STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ANGELL CARE OF NORTH MIAMI, INC., ) d/b/a MEADOWBROOK MANOR OF NORTH ) MIAMI, )

)

Petitioner, )

)

vs. ) CASE NO. 86-0932

)

DEPARTMENT OF HEALTH AND )

REHABILITATIVE SERVICES, )

)

Respondent. )

)

RECOMMENDED ORDER

This matter was heard in Coral Gables, Florida, on May 19-23, 1986, by William R. Dorsey, Jr., the Hearing Officer assigned by the Division of Administrative Hearings. A transcript of the proceedings was filed and the parties filed proposed findings of fact and conclusions of law. Rulings on the proposed findings of fact are found in the Appendix to this Recommended Order.

For Petitioner: Nancy Schleifer, Esquire

Miami, Florida

For Respondent: Dennis Berger, Esquire

North Miami, Florida

ISSUES

The issue in this matter is whether the superior nursing home license which Meadowbrook Manor had received should be replaced with a standard license?

Meadowbrook Manor contests deficiencies cited during a survey of the facility by the Department of Health and Rehabilitative Services, Office of Licensure and Certification. The facility contends that the deficiencies were not cited according to standard departmental procedures, were cited for circumstances which are not violations of statutes or rules, or should have been waived by the Department, and that it is entitled to a superior license.

I. FINDINGS OF FACT

1. Meadowbrook Manor is a nursing home located in Dade County, Florida. It received a standard rating after a survey was conducted by the Department of Health and Rehabilitative Services Office of Licensure and Certification which occurred on September 23, 1985, through September 25, 1985.

   
   

2. Meadowbrook Manor had between 240 and 245 patients at that time, it is a large nursing home.

3. The Department of Health and Rehabilitative Services performs interdisciplinary surveys annually for the purpose of determining licensure ratings of nursing homes. A facility with a superior rating receives a higher Medicaid reimbursement rate than one with a standard rating. Immediately prior to the survey which gave rise to this dispute, Meadowbrook Manor had a superior rating.

   
   

   1. The Change Over in Criteria for Determining Superior and Standard Ratings

      
      

4. Under the survey protocol in effect when the survey was conducted, a nursing home would obtain a superior rating if (1) it had no more than 20 deficiencies, with fewer than 4 deficiencies among 14 major areas, (2) had no more than 5 deficiencies in each remaining area, (3) had no class 1 or class II deficiencies (i.e., serious deficiencies posing a threat to the safety of clients, Section 400.23(4), Florida Statutes), (4) all deficiencies were corrected within certain time frames set by the Department, and (5) the nursing home met additional criteria outlined in a document entitled Guidelines for Determining Whether a Facility Exceeds Minimum Standards.

   
   

5. A new rating system became effective on September 26, 1985, after the Meadowbrook Manor survey was performed but before the report of the survey was compiled, due to the promulgation of Rule 10D-29.128, Florida Administrative Code. Under the new rule a superior nursing home still may have no class I or class II deficiencies, but the number of class III (ordinary) deficiencies would not preclude a superior rating if they were corrected in a timely manner. The facility must be in compliance with all evaluation standards contained in the nursing home licensure survey report. Finally, to determine whether a home is superior, the surveyors utilize a document entitled "Guidelines for Exceeding Minimum Standards", which was published in August or September 1985, which incorporates the requirements of Rule 100-29.128(6)(c), (d) and (e), Florida Administrative Code.

   
   

6. The parties stipulated that all deficiencies cited at Meadowbrook Manor as the result of the survey were class III deficiencies and that all deficiencies were corrected in a timely manner.

   
   

   1. The Survey Report

      
      

7. Under the current licensure System prescribed by the amendment to Rule 100-29.128, Florida Administrative Code, the Department uses a protocol entitled "Nursing Home Licensure Survey Report" when annual licensure surveys are conducted. The report contains three hierarchical categories of evaluation.

   The most general categories are conditions, conditions are made up of more specific sub-units known as standards, and standards are made up of very specific individual factual elements to be evaluated during the survey, which are numbered NH1-NH509. (The NH presumably identifies the elements as nursing home elements.) The first element in each standard is a general element which is used to record whether, based on the findings on individual elements, the standard has been met.

   
   

8. When the survey at Meadowbrook Manor occurred, the protocol in use today was not used. A different protocol had been used through September 26, 1985, which also had numbered, discrete elements which were evaluated. While the numbering system for elements to be surveyed changed on September 26, 1985,

   the substantive criteria embodied in the elements to be reviewed remained essentially the same. Any deficient element which the survey team documented in its survey using the old protocol has an analogous element under the new nursing home licensure survey report now in effect.

   
   

9. The presentation at final hearing made by the Department was generally cast in terms of the prior survey protocol and criteria for obtaining a superior rating in effect before September 26, 1985. Based on a motion filed by the facility, a ruling was made at the final hearing that the licensure decision based on the survey information collected on September 23-25, 1985, was being made after the new evaluation System embodied in Rule 100-29.128, Florida Administrative Code, became effective on September 26, 1985, so the new evaluation system applied to the information collected during the survey. Testimony from the survey team members about deficiencies they believe they found was received, and cross-referenced to the numbered elements of the old and new survey system. In this recommended order, the surveyors' findings will be evaluated with reference according to the new system for numbering elements, unless otherwise indicated.

   
   

   1. HRS Survey Procedures

      
      

10. HRS has published a manual setting out policies and procedures which members of survey teams are to follow in conducting licensure and certification surveys. For example, medical records of 10 percent of the patients at a facility are to be reviewed during the survey process. This sample is to be generated through the use of a random number table to provide the surveyors with a random sample. A table of random numbers and instructions for its use is found in the Department's survey manual.

    
    

11. If surveyors find minor deficiencies which can be corrected prior to the survey team's exit conference with the facility's staff and the deficiencies are corrected before departure, it is departmental policy that the facility should not be cited for those deficiencies. If a deficiency fits into two or more possible classifications, it should be treated as a single deficiency to avoid double counting.

    
    

12. In order to enhance the ability of surveyors to determine the quality of care provided at the nursing home, rather than assess mere paper compliance with regulatory standards, surveyors conduct interviews with patients.

    
    

13. The survey team members are required by departmental policy to discuss their findings during the survey process with the facility's staff so the staff members can direct the survey team to appropriate sources of information or provide appropriate explanations of what team members find during the survey.

    
    

14. The survey team members are required by departmental policy to conduct an exit conference with the staff of the facility after they have held, among themselves, a pro-exit conference to discuss the findings of each team member and to ensure that there is agreement among the team members on elements found deficient, i.e., not in compliance with statutory and rule requirements. The survey team leader conducts the exit conference, during which the team leader or team members announce each deficiency so that the staff of the facility will be aware of deficiencies. If deficiencies are found, the Department of Health and Rehabilitative Services resurveys to determine whether the deficiency has been corrected. These resurveys are usually conducted within 90 days.

15. The review of medical records of nursing home patients is an important part of the survey; clinical records and administrative records are also reviewed. The Department's survey handbook prescribes a selection procedure to generate a 10 percent random sample of medical records. See Finding of Fact 10, ante. This obviously is designed to provide a sample which will give the team a reliable overview of the quality of care being provided to residents.

    
    

    1. Deficiencies in the Survey Process

       
       

16. The testimony of the team leader, Mr. Bavetta, established that the proper procedure was not followed to draw the sample of records reviewed by the survey team. Rather than use the random selection procedure found in the handbook, Mr. Bavetta took patient records from each section of the facility, so if there are four wings he would pick records from each wing. While this has intuitive appeal, proper use of the sampling procedure would produce a representative sample. The procedure utilized here did not comply with the Department's own selection criteria, which seriously undermines the ability to generalize about trends at the facility, based on the findings made on the records that team members did review.

    
    

17. Five deficiencies found in the report of the team's findings had actually been corrected before the survey team left, or should have been treated as corrected. These include: old NH272, violation relating to the height of storage of items in the pantry; old NH 352, relating to maintenance of moldings, and louvered doors; old NH354, arising from a minor drainage problem in a beauty salon sink; old NH335, dealing with labeling of electrical circuits; and old NH267, relating to flame retarding treatment of paneling in an office which could have been completed before the survey team left, but was briefly delayed because the team used that room for its work and could not have done so due to fumes if the treatment material on hand had been applied while the team was at the facility.

    
    

18. With respect to the social services survey, the surveyor did very little patient interviewing (compare Finding of Fact 12, ante), and declined to discuss her findings with the facility's staff (compare Finding of Fact 13, ante). These failures did not significantly affect the surveyor's findings, however.

    
    

19. The suggestion by the facility that the survey was scheduled at a time too far in advance of the date Meadowbrook's superior license was to expire is rejected. Although by Departmental practice, surveys may usually take place within one hundred twenty (120) days of licensure expiration, the Department has the authority to survey at any time. Rule 100-29.128(2), provides that the scheduling of annual inspection "shall be at the discretion of the department".

    
    

    1. Deficiencies Admitted by Meadowbrook

       
       

20. Notwithstanding the errors in the generation of the medical records sample, Meadowbrook Manor admitted in the pre-trial stipulation that deficiencies in the following survey elements were found during the survey. As stated in Finding of Fact 6, however, these deficiencies were class III deficiencies which were corrected in a timely manner (numerical references are to survey elements):

    
    

    1. Condition IV, Dietary Services; Standard (f), Preparation and Food Service; element NH185, requiring that food be prepared by methods that conserve nutritive value, flavor, and far appearance; is of high consumer palatability;

       is attractively served at the proper temperatures to meet individual needs; and includes consideration of the cultural food preferences of the residents. Since the survey a wholly new food delivery system has been purchased at a cost of

       $21,000 to ensure that food remains at the appropriate temperature while moving from the kitchen to patient rooms.

       
       

    2. Element NH190, which is part of the same condition and standard as the preceeding item, which requires an over-bed table be provided whenever residents eat in bed. Additional tables have been purchased so patients do not need to wait for another patient to finish with a table before they may eat in bed.

       
       

    3. Condition IV, Dietary Services; Standard (g), Sanitary Conditions; element NH195, which requires that sanitarian reports, Food Service Establishment Inspection form number 4023, and any other written reports of inspections by state and local health authorities be maintained on file in the facility for one year from issuance, showing correction of any deficiencies.

       
       

    4. Condition XII, Physical Environment; standard (a), Fire Prevention, Fire Protection and Life Safety; element NH369, which requires that building service equipment be in accordance with national fire prevention act section 90A, and other applicable sections of the Life Safety Code. All Life Safety violations have been corrected.

       
       

    5. Condition XII, Physical Environment; standard (a), Fire Prevention, Fire Protection and Life Safety; element NH364, which requires fire alarm systems meeting applicable codes are installed, maintained, and tested as required. These have also been corrected.

       
       

21. Although these deficiencies have been admitted, because both parties agree they are class III deficiencies, and agree that they have been timely corrected, these stipulated deficiencies on individual elements are not sufficient in and of themselves to place the facility in violation of any standard. A contrary ruling would be dispositive here, because Rule 100- 29.128(6)(b), Florida Administrative Code, makes clear that to be eligible for superior rating, a facility must be in compliance with all standards (but not necessarily all elements) contained in the nursing home licensure survey report.

    
    

    1. Deficiencies Relied on by the Department but Contested by Meadowbrook

    
    

22. In its proposed recommended order, the Department maintains that the evidence supports findings that the following standards were not met: (1) Condition III, Nursing Services; Standard (b), Charge Nurse, general element 100; (2) Condition IV, Dietary Services; Standard (f), Preparation and Service of Food, general element 183; (3) Condition IX, Social Services; Standard (a), Provision of Services, general element 284; and (4) Condition XII, Physical Environment; Standard (a), Fire Prevention, Fire Protection and Life Safety, general element 355.

    
    

    1. Nursing Care

    
    

23. Under standard 100, which requires that during specific hours of duty, a charge nurse is responsible for the total nursing care of residents, the Department contends the following elements were not met: NH102, which requires that the charge nurse ensure that nursing services are delivered in accordance with the established standards, policies and procedures of the facility; NH109,

    which requires that nursing care include measurement of basic vital functions including height and weight measurements on all residents, with abnormalities documented in the resident's medical record and reported to the attending physician; NH110, which requires that nursing care include maintenance of adequate hydration; NH122, which requires that each resident's diet is served as prescribed and the resident's food and fluid intake and output is observed; NH128, which requires that nursing services personnel encourage, and when necessary, teach residents to function at their maximum level in appropriate activities of daily living, for as long and to the degree that they are able; NH130, which requires nursing services personnel to encourage and assist residents who are learning to use and adjust to the use of adaptive equipment and prosthetic devices; NH142, which requires a preliminary resident assessment and preliminary care plan be initiated upon admission; and NH143, which requires a comprehensive resident assessment be performed and a comprehensive resident care plan based on the comprehensive assessment be developed and implemented within 14 days of the resident's admission into the facility.

    
    

24. NH102 requires the charge nurse to ensure that the facility's own procedures are followed. The survey report criticized the facility for other specific deficiencies discussed below in Findings of Fact 25-28. To count a deficiency under this general heading and also for the specific nursing elements is an example of impermissible double counting. NH109 requires the measurement of basic functions. It is clear that at least 5 residents were not weighed when they should have been, and 1 had lost at least 30 pounds without having the matter referred to the attending physician. Since there apparently was a policy in effect for some time of taking waist measurements for some residents with a tape measure rather than weighing them, and since the resident who lost 30 pounds presented an egregious situation that this should have come to the attention of the physician, I find that the facility did violate NH109.

    
    

25. As to element NH110, there were at least two patients with the specific orders to force fluids whose fluid intake and output was not documented. Due to the failure to select the sample in a random fashion is impossible to generalize that this constituted a trend at the facility. These were isolated cases and the deficiency is not sustained.

    
    

26. With respect to NH128, the absence of handrolls for patients with contracted hands to assist them in keeping their hands in a functional position, there is insufficient evidence that what was observed was anything other than an isolated incident. With respect to NH130, the absence of special cups or self grooming devices, the testimony of Mr. Biondi that these were available at the time the survey was conducted is accepted.

    
    

27. The surveyors also noted that, with respect to initial nursing care plans, plans were being drawn up within 96 hours of the resident's arrival at the facility, but criticized the plans because they included goals for fewer than all of the resident's needs. There was also criticism that in approximately 8 cases patients with problems such as decubitus did not have those problems integrated later into their comprehensive care plan. Due to the failure of the team to draw a random sample, there is not persuasive evidence that comprehensive care plans were not being properly evaluated. The findings in the survey of deficiencies with respect to elements NH142 and NH143, which deal with the initial care plans and comprehensive care plans, are not sustained.

    
    

28. It is also significant that, in its proposed recommended order, the Department of Health and Rehabilitative Services maintains that standard 100

    (which relates to the duty of a charge nurse) had not been met due to the survey of deficiencies in elements 102, 109, 110, 122, 128, 130, 142 and 143. The only element which actually falls under the standard with respect to the duties of the charge nurse is element NH102 (old element NH75). All other elements fall under different standards. I cannot conclude that element NH102 was deficient and therefore reject the contention that the standard with respect to the charge nurse was not met. The deficiency in element NH109 i not sufficient to support a violation of the standard in which it is contained, Condition III, Nursing Services, Standard (d), Nursing Care.

    
    

    2. Food Service

    
    

29. The same problem of misapplication of elements to appropriate standards appears with respect to the contention made by the Department in its proposed recommended order that Condition IV, Dietary Services, standard (f), Preparation and Service of Food (general element 183), was not met. The Department relies on deficiencies for elements NH177, NH178, NH185, NH188, NH190 and NH193, to support its contention that that standard was deficient. Elements NH177 and NH178 relate to a wholly different standard (standard (e), Menus and Nutritional Adequacy). Element NH193 is a broad element relating to standard (g), Sanitary Conditions, which requires compliance with Chapter 100-13, Florida Administrative Code, pertaining to food service. None of these five elements therefore are relevant to the contention that Standard (f) for preparation of service and food was not met. With respect to the relevant elements, the evidence fails to support the contention that sufficient eating utensils and dinnerware were not available in an amount for each resident; the survey deficiency with respect to element NH188 is not sustained. With respect to element NH190, there were not sufficient overbed tables for all residents who eat at their beds to eat simultaneously. This was one of the stipulated deficiencies. See Finding of Fact 20(b), ante. It is not sufficient to support a finding that the standard encompassing that element was not met, however.

    
    

    3. Social Services

    
    

30. As to the contention that Condition IX, Social Services, Standard (a), Provision of Services, element NH286 was deficient, there is persuasive evidence that social services are provided to residents to assist them in adjusting to the effects of their illnesses or disabilities. Moreover, the social service surveyor relied in part on her analysis of four of ten records which she reviewed to provide the basis for the deficiency. Due to the inadequacy in gathering the sample, this is not persuasive evidence of a trend showing that the facility failed to provide required social services; the testimony of the Meadowbrook's social service director in opposition to the deficiency is credible and accepted. With respect to element NH321 concerning the activity component of residents' care plans, the instances which gave rise to this survey deficiency were drawn from an inadequate sample, and the testimony concerning the efforts the social service director at the facility makes to identify therapeutic recreational activities contributing to the residents' well being was persuasive, and has been accepted. The facility met Condition IX, Social Services; Standard (a), with respect to the provision of services.

    
    

    4. Fire Prevention, Fire Protection and Life Safety

    
    

31. On the deficiency cited for element NH356, that the building's construction did not comply with applicable codes and standards, the maintenance workshop, which had existed for a number of years, did not comply with the fire

    safety code. Yet the Department had never cited this as a deficiency over the years; including last year when the facility received its superior rating. The workshop was removed the next day after this deficiency was pointed out. The deficiency for NH357 cited due to the wood paneling in the facility's office not having been properly flame-spread rated, is not accepted; it had existed during past surveys without criticism, and the facility treated the paneling immediately after this was pointed out. See also the discussion of this deficiency in Finding of Fact 17, ante. With regard to the inaccessibility of a tamper switch, I find the maintenance supervisor was able to locate the switch, and that the lock on the switch is one of the options which may be used to satisfy fire code requirements; NH367 was not deficient.

    
    

32. The problems with the smoke detection system in the west section of the building, where the smoke detectors did not function is a more serious problem, and the fact that those detectors did not work sustains the deficiency for element NH 359. Similarly, the removal of smoke detectors from the west wing and the absence of fire dampers in the air conditioning system which would have isolated smoke in a given wing had their been a fire sustains the deficiency for element NH369.

    
    

33. There was also a problem with the fire alarm annunciator panel, which was locked in a closet. That panel shows the zone of the facility in which a fire has occurred, and also indicates whether the power is on, and the fire and smoke detectors are operating. Being locked in the closet, it could not perform its function because it could not be observed from a nurse's station. The annunciator panel must be monitored from a 24-hour attended location, such as a nursing station. There was a violation of NH364. The facility installed a new panel by the nurse's station, at a cost of approximately $12,000.

    
    

34. There was also a violation of NH360 because the kitchen doors did not have an automatic latch. This is important in order to segregate the kitchen in the event of a fire in order to control the spread of smoke. This has been corrected.

    
    

35. All of these Life Safety violations raise the question of whether the facility should fail standard (a) of Condition XII, Physical Environment. The question is a close one, but I do not believe the evidence sustains a finding that the standard was violated. The building had been annually inspected by the Department for a number of years and none of these violations had been pointed out in the past. In addition, the facility had its own Life Safety inspection done four months prior to the Department's inspection, which did not reveal these violations. The quality of that inspection may be subject to question, but the fact that it was done indicates that the facility was making a serious effort to comply with Life Safety requirements. Moreover, the parties stipulated that all of these deficiencies were corrected in a timely manner and that they were category III deficiencies. All things considered, I do not find that the violation of certain elements relating to Life Safety put the facility in violation of Condition XII, standard (a). G. Exceeding Minimum Standards

    
    

36. Meadowbrook Manor presented convincing evidence that it is a superior nursing home facility. This evidence included the scrapbook of photographs of its monthly activities for the residents, which resulted in an award for the outstanding number and diversity of the facility's activities.

    
    

37. The facility has a van equipped with a wheelchair lift which is used to take residents on frequent trips, the facility has a lady's club and a men's club, a happy hour every week, weekly parties and monthly theme parties, art

    classes, sing-alongs, exercise classes and a monthly newsletter to inform residents of the activities available. Meadowbrook also has an extensive volunteer program. The physical environment is attractive. Since 1983 approximately $800,000 has been spent on renovations of the building.

    
    

38. With respect to resident choice, the facility provides residents with choices of sleeping and waking hours, their dress, the manner in which they are addressed by staff, choice of staff members to work with them, choice of rooms to the extent possible, choice of treatment schedules, choice of entrees for meals, choice of meal partners.

    
    

39. The facility has a resident's council which meets regularly with the staff.

    
    

40. The institution also has ongoing education programs, a staff nurse educator, continuing education programs in-house for the staff, and the facility has a policy to pay for employees to attend outside educational seminars.

    
    

41. Staffing ratios exceed the minimum required in all areas.

    
    

42. The staff turnover is low at the facility.

    
    

43. Meadowbrook also has a system to notify physicians who do not visit patients.

    
    

44. Numerous consultants work with the facility, including a social work consultant, Kay Kuge, a pharmacy consultant, Joseph Klalo, a consulting dietician, Angela Fernandez, a speech therapist consultant, an occupational therapist consultant, and a full-time activities coordinator.

    
    

45. The facility has an in-house physical therapy department which includes a full-time physical therapist and several therapy aides.

    
    

    CONCLUSIONS OF LAW

    
    

46. The Division of Administrative Hearings has

    jurisdiction over this matter. Section 120.57(1), Florida Statutes.

    
    

47. The facts proven by the facility, Meadowbrook Manor, show that it meets all of the requirements set out in Rule 100-29.128, Florida Administrative Code, for a superior rating. There are no class I or class II deficiencies at the facility, Rule 10D-29.128(5)(a) and (b). It has corrected all class III deficiencies within the time prescribed by the Department, Rule 100- 29.128(5)(c). It complies with all standards contained in the nursing home licensure survey report, Rule 10D-29.128(6)(b). Its programs exceed minimum requirements for nursing services, dietary and nutritional services, housekeeping and maintenance services, and activities and volunteer services, Rule 100- 29.128(6)(c). Its staffing ratios exceed minimum requirements, its physical environment is good. The physical and restorative therapy and self- help activities exceed the minimum, as do social services, professional consultant services and its program for notifying and monitoring visitation of residents by physicians, Rule 100-29.128(6)(d).

    
    

48. The facility does offer residents choices for decision-making regarding daily care, and its programs and services are superior on a regular, on-going basis. Rule 100- 29.128(6)(e), Florida Administrative Code.

RECOMMENDATION

Based on the foregoing, it is RECOMMENDED:

That the superior nursing home rating which Meadowbrook Manor had received BE CONTINUED.

DONE AND ORDERED this 23rd day of February, 1987, in Tallahassee, Florida.

WILLIAM R. DORSEY, JR.

Hearing Officer

Division of Administrative Hearings The Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 23rd day of February, 1987.

APPENDIX TO RECOMMENDED ORDER, CASE NO. 86-0932

The following constitute my specific rulings pursuant to Section 120.59(2), Florida Statutes (1985), on the proposed findings of fact submitted by the parties.

Rulings on Proposed Findings of Fact Submitted by Petitioner

1. Covered in the statement of the issues.

2. Sentences 1 and 2 covered in Finding of Fact 2. Sentence 3 covered in Finding of Fact 37. Sentence 4 covered in Findings of Fact 20(a) and 33. Sentences 6- 8 rejected as unnecessary. Sentence 9 covered in Finding of Fact 35.

3. Sentences 1 and 2 covered in Finding of Fact 3. The remainder rejected as unnecessary.

4. Sentence 1 covered in Finding of Fact 1. Sentences 2-4 rejected as unnecessary. Sentence 5 covered in Finding of Fact 9.

5. Rejected as unnecessary and irrelevant.

6. Covered in Finding of Fact 4.

7. Covered in Finding of Fact 5.

8. Covered in Finding of Fact 9.

9. Covered in Finding of Fact 6.

10. Covered in Finding of Fact 6.

11. Rejected as unnecessary.

12(a). Covered in Finding of Fact 10. 12(b). Covered in Finding of Fact 11. 12(c). Covered in Finding of Fact 11. 12(d). Covered in Finding of Fact 12. 12(e). Covered in Finding of Fact 13. 12(f). Covered in Finding of Fact 14. 12(g). Covered in Finding of Fact 14.

12(h). Rejected for the reasons stated in Finding of Fact 19.

12(i). Covered in Finding of Fact 14. 13(a). Rejected as unnecessary.

13(b). Rejected as unnecessary. 13(c). Covered in Finding of Fact 24. 13(d). Covered in Finding of Fact 24.

13(e). To the extent appropriate, covered in Finding of Fact 20(a). 13(f). Rejected as unnecessary.

13(g). Covered in Finding of Fact 25.

14(a). Covered in Finding of Fact 16, to the extent appropriate. 14(b). Covered in Findings of Fact 16 and 30.

15(a). Covered in Finding of Fact 17. 15(b). Covered in Finding of Fact 17. 15(c). Covered in Finding of Fact 17. 15(d). Covered in Finding of Fact 17. 15(e). Covered in Finding of Fact 17.

16. Covered in Finding of Fact 24. 17(a). Covered in Finding of Fact 18. 17(b). Covered in Finding of Fact 18. 17(c). Covered in Finding of Fact 18.

1. Covered in Findings of Fact 14 and 18.

2. Rejected as unnecessary.

   21 at page 11. Rejected as unnecessary.

3. Rejected for the reasons stated in Finding of Fact 19. 21(a) at page 12. Rejected as unnecessary.

21(b). Covered in Finding of Fact 24.

21(c). Covered in Findings of Fact 24 and 25. 21(d). Covered in Finding of Fact 24.

21(e). Covered in Finding of Fact 20(a). 21(f). Covered in Finding of Fact 26.

21(g). Covered in Finding of Fact 26. 21(h). Covered in Finding of Fact 27. 21(i). Rejected as unnecessary.

21(j). Covered in Finding of Fact 29.

21(k). Covered in Findings of Fact 20(b) and 29. 21(1). Covered in Finding of Fact 24.

21(m). Covered in Finding of Fact 31. 21(n). Covered in Finding of Fact 31. 21(o). Covered in Finding of Fact 33.

1. Covered in Finding of Fact 4.

2. Covered in Finding of Fact 6. 24(a). Covered in Finding of Fact 36. 24(b). Covered in Finding of Fact 36. 24(c). Covered in Finding of Fact 37. 24(d). Covered in Finding of Fact 37. 24(e). Covered in Finding of Fact 37. 24(f). Covered in Finding of Fact 38. 24(g). Covered in Finding of Fact 40.

24(h). Rejected as irrelevant and unnecessary. 24(i). Covered in Finding of Fact 41.

24(j). Covered in Finding of Fact 43. 24(k). Covered in Finding of Fact 44. 24(1). Covered in Finding of Fact 39. 24(m). Covered in Finding of Fact 42. 24(n). Covered in Finding of Fact 37.

24(o). Rejected as cumulative to Finding of Fact 41.

24(p). Covered in Finding of Fact 45.

1. Rejected as argument.

2. Rejected as argument.

3. Rejected as argument, the inference of bias against the facility is specifically rejected.

4. Rejected as unnecessary, irrelevant, and not sustained by the evidence. Whatever errors the surveyors made, I specifically reject the argument that a standard rating was given because of a dispute between Mr. Biondi at Meadowbrook and Mr. Dykes of the Office of the Licensure and Certification.

5. Rejected for the reasons stated in the preceding paragraph.

6. Generally accepted in the Conclusions of Law.

Rulings on Proposed Findings of Fact Submitted by Respondent

1. Covered in the statement of the issues.

2. Covered in Finding of Fact 2.

3. Covered in Finding of Fact 3.

4. Covered in Finding of Fact 1.

5. Covered in Finding of Fact 4.

6. Covered in Finding of Fact 5.

7. Covered in Finding of Fact 9.

8. Covered in Findings of Fact 4 and 6.

9. Covered in Finding of Fact 6.

10(a). Rejected for the reasons stated in Findings of Fact

10 and 16.

10(b). Covered in Finding of Fact 11. 10(c). Covered in Finding of Fact 12. 10(d). Covered in Finding of Fact 13. 10(e). Covered in Finding of Fact 14. 10(f). Covered in Finding of Fact 14.

Nursing Care:

(a). Covered in Finding of Fact 24.

Dietary:

(a). Covered in Finding of Fact 29. Covered in Findings of Fact 20(a) and

29. Rejected for the reasons stated in Finding of Fact 29. Covered in Findings of Fact 20(b) and 29. Rejected for the reasons stated in Finding of Fact 29.

Social Services:

(a). Rejected for the reasons stated in Finding of Fact 30. Rejected for the reasons stated in Finding of Fact 30.

Life Safety:

(a). Rejected for the reasons stated in Finding of Fact 31. Accepted for the reasons stated in Finding of Fact 32. Rejected for the reasons stated in

Findings of Fact 17 and 31. Rejected for the reasons stated in Finding of Fact

31. Accepted in Finding of Fact 33. Accepted in Finding of Fact 32. Accepted in Finding of Fact 34.

COPIES FURNISHED:

Nancy Schleifer, Esquire 29th and 30th Floors, AmeriFirst Building

One Southeast Third Avenue Miami, Florida 33131

Dennis Berger, Esquire Office of Licensure and Certification

5190 N.W. 167th Street, Suite 210 North Miami, Florida 33014

Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard

Tallahassee, Florida 32399-0700

Enoch Jon Whitney, General Counsel Department of Health and Rehabilitative Services

1323 Winewood Boulevard

Tallahassee, Florida 32399-0700

Docket for Case No: 86-000932

Orders for Case No: 86-000932