered CD Return Receipt for Merchandise : . ancl ABA . * O insured Mai = Oc... } be a 3 QOS [4 Restricted Delivery? (Extra Fee) C Yes an ! . ' 2. 7004 2850 nooo 552b 4753 be . : ; ; PS Form 3811, July 1999 Doinestic Return Receipt f Postage | # Certified Fee Return Receipt Fee (Endorsement Reduired) Restricted Delivery Fea (Endorsemant Required) ‘Total Postage & Fess $ Postmark Here i Complete iterris item 4 if Restricted Delivery is desired. Print your name and address on the reverse so that we.can return the card to you. Attach this card to the back of the mailpiece, or on the front if space permits. , ‘4nd'3. Also complete oe 5 B. Date of Delivery b-Lh-c0 i CI Agent C1 Addressee D. Is delivery address different from item 1? [1 Yes 1. Article Addressed to: Voce, Qonreg TNL soins « ei Breer iy TAT Danser CgeaersDh, It YES, enter delivery address below: No 3. Servjaé Type Certified Mail © Express Mail (1 Registered ( Return Receipt for Merchandise { O insured Mail = C.0.0. | 4. Restricted Delivery? (Extra Fee) O Yes 7004 2890 O000 PS Form 3811, July 1999 55eb FW4b Domestic Return Receipt ae 102696-00-M-0952

Docket for Case No: 10-004979