ana Coes that STATE OF FLORIDA OG6SEP 18 PM 4:23 AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION GF AGENCY FOR HEALTH CARE ADMIHISTRATIVE ‘ HEARINGS ADMINISTRATION, LARS Petitioner, AHCA No.: 2006005722 AHCA No.: 2006005726 Return Receipt Requested: 7002 2410 0001 4234 9504 HEBREW HOME SINAI, INC., d/b/a 7002 2410 0001 4234 9511 SINAI PLAZA NURSING & REHAB CENTER, 7002 2410 0001 4234 9528 Respondent. ) O (o . Q JoO ADMINISTRATIVE COMPLAINT v. COMES NOW the Agency for Health Care Administration ‘(hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Hebrew Home Sinai, Inc., d/b/a Sinai Plaza Nursing & Rehab Center (hereinafter “Sinai Plaza Nursing & Rehab Center”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2005), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Section 400.23(8), Florida Statutes (2005), for the protection of the public health, safety and welfare. 2. This is an action to, impose Conditional Licensure status to Sinai Plaza Nursing & Rehab Center, pursuant to Section 400.23(7) (b), Florida Statutes (2005). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2005), and Chapter 28- 106, Florida Administrative Code. 4. Venue lays in Miami-Dade County, pursuant to Section 400.121(1) (e), Florida Statutes (2005), and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part ITI, Florida Statutes, (2005), and Chapter 59A-4 Florida Administrative Code. 6. Sinai Plaza Nursing & Rehab Center is a 150-bed skilled nursing facility located at 201 N.E. 112™ Street, Miami, Florida 33161. Sinai Plaza Nursing & Rehab Center is licensed as a skilled nursing facility; license number SNF15190961; certificate number 13566, effective 12/01/2005, through 06/06/2006. Sinai Plaza Nursing & Rehab Center 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. N COUNT I SINAI PLAZA NURSING & REHAB CENTER FAILED TO MAINTAIN THE SOILED LINEN COLLECTION RECEPTACLES IN A ROOM PROTECTED AS A HAZARDOUS AREA, INCREASING THE RISK TO RESIDENTS NFPA 101, 2000 Edition, and/or Rule 59A-4.130, Florida Administrative Code. (LIFE SAFETY CODE STANDARD) UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 8. During the Life Safety Survey conducted on 12/01/05 and based on observation and interview, the facility failed to maintain the soiled linen collection receptacles in a room protected as a hazardous area, increasing the risk to residents. 9. During the Life Safety Survey conducted with the facility Director of Maintenance on 12/01/05, the soiled linen rooms in Sections A, B, & C did not have operational ventilation with negative air flow. Soiled linen is required to be stored in a room protected as a hazardous area when not attended. This protected hazardous area must be maintained and protected with ventilation that ensures a negative air flow environment. Interview with the Director of Maintenance on 12/01/05 at 3:17pm confirmed the findings. Correction Date: 01/01/06. 10. During the’ Life Safety follow-up visit to the 12/01/05 recertification survey conducted with the facility Director of Maintenance on 01/05/06, the soiled linen rooms in Sections A, B, & C did not have operational ventilation with negative air flow. Soiled linen is required to be stored in a room protected as a hazardous area when not attended. This protected hazardous area must be maintained and protected with ventilation that ensures a negative air flow environment. Interview with the Administrator and the Director of Maintenance on 01/05/06 at 1:36pm confirmed the findings. They have contracted a licensed company to correct the existing problem. This is an uncorrected deficiency from the 12/01/05 survey. 11. Based on the foregoing, Sinai Plaza Nursing & Rehab Center violated NFPA 101, 2000 Edition, and/or Rule S9A-4.130, Florida Administrative Code, herein classified as an uncorrected Class III deficiency pursuant to Section 400.23(8)(c), Florida Statutes, which carries, in this case, an assessed fine of $1,000.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, Sinai Plaza Nursing & Rehab Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents'are being admitted to the facility. The Conditional License is attached hereto as Exhibit “a” CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $1,000.00 against Sinai Plaza Nursing & Rehab Center on Count I. c. Assess and assign a conditional license status to Sinai Plaza Nursing & Rehab Center in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922- 5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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. Nelson E. Rodney Assistant General Counse Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52™ Terrace Miami, Copies furnished to: Harold William Field Office Manager Agency for Health Care Administration 8355 N.W. 53°¢ street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Florida 33166 EXHIBIT “A” Conditional License License No. SNF 15190961 Certificate No. 13566 Effective date: 12/01/2005 Expiration date: 06/06/2006

Docket for Case No: 06-003520