(O¥-Ob17 Pipe, “Ley STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION) “/j,,. Y y We, ae » 'O> STATE OF FLORIDA, AGENCY FOR ABR HEALTH CARE ADMINISTRATION, ‘ Petitioner, AHCA No.: 2007009907 AHCA No.: 2007009909 v. Return Receipt Requested: 7002 2410 0001 4235 7738 FLORIDEAN NURSING HOME, INC 7002 2410 0001 4235 7745 d/b/a FLORIDEAN NURSING HOME, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter “AHCA") , by and through the undersigned counsel, and files this administrative complaint against Floridean Nursing Home, Inc. d/b/a Floridean Nursing Home, Inc. (hereinafter “Floridean Nursing Home, Inc.”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2005) hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $3,000.00 pursuant to Sections 400.23(8) (b), Florida Statutes [AHCA No.: 2007009907]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2007009909]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Miami-Dade County pursuant to Section 120.57, Florida Statutes (2006), and Rule 28-106.207, Florida Administrative Code (2006). PARTIES 5. AHCA is the regulatory authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Floridean Nursing Home, Inc. operates a 60-bed skilled nursing facility located at 47 N. W. 32 Place, Miami, Florida 33125. Floridean Nursing Home, Inc. is licensed as a skilled nursing facility under license number 11570951. Floridean Nursing Home, Inc. 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 FORT PIERCE HEALTH CARE FAILED TO PROPERLY MAINTAIN THE FIRE SPRINKLER SYSTEM. SECTION 400.141(8), FLORIDA STATUTES (2006) SECTION 400.23(2) (a), FLORIDA STATUTES (2006) RULE 59A-4.130, FLORIDA ADMINISTRATIVE CODE (LIFE SAFETY CODE STANDARD) CLASS IIIT 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Because Floridean Nursing Home, Inc. participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. Floridean Nursing Home, Inc. was cited with one (1) Class III deficiency due to a Fire Life Safety State Re- licensure and Federal Recertification surveys conducted on March 20, 2007 and May 1, 2007. 10. A Fire Life Safety State Re-licensure and Federal Recertification survey annual survey was conducted on March 20, 2007. Based on documentation review and staff interview between the hours of 10:00 am and 11:30 am, it was determined that Floridean Nursing Home failed to properly maintain the fire sprinkler system. This condition could cause the fire sprinkler system to fail during a fire situation, thus endangering the occupants of the facility. The findings include the following. 3 11. The staff could not find any documentation for the required five year inspection and test per NFPA 25, 9.7.5. The director of maintenance and the operator of facility have no knowledge of this inspection ever being performed. NFPA 101- 2000; NFPA 13, 25, 19.3.5. 12. The mandated date of correction was designated as April 20, 2007. 13. A revisit survey was conducted on May 1, 2007. Based on documentation review and staff interview between the hours of 10:00 am and 11:30 am, it was determined that Floridean Nursing Home failed to ensure that the fire sprinkler system testing that was cited during the annual survey on 3/20/07 was conducted. This condition renders the fire sprinkler system unreliable during a fire situation, thus endangering the occupants of the facility. The findings include the following. 14. The deficiency findings during the revisit survey conducted on May 1, 2007 revealed that the fire sprinkler system was not tested as frequently as required demonstrating continued non-compliance. 15. Interview with the director of maintenance and the facility owner at 12:45 PM revealed the required inspection and testing has not been completed as stated on the Plan of Correction. 16. The Plan of Correction that was sent to the agency stating. that the work was completed on 04/22/07. The owner produced a proposal from All Fire Services, Inc which was signed by the owner, accepting the proposal. This document was dated 03/26/07. The owner then called the sprinkler company and the surveyor spoke directly to a representative who stated that the facility staff never scheduled the work to be completed nor had they signed and returned the damage waiver. 17. The owner nor the director of maintenance was unsure why this work was never scheduled. NFPA 101-2000. NFPA 13, 25, 19.3.5. This is an uncorrected deficiency from the survey of March 20, 2007. 18. Based on the foregoing facts, Floridean Nursing Home, Inc. violated Section 400.141(8), Florida Statutes (2006), Section 400.23(2) (a), Florida Statutes (2006), and Rule 59A- 4.130, Florida Administrative Code, herein classified as a widespread, uncorrected Class III violation pursuant to Section 400.23(8), Florida Statutes(2006), which carries an assessed fine of $3,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23 (7) (b), Florida Statutes (2006). DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Floridean Nursing Home, Inc. shall post the license in a prominent place that is 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”

Docket for Case No: 08-000617