YAK aw, bY “ke, ‘ STATE OF FLORIDA 2 AGENCY FOR HEALTH CARE ADMINISTRATESH/ fy, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2008006651 AHCA No.: 2008006652 v. Return Receipt Requested: 7002 2410 0001 4236 1018 COVENANT VILLAGE OF FLORIDA, 7002 2410 0001 4236 1025 INC. d/b/a COVENANT VILLAGE 7002 2410 0001 4236 1032 CARE CENTER, 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 Covenant Village of Florida, Inc. d/b/a Covenant Village Care Center (hereinafter “Covenant Village Care Center” ) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2007, and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $7,500.00 pursuant to Sections 400.23(8) (b), Florida Statutes (2007), [AHCA No.: 2008006651]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes (2007), [AHCA No. 2008006652]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes (2007), and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Broward County pursuant to Section 120.57, Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code (2007). PARTIES 5. AHCA is the regulatory authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2007), and Rule 59A-4, Florida Administrative Code. 6. Covenant Village Care Center operates a 60-bed skilled nursing facility located at 9211 W. Broward Blvd., Plantation, Florida 33324. Covenant Village Care Center is licensed as a skilled nursing facility under license number 110080961. Covenant Village Care 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. COUNT I FLORIDIAN NURSING HOME, INC. FAILED TO MEET THE STATE MINIMUM STAFFING REQUIREMENTS : SECTION 400.141(15) (D), FLORIDA STATUTES (STAFFING STANDARD) CLASS II 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Covenant Village Care Center was cited with one (1) Class II deficiency as a result of a complaint investigation survey that was conducted on April 8, 2008. 9, A complaint investigation survey was conducted on April 8, 2008. Based on interview and record review, it was determined that the facility failed to meet the state minimum- staffing requirement for 2 consecutive days, then failed to achieve the minimum staffing requirement for a period of 6 consecutive days before admitting 7 of 8 new residents to the facility (resident # 1, #2, #4, #5, #6, #7 and #8). Findings include the following. 10. Review of the staffing (Hours by Labor Account, Census, State form for Calculating Nursing Hours, Report of Nursing Staff Directly Responsible for Resident Care and Sign-In Sheets) provided by the facility showed the facility did not the minimum staffing Requirement the following days: Date 2/2/08 2/3/08 2/4/08 2/5/08 2.8.08 2/10/08 2/11/08 2/13/08 2/14/08 2/18/08 2/21/08 2/27/08 11. Review of the Census 58 58 58 57 58 55 55 56 56 54 54 '54 form for for the licensed Facility 42 50 40 nursing staff Short 14 for Calculating Nursing Hours, Report of Nursing Staff Directly Responsible for Resident Care and Sign-In Sheets, provided by the facility showed the facility did not meet the minimum requirement for Certified Nursing Assistants (CNA). The weekly average of 2.9 hours per resident per day, not falling below 2.7 hours daily was not met for CNA's for the following days: Date Census Req. Facility Short 2/17/08 55 159.5 145. 14.5 2/22/08 55 159.5 143 16.5 2/23/08 56 162.4 138 24.4 2/25/08 56 162.4 144 18.4 12. On 2/4/08 resident #5 was admitted to the facility, his/her first admission to the facility based on record review and interview on 4/8/08 at 1:30 PM with the Secretary. The facility was below the minimum staffing pattern for licensed nurses on 2/2/08 and 2/3/08. 13. On 2/11/08 resident #4 was admitted (not a re- admission) to the facility without the facility maintaining the minimum staffing hours for 6-consecutive days. The facility was below the minimum staffing for licensed nurses on 2/5/08, 2/8/08 and 2/10/08. 14. On 2/19/08 resident #6 was admitted (not a re- admission) to the facility without the facility maintaining the minimum staffing hours for 6-consecutive days. The facility was below the minimum staffing for licensed nurses on 2/13/08, 2/14/08 and 2/18/08. Additionally, on 2/17/08 the minimum staffing hours were not met for CNA's. 15. On 2/22/08 resident #'s 1 and 8 were admitted (not a re-admission) to the facility without the facility maintaining the minimum staffing hours for 6-consecutive days. The facility was below the minimum staffing for licensed nurses on 2/18/08 and 2/21/08. CNA's hours were not met on 2/17/08. 16. On 2/23/08 resident #2 was admitted (not a re- admission) to the facility without the facility maintaining the minimum staffing hours for 6-consecutive days. The facility was below the minimum staffing for licensed nurses on 2/18/08 and 2/21/08. Minimum hours for CNA's were not met on 2/22/08. 17. On 2/29/08 resident #7 was admitted (not ai re- admission) to the facility without the facility maintaining the minimum staffing hours for 6-consecutive days. The facility was below the minimum staffing for licensed nurses on 2/27/08. Additionally, on 2/22/08, 2/23/08 and 2/25/08 the facility did not meet the minimum staff for CNA's. 18. Based on the foregoing facts, Covenant Village Care Center violated Section 400.141(15), Florida Statutes (2007), herein classified as a widespread, Class II violation pursuant to Section 400.23(8), Florida Statutes (2007), which carries an assessed fine of $7,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes (2007). DISPLAY OF LICENSE Pursuant tg Section 400.25(7), Florida Statutes (2007), Covenant Village Care Center 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” EXHIBIT “A” Conditional License License # SNF11080961; Certificate No.: Effective date: 04/08/2008 Expiration date: 02/28/2010 Conditional License License # SNF11080961; Certificate No.: Effective date: 05/16/2008 Expiration date: 02/28/2010 15278 15279 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Covenant Village Care Center an administrative fine of $7,500.00 for the violation cited above. 3. Assess against Covenant Village Care Center a conditional license in accordance with Section 400.23(7) Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. Grant such other relief as the 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 (2007). Specific options for administrative action are set out in the attached Election of Rights. 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 NO REQUEST A HEARING WITHIN TWENT _ COMPLAINT, PURSUANT RESULT IN AN ADMISSION OF THE THE ENTRY OF A FINAL ORDER BY 1 IF YOU WANT TO HIRE AN A’ REPRES} ENTED BY AN ATTORNEY IN 1 Fla. Copies furnished to: Arlene Mayo-Davis Field Office Manager TO THE AT’ TIFIED THAT FAILURE TO RECEILV E A Y-ONE (21) DAYS OF RECI EIPT OF THIS TACHED ELECTION OF RIGHTS, WILL = By r FACTS ALLEGED IN THE COMPLAINT AND THE AGENCY. = sh TTORNEY, YOU HAVE THI RIGHT TO BE THIS MATTER Alba M. fot Kiba, Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace Miami, Florida 33166 #103 Agency for Health Care Administration 5150 Linton Blvd., Suite 500 Delray Bach, Florida 33484 (U.S. Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 10 Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 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 Terri Cunliffe, Administrator, Covenant Village Care Center, 9211 W. Broward Blvd., Plantation, Florida 33324; Covenant Village of Florida, Inc., 5115 N. Francisco Avenue, Chicago, Illinois 60625; Corporation Services Company, 1201 Hays Street - Suite 105, Tallahassee, Florida 32301 on this pp {7 day of July, 2008. Alba M. Lge ral 3

Docket for Case No: 08-003918