The Issue This is a license discipline proceeding in which the Petitioner seeks to take disciplinary action against the licenses of two public lodging establishments and against an individual alleged to have operated a public lodging establishment without a license, on the basis of allegations set forth in three separate Administrative Complaints.
Findings Of Fact At all times material hereto, the Respondent Fountain View Hotel (Fountain View) was a public lodging establishment, license number 60-00163-H, located at 5617 44th Street, West Palm Beach, Florida. Lawrence Joseph Vavala (Inspector Vavala) was at all material times employed by the Department of Business and Professional Regulation, Division of Hotels and Restaurants, as a Sanitation and Safety Specialist (Inspector). Catherine Driscoll (Supervisor Driscoll) was at all material times employed by the Department of Business and Professional Regulation, Division of Hotels and Restaurants, as a Sanitation and Safety Supervisor. On April 17, 2000, Inspector Vavala inspected the Fountain View and found numerous violations of public lodging service rules, all of which he marked on his lodging service inspection report of April 17, 2000. On April 17, 2000, when Inspector Vavala performed an inspection on Fountain View, he observed that the smoke detectors were inoperable in Apartments 3 and 4 in the front building. This violation is a critical violation because it endangers the life and safety of individuals living in the public lodging establishment. On April 17, 2000, during his inspection of the premises, Inspector Vavala observed that there were no portable fire extinguishers installed in the back building on either landing on either floor. Further, there was no fire extinguisher on the first floor, bottom landing, in the front building. In public lodging establishments, fire extinguishers are required to be within 75 feet of potential fire hazards. There was a fire extinguisher in the hallway on the second floor, but it had not been inspected since September 1994. Fire extinguishers are required to be inspected annually. These violations are critical in that they endanger the lives and safety of individuals residing in the public lodging establishment. On April 17, 2000, during his inspection of the premises, Inspector Vavala observed evidence of rodent droppings in the water heater room on the south side of the building and cockroaches in the kitchen cabinets of Apartment 4. These are critical violations in that disease is spread in this manner which endangers the health and safety of individuals residing in the public lodging establishment. During his inspection of the premises, Inspector Vavala observed electrical wiring in disrepair in Apartments 3 and 4. Wires were hung through a window out to the back porch, simply hanging by cord and socket. These are critical violations in that someone could be injured by the wiring. Further, in being exposed to the outside elements, it could cause shortage and fire. These are critical violations in that they endanger the safety and lives of individuals residing in the public lodging establishment. On April 17, 2000, during his inspection of the premises, Inspector Vavala observed that the cooking stove was inoperable in Apartment 4 and the air conditioning units were inoperable in Apartments 3 and 4. This is a critical violation because tenants may bring in propane or charcoal stoves to prepare food which would be a fire hazard and could endanger the safety and lives of individuals residing in the public lodging establishment. Inspector Vavala also observed that the air conditioning units were inoperable in Apartments 3 and 4. On April 17, 2000, during his inspection of the premises, Inspector Vavala observed the locks were inoperable on the kitchen door to the outside stairway in Apartment 3. This is a critical violation in that if the door could not be locked, an intruder could enter the premises and take property or physically harm an individual inside the apartment. On April 17, 2000, during his inspection of the premises, Inspector Vavala observed a broken window at the front door of the front apartment; the ceiling on top of the stairwell in the front of the building had a hole through the roof; a hole was in the stucco on the west side of the front building; a window was in disrepair on the west side of the front building; windows were boarded up on the west side of the building; stucco was missing on the south side of the front building; a window was broken on the lower floor of the front building on the south side; a window was in disrepair, and one window was broken on the lower floor of the front building on the east side; stucco was cracked on the north side of the exterior wall of the back building; the door frame was rotting at Apartment 6 in the back building; a window was broken on the north side of the back building at Apartment 6; there were holes in the wall and ceiling of the water heater room on the south side of the back building; a window was broken on the south side of the back building on the second floor; and the cross face on the west side of the front building and on the east side of the front building was not enclosed. Further, he observed excessive debris outside apartments around the building, a broken soda machine on the north side of the back building was falling over, and the refrigeration units in it could contaminate the ground water; he observed a rusting LP gas tank from a barbecue which, when left outside, will rust through the tank and release the gas in the air, which would endanger the health and welfare of persons in the area; there were cars lying around and the oil from those could contaminate the ground water. On April 17, 2000, in Apartment 4, Inspector Vavala observed kitchen cabinets in disrepair; tile was chipped, broken, and missing on the kitchen floor; there was a hole in the wall of the living area; the window operating assembly was in disrepair allowing the windows to either remain in a stuck open or stuck closed position; the clamps no longer worked on the window; the wood framing around a window air conditioner was rotting and had a hole below it; the plaster was cracked and chipping in the bathroom; there was a hole in the wall above the tub in the shower stall; a hole was in the wall behind the toilet in the bathroom; and the carpet was stained and unclean in the living area. The poor condition of the kitchen cabinets, the holes in the wall of the living room and bathroom, and the broken, chipped and missing tile could harbor rodents and bugs and nesting vermin. The rotting frame and hole in the wall underneath could allow the air conditioner, which was located on the second floor, to fall and endanger lives of persons beneath the window. Further, the hole in the wall allowed pests and vermin to enter the apartment. The window operating assembly which would not allow the windows to open was dangerous should there be a fire or other disaster blocking other exits to the apartment. The window operating assembly, which would not allow the windows to close, allows the outside elements to enter the apartment during inclement weather causing further deterioration to the apartments and personal belongings of tenants. The cracked and chipped plaster in the bathroom would not allow adequate cleaning which contributes to poor sanitation. The dirty carpet in the living area could be harboring insects, mold and mildew. The violations observed in Apartment 4 affect the health and safety of its tenants. On April 17, 2000, in Apartment 3, Inspector Vavala observed the ceiling stained in the back bedroom, reflecting leaking water damage; the ceiling plaster cracked in the back bedroom; broken and missing tiles in the kitchen, exposing plywood; kitchen cabinets that were in disrepair; an inoperative assembly in a shower stall window; all the window operating assemblies in the middle bedroom in disrepair; a closet door in disrepair in the middle bedroom; a sink was falling off the wall in the bathroom; there was a hole in the wall under the toilet in the bathroom; and backflow prevention was not provided on exterior hose bins. The violations observed in Apartment 4 endangered the health and safety of its tenants. On April 17, 2000, Inspector Vavala observed that the establishment was operating without a new license in 1998, 1999, and 2000. On May 2, 2000, an Administrative Complaint was issued against the Respondent Fountain View Hotel which was docketed as Case No. 2-00-185 before the Division of Hotels and Restaurants, and as Case No. 00-2949 before the Division of Administrative Hearings. On April 8, 1999, one year prior to the violations enumerated in paragraphs 5 through 15 above, Supervisor Driscoll and Inspector Paul Landmann, inspected the same Fountain View Hotel described above. Numerous violations observed during the April 8, 1999, inspection were still not corrected on April 17, 2000. On February 23, 2000, Supervisor Driscoll made a follow-up inspection of the same Fountain View and found numerous violations of public lodging service rules, all of which she marked on the lodging service inspection report of February 23, 2000. On April 8, 1999, the Petitioner issued an Administrative Complaint against Respondent Joseph Sansalone d/b/a Fountain View Hotel (Sansalone) which was docketed as Case No. 2-99-79 before the Division of Hotels and Restaurants, and as Case No. 00-3040 before the Division of Administrative Hearings. At all times material hereto, Respondent Lamplighter Hotel & Apartments (Lamplighter) was a public lodging establishment, license number 60-00167-H, located at 433 40th Street, West Palm Beach, Florida. On April 17, 2000, during his inspection of the Lamplighter, Inspector Vavala, observed that there were no fire extinguishers located anywhere on the premises. This violation is a critical violation because it endangers the life and safety of individuals living in the public lodging establishment. On April 17, 2000, during his inspection of the Lamplighter, Inspector Vavala observed rodent droppings in an upstairs apartment in the back building and in the storage shed adjacent to the back building. This is a critical violation in that disease is spread in this manner which endangers the health and safety of individuals residing in the public lodging establishment. On April 17, 2000, during his inspection of the Lamplighter, Inspector Vavala observed that there was no cover on the wall socket at the top of the stairs in the front building, and that cover plates were missing on the electrical sockets on the outside receptacle on the outside of the front area. This violation is critical because the health and safety of children are endangered because children could stick their fingers in the outlets and be electrocuted. Further Inspector Vavala observed a soda machine plugged into an outlet on the outside which was exposed to the elements, which could also be a potential danger to the health and welfare of persons in the vicinity. On April 17, 2000, during his inspection of the Lamplighter, Inspector Vavala observed that the stairway in the rear of the building and the back building on the east side was in disrepair. These are critical violations because it would not be safe to evacuate the rear building from the stairwells, in case of fire or other emergency. On April 17, 2000, during his inspection of the Lamplighter, Inspector Vavala observed windows broken on the first and second floors of the front building on the south side; broken windows on the first and second floor of the front building on the east side; a broken window on the lower floor of the front building on the north side; a broken window on the door to the downstairs apartment in the back building; and a broken window on the east side of the back building on the second floor. These are violations because there is sharp glass exposed and no protection from the outside against vermin or the elements. He also observed stucco falling off the exterior wall of the front building on the north side; doors falling off the storage shed at the back of the building, adjacent to the living establishment, which harbored vermin; and a hole in the roof of the storage shed attached to the back of the building. The crawl space under the front building on the south side and under the front building on the north side was not enclosed; screens were ripped on the north side of the front building on the first floor and on the west side of the front building, which would allow insects to enter the establishment. On April 17, 2000, during his inspection, Inspector Vavala observed a second floor hurricane shutter broken in the down position. This broken shutter would not allow evacuation through the window in case of fire or other emergency. On April 17, 2000, during his inspection, Inspector Vavala observed a door missing at the upstairs apartment on the back building, and the ceiling was falling in the kitchen and family room in an upstairs back apartment. The apartment appeared to be unoccupied; however, it would endanger the health and welfare of the tenants if it was occupied. Further, the missing door would allow children playing in the area to enter the apartment where the ceiling is falling, which could result in serious injury to a child. On April 17, 2000, during his inspection, Inspector Vavala observed an excessive amount of debris in and around the premises, including a refrigerator in an unused condition that still had the door attached which could be a hazard to children that lived in the establishment. On April 17, 2000, during his inspection, Inspector Vavala observed inoperable kitchen appliances located in the upstairs back building. These are critical violations because individuals may bring in propane or charcoal stoves to prepare food which would be a fire hazard and could endanger the safety and lives of individuals residing in the public lodging establishment. On April 17, 2000, during his inspection, Inspector Vavala observed that lighting was not provided in the hallway staircase in the front building. This is a critical violation because the unlighted area endangers the health and safety of tenants of the establishment. On April 17, 2000, Inspector Vavala also observed that the establishment was operating without a new license in 1998, 1999, and 2000. On May 2, 2000, the Division issued an Administrative Complaint against Respondent, Lamplighter Hotel & Apartments, which was docketed as Case No. 2-00-186 before the Division of Hotels and Restaurants, and as Case No. 00-2950 before the Division of Administrative Hearings. The Lamplighter Hotel & Apartments, located at 433 40th Street, West Palm Beach, Florida, and the Fountain View Hotel, located at 516 44th Street, West Palm Beach, Florida, are owned by Americorp Mortgage Co., Inc., whose president is Joseph D. Sansalone.
Recommendation On the basis of all of the foregoing, it is RECOMMENDED that the Division of Hotels and Restaurants issue a final order to the following effect: Concluding that the Respondent Fountain View Hotel is guilty of the violations observed during the inspection of its premises on April 17, 2000, as described in the foregoing Findings of Fact and Conclusions of Law, and imposing a penalty on the Respondent Fountain View Hotel consisting of an administrative fine in the amount of $5,000.00 and the revocation of its license. Concluding that the Respondent Lamplighter Hotel & Apartments is guilty of the violations observed during the inspection of its premises on April 17, 2000, as described in the foregoing Findings of Fact and Conclusions of Law, and imposing a penalty on the Respondent Lamplighter Hotel & Apartments consisting of an administrative fine in the amount of $5,000.00 and the revocation of its license. Concluding that the Respondent Joseph Sansalone is guilty of operating a public lodging establishment at the premises of the Fountain View Hotel during April of 1999 without a then-current license for that establishment, and imposing a penalty on the Respondent Joseph Sansalone consisting of an administrative fine in the amount of $1,000.00. DONE AND ENTERED this 18th day of January, 2001, in Tallahassee, Leon County, Florida. MICHAEL M. PARRISH Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 18th day of January, 2001.
The Issue Respondent's alleged violations of safety regulations, as set forth in Notice and Order to Show Cause, dated May 14, 1980. At the commencement of the hearing, the Hearing Officer granted Petitioner's Motion for Leave to Amend its complaint to substitute Baron Fun Frite's Castle, Inc. as Respondent in this proceeding, and to replace references to Charles Amara as an individual to Charles Amara as an officer of Baron Fun Frite's Castle, Inc.
Findings Of Fact Respondent Baron Fun Frite's Castle, Inc. is a Florida corporation which operates an amusement business at 1100 Main Street, Daytona Beach, Florida. The business is conducted in a two-story building owned by Amara Hotel, Inc. Charles R. Amara is the president of both corporations. The facility is operated as a "fun house" where customers pay an admission to walk through the premises in a period of ten to twenty minutes. There is approximately 1,000 square feet of space in the building with three exits, including an outside fire exit on the south side. The walls and ceilings of the interior of the building consist of sheetrock over which has been sprayed a polyurethane foam material manufactured by Chemetics Systems, Inc., with a tradename of CSI-9l52 Spray. The foam material is coated with an intumescent latex paint coating manufactured by United Paint Manufacturing, Inc. with a tradename of Thermogard. Although the building can accommodate between 50 to 55 persons in the period of one hour, it has never been occupied by more than 43 customers within that period in the past. (Testimony of Nelson, Amara, Stipulation, Respondent's Exhibit 1) On March 4, 1980, Petitioner's Regional State Fire Protection Specialist John R. Nelson inspected Respondent's premises pursuant to a request of the fire department of the City of Daytona Beach. Nelson determined that the building was a "place of assembly" which conferred jurisdiction under Petitioner's rules to enforce fire regulations, based on the building's occupant load of 150 persons as assigned by the City of Daytona Beach. A number of alleged deficiencies were discovered as to which Respondent was advised in a letter from Nelson dated March 10, 1980. The letter and accompanying inspection report required that corrective action be taken by April 7, 1980. Although the letter stated that the items noted were in violation of "Florida Statutes and/or the State Fire Marshal's Rules and Regulations," and that specific references would be provided upon request, neither the letter or the report specified statutes or rules alleged to have been violated. On May 5, 1980, Nelson conducted a re-inspection and found that three violations had not been corrected. Thereafter, on May 14, 1980, Petitioner filed its Notice and Order to Show Cause which constitutes the complaint in this proceeding. On June 11, 1980, Respondent requested a hearing under Chapter 120, Florida Statutes. (Testimony of Nelson, Case Pleadings, Petitioner's Exhibit 1) The rear fire stairs of Respondent's facility on the exterior of the building provide headroom at a landing of six feet two inches. Petitioner's inspector found that such clearance was insufficient under pertinent regulations and could block the exit during an emergency, thereby creating a possibility of crowd panic and consequent danger to public safety. The stairs presently extend out from the building over property owned by the City of Daytona Beach and therefore was the subject of a variance from the City Fire Code when constructed. Although there are two other exits from the building, the rear fire stairs are required in order that the maximum travel from any point inside the building to an exit will net exceed 150 feet. (Testimony of Nelson, Amara, Petitioner's Exhibit 1) The inspection also disclosed that the maintenance and air conditioning rooms of the building had openings in the walls and ceiling which would allow smoke, fire, and toxic gases to spread in the event of a fire. These consisted of openings in duct work and electrical outlets. Respondent testified at the hearing that the openings have been covered since the date of re-inspection. (Testimony of Nelson, Amara, Petitioner's Exhibit 1) The urethane foam product on the walls and ceilings of Respondent' s building is recommended for use by the manufacturer whenever maximum insulation and flammable standards are required. It is safe when used as a "sandwich" material between the interior and exterior materials such as gypsum board or fir wood material. However, if it is exposed on the surface, it is highly flammable and combustible, and subject to rapid vertical spread of fire. At certain temperatures, hydrogen cyanide and carbon monoxide gases would be released. Intumescent paint such as Thermogard will not provide a 15 minute thermal barrier because the foam material will expand and swell when afire and the flame will cause an expansion which in turn causes the paint covering to pop off. The foam material can be adequately protected by spraying with a cement plaster material which will form a hard surface to prevent the formation of gas. At the time the foam material was placed on the interior of the building, it was inspected and approved by the City of Daytona Beach as meeting its existing fire code. The existence of the polyurethane foam material was the subject of one of the violations of applicable law found by Petitioner during its inspection of the premises in March 1980. (Testimony of Nelson, Hogan, Folsom, Petitioner's Exhibit 1, Respondent's Exhibit 1, Respondent's Exhibit 2)
Recommendation That Petitioner issue an order to Respondent directing that it cease and desist within 30 days from continued violation of Section 6-2.1.3 of the National Fire Protection Association No. 101 Life Safety Code (1976) , pursuant to Rule 4A-27.13, Florida Administrative Code and Section 633.161, Florida Statutes. DONE and ENTERED this 18th day of September, 1980, in Tallahassee, Florida. THOMAS C. OLDHAM Hearing Officer Division of Administrative Hearings 101 Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Daniel Y. Sumner, Esquire Office of Treasurer and Insurance Commissioner 428-A Larson Building Tallahassee, Florida 32301 Richard R. Cook, Esquire 213 Silver Beach Avenue Daytona Beach, Florida 32018
The Issue Whether Petitioner Agency for Health Care Administration properly assigned conditional license status to Respondent, Westminster Woods on Julington Creek, based upon its determination that Respondent had violated Florida Administrative Code, Rule 59A-4.130, and 42 CFR Section 483.70 via Florida Administrative Code Rule 59A-4.1288, due to the presence of two wide-spread Class I deficiencies cited at the most recent annual licensure survey of January 27-29, 2003. Whether Petitioner Agency for Health Care Administration properly assessed a $30,000.00 fine against Respondent for violating 42 CFR Section 483.70 via Florida Administrative Code Rule 59A-4.1288, as well as Florida Administrative Code Rule 59A-4.130, due to the presence of two wide-spread Class I deficiencies at the most recent annual survey on January 27-29, 2003. Whether the Agency for Health Care Administration is entitled to $6,000.00 in costs related to the investigation and prosecution of this case(s), pursuant to Section 400.121(10), Florida Statutes.
Findings Of Fact Pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code (2002), AHCA is the regulatory authority responsible for licensure of skilled nursing facilities and for enforcement of all applicable statutes and rules governing skilled nursing facilities, of which Respondent Westminster Woods at Julington Creek is one. On January 27-29, 2003, AHCA conducted an annual licensure and re-certification survey of Respondent's facility. As a result of that survey, the facility was cited for two Class I deficiencies related to failure of the facility's fire alarm system. Each of these deficiencies was cited upon the same underlying facts. AHCA represented that one was cited as a Federal "tag" and the other was cited as a State "tag." In the Administrative Complaints, AHCA alleged, in a single Count, two separate Class I deficiencies. Respondent is a 60-bed skilled nursing facility located in Jacksonville, Florida. Respondent houses more of the "older- old" or "elderly-elderly" residents than the average skilled nursing facility. Respondent is a second floor facility with two stairwells that provide direct outside egress from the facility and that can be used as fire exits. During the January 27-29, 2003, survey, the facility housed 58 residents. Respondent's 58 residents on those dates were fairly dependent in terms of their physical capabilities. More than one-half of them were over the age of 85, and a couple of the residents were over 100 years old. Only one of the residents on January 27-29, 2003, was independently ambulatory. The remainder of the residents were incapable of independent ambulation. One of the residents was bed-ridden. Thirty-eight residents required extensive assistance in transferring or ambulating. The remainder of the resident population required assistive devices such as canes or walkers to transfer or ambulate. Due to their age, physical condition, and inability to engage in self preservation, these residents were extremely vulnerable in the event of a fire. The survey team arrived at the facility at 6:00 a.m. on January 27, 2003. At around 8:00 a.m., the facility's maintenance supervisor, John Doran, conducted his usual rounds of the facility. Mr. Doran personally checks the fire alarm panel twice daily, and did so that morning. The panel has three lights: A green light which means that the panel is working; a yellow light which means a mechanical failure has occurred; and a red light which signifies an alarm. Mr. Doran noted that no light was on. The fire doors, which close automatically if the alarm is activated, were still open. Except for the absence of any alarm panel light, everything seemed to be normal. Therefore, on the morning of January 27, 2003, Mr. Doran believed that there was a problem with the fire alarm panel, not the fire alarm system. In addition to Mr. Doran's twice-daily checks, Respondent's alarm system is monitored by an outside monitoring company which is supposed to call the facility if any problem is detected with its fire alarm system. The monitoring company did not call, which also suggested that the system itself was not malfunctioning, but merely that a light was out on the alarm panel. Nonetheless, Mr. Doran called his secretary, who contacted "W. W. Gay," the contract repair company for the system, and asked that a technician come to the facility. Thinking there was no immediate danger, but only that there was a problem with the alarm panel lights, and believing that everything that could be done up to that point had been done, Mr. Doran did not mention the alarm panel/system to surveyor Patricia McIntire, R.N., when she interviewed him about hot water temperatures around 10:00 a.m. on January 27, 2003. W. W. Gay's technician arrived at the facility about 10:30 a.m. and began trouble shooting the fire alarm system. The first technician could not find the problem, so he called for a second technician. During the course of January 27, 2003, three technicians arrived at Respondent's facility and worked on the panel, in full view of staff and surveyors who were in and around the nurses' station. During the entire period that the fire alarm panel was not working, which ultimately amounted to at least three days, a large number of staff and other responsible people were around the resident areas. The January 27, 2003, morning shift had a minimum of 17 staff members directly assigned, with others coming and going from the unit. In all, there were around 25 people circulating in the nursing home during the day shift. After the surveyors had left, the evening shift had nine staff members assigned to the unit, with additional staff overlapping from the day shift. The night shift had six assigned staff members, plus "Ron," Respondent's security man, who was assigned to a fire watch, beginning late on the afternoon of January 27, 2003. (See Finding of Fact 32.) On Tuesday, January 28, 2003, there were 20 staff people directly assigned to the unit on the day shift. Counting the AHCA surveyors and ancillary staff, there were approximately 27 people on the floor. The evening shift had nine specifically assigned staff members, with others overlapping. The night shift had at least six staff members. On Wednesday, January 29, 2003, the numbers were similar. During the course of January 27, 2003, Mr. Doran did not tell Respondent's administrators, Don Wilson or Mike Sweeney, about the problem with the fire alarm panel because he thought the fire alarm panel problem was being resolved by the W. W. Gay technicians and because both administrators were very busy with the AHCA survey. Around 4:00 p.m., January 27, 2003, Mr. Doran found out that the problem with the fire panel was more serious than he had earlier thought. The AHCA surveyors had already left the facility. Mr. Doran went to Mr. Sweeney and Mr. Wilson. He told them at that time that W. W. Gay's third technician had told him that it would be the next morning before the fire alarm/system panel could be repaired. Mr. Sweeney and Mr. Wilson advised Mr. Doran that the situation was unacceptable. They instructed Mr. Doran to call W. W. Gay and tell that company to return and fix the panel immediately. Mr. Doran made the phone call, but as it ultimately turned out, the fire panel could not be fixed that night because a part had to be ordered. The facility had in-place a three-tiered system of evacuation in case of fire. First, residents in the room where the fire is located and those in the two adjoining rooms would be moved to safety. Second, if the fire continued to spread, all residents on the side of the fire doors where the fire was located would be moved to the other side of the doors and the fire doors closed. Third, and only if the fire were still not contained, would the residents be moved out of the building through the stairwells. The control panel of the fire alarm system is the "brains" of the facility's fire safety system. It has a direct connection to the local fire department and provides the fire department with direct, immediate notification if there is a fire in the facility. It provides immediate notification to the residents and staff of the facility through the sounding of bells, chimes, strobes, etc., of the existence of an emergency. It operates the smoke detectors. It automatically shuts down the air conditioning unit to prevent the spread of carbon monoxide, smoke, and fumes throughout the facility, and it automatically locks and unlocks the fire doors. It is the transfer of smoke and toxic gases generated during a fire which is the most common cause of casualty. The continued operation of the air conditioning system during a fire could make the lateral transfer of residents to another compartment on the same floor (tiers one and two of the facility's fire safety plan) ineffective because the continued operation of the air conditioning system could still transfer gases and smoke throughout the facility. However, in this case, although the facility's air conditioning system does move air, smoke being carried throughout the building was unlikely, since the intakes were located in common areas where smoke would be detected by staff. Fire drills are held by Respondent at least monthly. Staff is trained to respond to fires by Scott Fogg, a facility employee who has 23 years' United States Navy experience in training to fight fires, watching for fires, and fighting fires. Mr. Fogg has personally fought over 30 fires. He orients each new employee for at least one and one-half to two hours. He also does annual training of staff. Part of the training provided by Mr. Fogg consists of going step by step through the facility's fire plan. The plan includes contacting the fire department. Once the charge nurse knows of a fire, it is her responsibility to call "911." The facility's plan requires that the charge nurse notify the fire department, regardless of whether or not the alarm system is functioning.1/ The facility's fire plan is kept at several locations, including in the possession of the charge nurse and at the nurses' station. Every individual who goes through orientation also receives a copy. There is a sprinkling system for the entire facility. The sprinkling system is not dependent on the alarm system functioning. Each resident's room has at least two sprinklers, and some rooms have three sprinklers. The bathrooms inside the residents' rooms have an additional sprinkler. The dining room, halls, common area, and stairwells have sprinklers. There are fire extinguishers located at each corner of the building and fire hoses on the walls. Mr. Fogg evaluates the monthly fire drills. If he notes a problem, he writes it up and does follow-up training. The building is made of concrete, and nonflammable paint is used. Smoking is not permitted in the facility building. Staff are required to smoke in a designated smoking area behind another building. Residents are not allowed to keep combustible materials in their rooms. The kitchen and laundry are located in another building. Evacuation routes are posted throughout the building. Upon learning at approximately 4:00 p.m. January 27, 2003, that the fire alarm/system could not be fixed that night, Messrs. Wilson and Sweeney instructed Mr. Doran to institute a one-hour fire watch. A fire watch involves dedicating an individual to go around the building at stated intervals (in this case, hourly) looking for potential fire, smoke, or fire risk. Mr. Sweeney is the facility's Executive Director. He is also a licensed nursing home administrator. Based on his 25 years of experience in health care and his knowledge of the properties of the facility's physical plant, he thought a one- hour fire watch was reasonable and appropriate. Mr. Wilson, the facility's Health Services Administrator, concurred. Respondent's security man, Ron, was instructed to perform the hourly fire watch. Mr. Doran walked Ron around the area and told him to use his eyes, ears, touch, and sense of smell to look for any signs of fire. Ron carried a cell phone so that he could quickly communicate with Messrs. Doran, Wilson, Sweeney, or the fire department, if necessary. There is no evidence that Ron failed in his instructed duties for an hourly fire watch. Most of the survey team returned about 7:00 a. m., on January 28, 2003. At approximately 8:30 a.m., another team member, Nicholas Linardi, AHCA's Life Safety Inspector, arrived at the facility for the first time. Mr. Doran met with Mr. Linardi in the administrative conference room at around 9:00 a.m. There is no dispute that the first order of business was Mr. Linardi's review of all of the facility's service and safety logs. Mr. Fogg was also present at that time. After this point, there are significant differences among the witnesses' respective testimonies as to the chronology of events and the time span involved. However, having weighed the credibility of the respective witnesses, it is found that no later than their arrival on the second floor skilled nursing unit at approximately 9:30 a.m., January 28, 2003, Mr. Doran told Mr. Linardi that there was a problem with the fire alarm panel/system. How clear Mr. Doran was in this first explanation of the extent of the problem or how much or how little of Mr. Doran's explanation Mr. Linardi appreciated at that time is not clear from the record, but Mr. Linardi inquired concerning what the facility was doing about solving the problem, and Mr. Doran told him. Mr. Linardi requested that Mr. Doran call W. W. Gay again. Mr. Linardi did not require that the facility shut off the air-conditioning, pending repair of the fire alarm system. He did not offer any immediate suggestions as to additional actions the facility staff should take to protect its residents. He did not state that the facility should increase the frequency of the fire watch. There also is no clear evidence that he told anyone at that time that the facility must notify the local fire department that the panel/system was inoperative. Mr. Linardi's testimony was clear that when he is on a facility's premises, he is one of the appropriate persons or entities to whom AHCA expects the facility will report a fire alarm/system malfunction, but he was also adamant that rigid enforcement of "tags and fire standards," means that the facility is required to report any malfunction to the local fire authority, in this case, to the St. Johns County Fire Department. It is Mr. Linardi's practice to issue a survey citation, regardless of the reason a fire alarm is out of commission. The rest of AHCA's survey team first became aware of the extent of the problem with the fire alarm system at approximately 2:45 p.m., on January 28, 2003, when Mr. Linardi conducted a fire drill in the facility for purposes of AHCA’s survey. During the fire drill, it became evident to the AHCA survey team that the alarm did not sound and the fire doors did not automatically close. During the fire drill, staff members had to yell out information to alert other staff members that there was a fire drill and to identify the location of the "pretend" fire. If the fire alarm system is working, it automatically closes the correct doors. If it is not working, staff members do not know which doors to close until told where the fire or pretend fire is, but during the fire drill, it took facility staff only four and one-half minutes to realize that the correct fire doors had not closed and to go to the north corridor to manually shut them. In general terms, Mr. Linardi felt that an incipient fire can start and be transferred throughout a facility within four minutes. He did not specifically discuss Respondent's facility. No one testified to what the response time should have been if an alarm had sounded. Beyond what could at most have been a half-minute response delay due to the absence of a functioning alarm, AHCA apparently found no fault with the staff's response to, and conduct of, the fire drill. Mr. Linardi was, in fact, complimentary of the results. After the fire drill on January 28, 2003, Mr. Linardi personally called W. W. Gay and verified that the part necessary to fix the panel/system was on order. Still later in the afternoon, Mr. Linardi notified the St. Johns Fire Marshal that Respondent's fire alarm system was not in service. The St. Johns Fire Marshal directed that the facility institute a 15-minute fire watch. Respondent immediately instituted the 15-minute fire watch on January 28, 2003. Mr. Linardi testified that he was concerned that the Fire Marshal's assigned fire watch frequency of 15 minutes was too liberal and that a fire watch perhaps should have been instituted at even shorter intervals, but since the regulations presume that the local authority shall set the protocol for fire watches, he said nothing. There was some surveyor commentary to the effect that laundry carts "stored" in Respondent's hallway near one of the exits to the stairs violated survey criteria and aggravated danger to residents, but Mr. Linardi conceded that laundry carts could legitimately be rolled through hallways as linen goods were transported in them from the linen closet to each resident's room. It was his opinion such carts should have been parked in residents' rooms for any extended period of time. No accurate measurements of acceptable time or unacceptable time that these carts remained in the hallways was advanced by any witness, so this survey criticism is not indicative of a citable flaw. A chair was found on the landing at the top of one of the two exit stairwells. The landing and stairwell are large. The chair was not blocking the door leading onto the second floor landing from the skilled nursing unit. The chair's location would not have prevented an ambulatory person or a person on a cane, assisted by another, from descending via the stairs. The only obstruction the chair might have represented would have been if a patient had to be carried on a stretcher or litter and the stretcher or litter had to be turned by two people on the landing. Mr. Linardi commented that actual egress was not at issue, but because survey criteria specifically prohibit furniture or any other object from being there, the chair's presence on the landing was still a citable offense. Renovations were ongoing in the facility during this period, and construction workers had temporarily stored some of the construction materials that they were using in the bottom recess of an exit stairwell. These supplies were stored without permission or knowledge of facility staff. The bottom of the stairwell is a large open area, 22 feet long by 10 feet wide. Most of the construction materials were stored beneath the stairs and were not blocking either a step down from the stairs or access to the outside exit door. However, one piece of flat molding protruded in front of the exit door, and had the potential of impeding egress. Although there was testimony that this molding could have been easily stepped over, the photographs make clear that this item could have impeded the speed of an evacuation of the above-described frail, elderly and non-ambulatory population if an evacuation had been necessary. There is no persuasive evidence that a hinge on any exit door prevented its being opened or that any exit door was otherwise unreachable or otherwise out of commission. During the 15-minute fire watch on the third day of the survey, January 29, 2003, Ron (See Findings of Fact 13, 32, and 42) found a tray on top of the juice machine in the beverage area of the facility’s dining room and removed it. This area is within three feet of a sprinkler head and within six feet of a fire extinguisher. The juice machine has thermal overload protection to prevent electricity going to the motor if the motor gets hot. In short, if the motor gets hot, the machine cuts off. When the surveyors arrived on that date, a number of residents and staff members were in the dining room. The surveyors noted an odor similar to that of a burning motor in the vicinity of the juice machine. At that time, the tray had already been found and removed as part of the 15-minute fire watch. When a motor overheats, the smell lingers for a long time. There is no evidence that the incident did more than produce an unpleasant odor. AHCA gave Respondent a written mandated correction date of February 6, 2003, but before the survey team finally exited on January 29, 2003, the facility had changed the fire watch to every 15 minutes and had advised that the fire alarm system would be operational on January 30, 2003. Therefore, AHCA removed the "immediate jeopardy" classification on January 29, 2003, prior to the end of the survey, when it determined that fire watches were being conducted every 15 minutes.
Recommendation Based on the foregoing Findings of Facts and Conclusions of, it is RECOMMENDED that the Agency for Health Care Administration enter a final order Finding Respondent guilty of a single, isolated Class III deficiency, fining Respondent $1,000.00 therefore, and removing Respondent's conditional licensure status; and Remanding to the Division of Administrative Hearings the issue of the amount of any costs related to the investigation and prosecution of these cases, pursuant to Section 400.121(10), in the event the parties cannot stipulate to those costs. DONE AND ENTERED this 13th day of November, 2003, in Tallahassee, Leon County, Florida. S ELLA JANE P. DAVIS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 13th day of November 2003.
The Issue Whether Respondent is guilty of violating Sections 509.221(1) and (7) and 509.032, Florida Statutes, and Florida Administrative Code Rules 61C-1.004(5), (6), and (13), 61C- 3.001(2), as set out in the Administrative Complaint dated March 24, 2003.
Findings Of Fact The Department of Business and Professional Regulation, Division of Hotels and Restaurants (DHR) is the State Agency charged with regulating the operation of hotel establishments pursuant to Section 20.165 and Chapter 509, Florida Statutes. At all times material hereto, Respondent has been licensed by DHR or otherwise subject to DHR's jurisdiction, pursuant to issued License No. 26-00783. Respondent's last known business address is Clark Apartment and Rooms, 9762 Bayview Avenue, Jacksonville, Florida 32208. On February 3, 2003, and again on March 10, 2003, a DHR sanitation and safety specialist, John Phelan, inspected Respondent's premises. On February 3, 2003, the initial inspection, Mr. Phelan was accompanied by his superior, David Futlon. At the February 3, 2003, initial inspection, the following deficiencies were observed by both inspectors and noted for Respondent by Mr. Phelan: No proof was observed that the smoke detectors were interconnected as required by law and as stated by management. The door of a gas oven was held in place by a garden spade. Live roaches were on the floor and climbing the walls around the oven. The inspectors observed a stained mattress and a missing mattress pad on the bed in room They also observed that the second floor bathroom was out- of-order, and that shower curtains and shower stalls were dirty with soap scum. On March 10, 2003, Mr. Phelan returned to Respondent's premises by himself and noted that the foregoing problems/violations remained. According to both inspectors, the most serious violation was that there was no documentation that the smoke detectors were interconnected. This is a critical violation because it could present a potential fire hazard. The next violation that was found to be critical was that there was "a garden spade holding the oven door closed." This was seen as a violation because of the potential for fire. Next down the urgent and critical scale was the presence of live roaches around the oven. The absence of a mattress pad on room 17's mattress and the stain on the mattress were of somewhat less concern. However, these bedding problems are violations because they pose a sanitary issue. The next-ranked violation was that the second floor bathroom was out-of-order. The bathroom also presented a lesser sanitary issue, which was that the shower curtain and shower stall were dirty with soap scum. Based on the foregoing uncorrected deficiencies, Mr. Phelan caused an administrative complaint to be issued against Respondent on March 24, 2003, alleging Respondent's violation of Chapter 509, Florida Statutes, and/or the administrative rules promulgated thereunder. Although it was demonstrated at hearing that Mr. Clark, Respondent's principal, had been attempting, between the two inspections, to fix the originally-cited deficiencies, and although some progress at renovation had been made, most problems had not been fully addressed as of the date of the follow-up inspection on March 10, 2003. The credible evidence and testimony as a whole show that Mr. Phelan had recognized that a gas heater which had been cited at the initial inspection had been disconnected by the date of the second inspection and that it was no longer in use at the time of the second inspection. Therefore, the gas heater had been crossed off the notification to Respondent by Mr. Phelan and had not been cited as a violation in the administrative complaint. The stove also had been disconnected prior to the re-inspection. The gas heater and gas stove were disconnected at the same time, so propping the stove door open or closed with a spade had no significance with regard to fire hazard. Like the heater, the stove should have been removed from the premises as a safety precaution, but because Mr. Phelan did not know that the stove had been disconnected when he made his re-inspection, it was cited and included in the administrative complaint. The reason the disconnected stove was still present on the premises was because Respondent was fumigating for roaches by setting off "roach bombs" inside it. The fumigation of the roaches in an area where all other exit holes for them were intentionally sealed had resulted in some dead roaches, but many live roaches had fled into the kitchen in the vicinity of the stove. The live roaches were observed by all the witnesses who saw the kitchen on or about the re-inspection date. The testimony of several witnesses was credible that the upstairs bathroom's sink and tub had been repaired prior to the re-inspection. Mr. Musselwhite recalled credibly that he had screwed the faucet handles back on the tub between the two inspections. However, the testimony of Mr. Musselwhite that he was using the tub and sink upstairs at the time of the re- inspection is not credible. The greater weight of the credible evidence is that the tub and sink upstairs might have been repaired, but they were not actually in working order at the time of the March 10, 2003, re-inspection, because the water had not yet been turned back on. The evidence is clear that plaster board had been installed in the shower by the date of the re-inspection and that this was done to deal with the prior notice concerning discoloration. A dispute among the witnesses as to whether the discoloration on the old shower walls was soap scum, discoloration by scum removers, or mildew cannot be resolved. However, it was proven that, despite several changes of shower curtains between the two inspections, the shower curtains present on the re-inspection date remained covered with soap scum and/or mildew. Respondent admitted that the lack of a mattress pad on the mattress in room 17 on the date of re-inspection was an oversight. It was proven that a mattress from a first floor room had been moved upstairs to room 17. In the opinion of Respondent's witnesses, this constituted, a "new" mattress which was not stained. In this situation, Mr. Phelan's observation of the mattress stain is more credible. On his first inspection, Mr. Phelan told Mr. Clark that in the absence of other documentation, Mr. Clark needed to have the State Fire Marshall inspect Respondent's smoke detectors, in order to provide documentation that they were interconnected. By "interconnectedness" the parties meant that if one smoke detector sounded, then all of the smoke detectors throughout the hotel should also sound. Mr. McGee and Mr. Clark testified that between the two inspections the issue of the smoke detectors had been "looked into" with employees of Home Depot and at the local fire department. Mr. Clark stated that he had contacted the Jacksonville Fire Department, which would not give him any documentation, but its employees agreed to come and inspect his smoke detectors. Mr. Clark testified convincingly that he had purchased and installed smoke detectors from the Home Depot which did not provide written documentation of interconnectedness but which could be tested for interconnectedness by pushing their buttons. He maintained that if the inspector had punched the button on any single smoke detector on the re-inspection date, the interconnectedness of all the smoke detectors would have been demonstrated by their all "going off" at once. The inspectors did not punch the smoke detectors' buttons during the two inspections because they could not reach the buttons, as they had no ladders. Respondent was written-up by DHR on both occasions because written documentation of interconnectedness was not provided and because interconnectedness was not otherwise demonstrated. In other words, Respondent provided neither papers showing interconnectedness nor a physical demonstration of interconnectedness during the second inspection.
Recommendation Based on the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED that the Department of Business and Professional Regulation, Division of Hotels and Restaurants, shall enter a final order: Finding Respondent guilty of violating Sections 509.221(1) and (7), Florida Statutes, and Florida Administrative Code Rules 61C-1.004(5) and (6), and 61C-3.001(2), and not guilty of violating Florida Administrative Code Rule 61C- 1.004(13); Ordering Respondent to pay an administrative penalty in the amount of $2,500.00, due and payable to the Department of Business and Professional Regulation, Division of Hotels and Restaurants, 1940 North Monroe Street, Tallahassee, Florida 32399, within 30 days of the final order; Requiring Respondent to attend a Hospitality Education Program class within 60 days of the date of the final order and provide proof thereof to the Department of Business and Professional Regulation Division of Hotels and Restaurants; and Requiring that Respondent pass a re-inspection of its premises within the same 60 days set out in (3), above. DONE AND ENTERED this 14th day of July, 2004, in Tallahassee, Leon County, Florida. S ELLA JANE P. DAVIS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 14th day of July, 2004.
The Issue The issue for consideration in this proceeding is whether the Respondent’s license as an adult living facility should be subject to an administrative fine in the amount of five hundred dollars ($500.00) for repeated class III deficiencies.
Findings Of Fact The Respondent is the owner/operator of San Juan Retirement Home. The home is licensed to operate a 6-bed assisted living facility in Jacksonville, Florida. On March 5, 2003, AHCA conducted a survey of Respondent's facility. During that survey, Respondent did not have a fire safety inspection report within 365 days from an earlier fire safety inspection report. Because of the lack of a timely report the facility was cited for violating Tag A209, a Class III deficiency. Tag A209 requires that all licensed facilities have an annual fire inspection conducted by the local fire marshal or authorities having jurisdiction. In this instance the Agency interprets the word annual to mean 365 days from the last inspection report. Respondent had the facility inspected by the Fire Marshal on March 12, 2003. She received the report the same day. A follow-up survey was conducted on April 15, 2003. Tag A209 was noted as corrected in a timely manner by Respondent. Since this was the first Class III deficiency regarding the timeliness of the inspection report, no penalties were imposed by Petitioner on Respondent. On April 23, 2004, AHCA again inspected Respondent's facility. During the inspection, Respondent again did not have a fire safety inspection report completed within 365 days of the earlier inspection report of March 12, 2003. Because of the lack of the report, the facility was cited for a class III deficiency under Tag A209. Respondent admitted that she twice did not have a timely fire safety inspection report completed for her facility. The evidence demonstrated that, prior to the April 2004 inspection by AHCA, Respondent had called the Fire Marshal’s office to schedule an inspection for the facility. However, the call was not made until the expiration of the March 12, 2003, fire safety inspection report. For some unknown reason the Fire Marshal’s office did not schedule the fire safety inspection until after the April 2004 inspection. However, the Fire Marshal’s failure to schedule the inspection does not excuse Respondent’s lack of a timely inspection and report since Respondent remains responsible for obtaining the inspection and report in a timely manner and did not call the Fire Marshal’s office until the expiration of the earlier report. To her credit, Respondent obtained a new fire safety inspection report on May 4 or 5, 2004, after AHCA had inspected the facility.
Recommendation Based on the foregoing Finding of Facts and Conclusions of Law, it is RECOMMENDED: That AHCA enter a final order imposing a $500.00 administrative fine for repeatedly failing to timely conduct or obtain an annual fire safety inspection report. DONE AND ENTERED this 9th day of November, 2004, in Tallahassee, Leon County, Florida. S DIANE CLEAVINGER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 9th day of November, 2004. COPIES FURNISHED: Michael O. Mathis, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Suite 3408D Mail Stop 3 Tallahassee, Florida 32308 Elvira C. Demdam San Juan Retirement home 6561 San Juan Avenue Jacksonville, Florida 32210 Alan Levine, Secretary Agency for Health Care Administration Fort Knox Building, Suite 3116 2727 Mahan Drive Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration Fort Knox Building, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308
