FILE AGENCY FoR 5 STATE OF FLORIDA DEPUTY Or ISTRATION AGENCY FOR HEALTH CARE ADMINIST@AION STATE OF FLORIDA LD el 1 Yog/ AGENCY FOR HEALTH CARE ADMINISTRATION, DM les S. of ~~ ek 2 Petitioner, AHCA NO. 2003003638 —, Le 2003002543 ©... v. DOAH NO. 03-2811 03-3315 9° < PRESBYTERIAN RETIREMENT COMMUNITIES, a d/b/a WESTMINSTER TOWERS, RENDITION NO.: AHCA-04-0253-S-OLC Respondent. FINAL ORDER Having reviewed the administrative complaint dated August 21, 2003, attached hereto and incorporated herein (Ex. 1- 2003002543), and the Notice of Assignment of Conditional Licensure Status served July 14, 2003, attached hereto and incorporated herein (Ex. 2 - 2003003638) and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 3), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. A fine of $7,500.00 is hereby imposed upon the Respondent. This amount is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this Case number, should be sent directly to Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, Mail Stop # 14 Tallahassee, Fl. 32308. 4. Unpaid fines will be subject to statutory interest, and may be collected by all methods legally available. 5. The conditional license rating will be imposed from March 28, 2003 to May 7, 2003. DONE and ORDERED this _/0 day of hay , 2004, in Tallahassee, Leon County, Florida. Mary Pat Moore, Interim Secreta Agency foy Health Care Administration abt Drute Leeahey/l. cog A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Jonathan S. Grout, Esquire Goldsmith, Grout & Lewis, P.A. 2180 Park Avenue N., #100 P.O. Box 2011 Winter Park, FL 32790-2011 (U. S. Mail) Katrina D. Lacy, Esq. Senior Attorney Agency for Health Care Administration 525 Mirror Lake Dr. N. #330G St. Petersburg, FL 33701 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bidg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Daniel M. Kilbride, AU Division of Admin. Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-3060 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the (7 day of _7Y a4 / , 2004. ape sod a Goan Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 ( EXHIBIT STATE OF FLORIDA —1 AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003002543 vs. PRESBYTERIAN RETIREMENT COMMUNITIES, INC., d/b/a WESTMINSTER TOWERS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against Presbyterian Retirement Communities, Inc., d/b/a Westminster Towers, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of thirty-six thousand dollars ($36,000) pursuant to Sections 400.102(1) (a) and (d), 400.23(8) (a) and (b) and 400.419(3), Florida Statutes (2002). 2. The Respondent was cited for the deficiencies set forth below as a result of an annual survey conducted on or about March 24-28, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2002). 4. Venue lies in Orange County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes (2002), and Chapter 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes (2002) and Rules 59A-4, Florida Administrative Code (2002). 6. Respondent is a nursing home located at 70 West Lucerne Circle, Orlando, FL 32801. The facility is licensed under Chapter 400, Part II, Florida Statutes (2002) and Chapter 59A-4, Florida Administrative Code (2002), having been issued license number SNF16010961. COUNT I RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS. R.59A-4.1288, Fla. Admin. Code (2002), ADOPTING BY REFERENCE 42 CFR § 483.25(h) (2) (2002) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about March 24-28 2003, an annual survey was conducted at Respondent’s facility. 9. Based on observation, record review, and interview, Respondent failed to provide supervision_and implementation. procedures to prevent falls/inj e of twenty-four sampled Findings: Resident #16 was originally admitted to the facility on January 3, 2002. During the survey, the resident was observed on multiple days at various times, either lying on the low bed or sitting in the recliner chair, in his/her room. During an interview on March 28, 2003 at approximately 9:30 AM, the Assistant Director of Nursing (ADON) explained that an investigation is conducted every time a resident has a°~-—— fallt/incident :~ The ADON also stated that therapy conducts a post fall Screen and recommends appropriate-fall precautions? Review of the nurses' notes, dated July 30, 2002 through Augus 29, 2002, described a resident who frequently attempted to get ke, out of bed without assistance. ; “a on‘November 16,2002) the resident fell in the facility and [elon broke his/her right hip. The resident went to the hospital for Qly od treatment and returned to the facility on November 20, 2002. Spi ]03 Nurse's note, dated January 21, 2003, indicated that the a o3 resident was out of bed and in a recliner chair for most of the 3 Y [P3 shift, and a note at 5 AM indicated: "attempts to get OOB(out of bed) & recliner; needs to be observed." FG [03 SS ne ne The-resident continued to be at risk for falls and fell again of February 4, 2003)at 10:45 PM. According to the fall investigation,— ident #16 had no injuries and required assistance to transfer/ambulate. Also, the resident did not use a bed/chair alarm, nor were restraints used by this resident. The Post Fall Screen was conducted 3 days later on February 7, 2003. The therapist indicated that the resident already has a low bed with floor mats and that Fall Management was already in place. The therapist did not recommend any new fall precautions. Interview with Therapy staff on March 28, 2003 at approximately 9:00 AM, revealed that the resident could ambulate, with hand held assistance from staff at the time of the fall on February 4, 2003. The resident fell again on FeSruary 21, 2003) seventeen days after the last fall. The fall investigation indicated that the resident was on the floor on his/her right side. The Post Fall Screen read: "Follow facility protocol for repositioning and toileting. Measures for injury management are in place and include low bed with bilateral floor mats." On February 26, 2003, therapy staff had recommended a Velcro belt for this resident, but the care plan was not updated with this new intervention until March 19, 2003. On’ Fe ry 28, 20 at approximately 7:00 PM, the resident took off the Velcro belt, stood up and fell. A Post Fall screen was conducted on March 3, 2003 and therapy staff xecommended restorative nursing for range of motion & ambulation. The resident received two days of r and 4, 2003, before falling again dn March 4, 10:00 PM. The resident sustained a laceration above eye and also to the left side on the nose. The resident was sent to the emergency room for treatment. When the resident returned to the facility on March 7, 2003, there was no evidence that the resident was placed back on restorative nursing. Interview with ADON and therapy staff on March 28, 2003 revealed that the staff person in charge of the restorative nursing program had quit. Therefore, resident #16 was never re-evaluated for restorative nursing. At that time, there was no evidence of new interventions to prevent falls, On\Warch 19, 2003 4t 9:20 PM, the resident fell again, this time $ s/her left hip. The resident was sent to the hospital for care and treatment and returned to the facility on March 22, 2003. Two days later, on March 24, 2003, a Post Fall Screen was conducted. The therapist recommended hip protectors for the resident. On March 28, 2003, the last day of the survey, after the surveyor questioned staff about the hip protectors, the nurse made a telephone call to inquire about ordering hip protectors for resident #16. This was four days after the hip protectors were recommended. Resident #16 had six falls in the period November 16, 2002 through March 19, 2003, three of which resulted in significant injury. During this time, there was no evidence that the facility's interdisciplinary care team assessed & provided a level of supervision to meet the needs of this resident. 10. The above actions or inactions are a violation of 42 CFR 483.25 (h) (2) (2002), which requires the facility to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 11. Pursuant to Section 400.23(8) (b), Florida Statutes (2002), the foregoing is an “isolated” class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 12. Respondent was provided a mandated correction date of April 21, 2003. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an “isolated” Class II deficiency. 14. During the annual survey of June 30, 2002, Respondent was cited for Tag F309, an “isolated” class II deficiency. Therefore, pursuant to Section 400.23(8) (b), Florida Statutes (2002), the fine amount is doubled to $5,000. COUNT II RESPONDENT FAILED TO MAINTAIN SUFFICIENT NURSING STAFF TO PROVIDE NURSING AND RELATED SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING OF EACH RESIDENT, AS DETERMINED BY RESIDENT ASSESSMENTS AND INDIVIDUAL PLANS OF CARE. R.59A-4.1288, Fla. Admin. Code (2002), ADOPTING BY REFERENCE 42 CFR § 483.30 (2002) CLASS I DEFICIENCY PATTERNED 15. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 16. On or about March 24-28, 2003, an annual survey was conducted at Respondent’s facility. 17. Based on observations, interviews, and record reviews, Respondent failed to provide a sufficient staff to ensure that residents residing on the secured Memory Support Unit, were supervised and monitored to prevent potential/actual negative outcomes. Findings: During initial tour of the third floor designated Dementia Care Unit, on March 24, 2003 at approximately 10:00 AM, two sets of doors were observed to be closed, separating the Memory Support Unit from the other side of the secured dementia care unit, where the nurse's station was located. The staff member identified approximately 25 residents residing on the Memory Support Unit and the residents were identified to use wander- guards due to elopement potential. If a resident came within a few feet of the doors, the doors would automatically lock, preventing the resident from leaving the unit. Interview with administrative staff on March 28, 2003 at approximately 2:30 PM, stated, "The magnetic pads for the double doors that kept the doors opened, were removed a week ago". Observation on March 24, 2003 at approximately 4:25 PM, Resident #15 was observed on the Memory Support Unit in a Merri-Walker propelling him/herself around the unit. Another resident was following Resident #15. A few minutes passed when Resident #15 became entrapped between a pole in the middle of the room and a dining room chair. The resident was observed to become extremely agitated. Resident # 15 was observed in this situation for approximately five minutes, when another resident entered the unit ambulating with a walker and was observed to be agitated with Resident #15 and yelling, "get moving," a number of times. The only staff member observed on this unit at this time was a Certified Nursing Assistant (CNA), who was located in a resident room passing out gowns and pads for residents for the evening shift. When approached and informed of the situation occurring on the unit, the CNA looked out the door of the room he/she was in and stated, "He always does that," and proceeded to re-enter the room and continued to pass out evening attire. On the other side of the double closed doors, a staff member was observed through the door window and summoned to assist Resident #15. The staff member entered the unit stating "He lives here," and proceeded to push the resident out of the Memory Support Unit through the double doors to the side of the dementia care unit where nursing staff. were observed. Interview with a staff member at this time revealed, " The (memory support unit) unit is not officially opened yet, tomorrow we will be opening the dining area". Residents were observed to be living on the Memory Support Unit. Clinical record review for Resident #15 identified an admission date of September 1, 2001 with a readmission date of November 14, 2001, status post hip fracture. Diagnoses included Alzheimer's Disease with Delusional Disorder, Dementia with Psychosis, Cerebral Vascular Accident, Seizure Disorder, and Depression. Review of the Minimum Data Set for Resident #15 dated December 13, 2002 and March 14, 2003 revealed the resident's cognitive skills for daily decision making coded as three (3), indicating the resident's cognitive abilities as severely impaired, unable to make decisions with a short and long term memory deficit. Review of the falls resident protocol (RAP) dated March 18, 2003, identified the resident as, "Risk for falls related to several risk factors besides Dementia. He wanders about unit in Merri-Walker. Impaired judgment to wait for assistance." Observation of R #15 on 3/24/03 at approximately 4:25 PM, identified that the resident was not either supervised or monitored. A 2/15/03 nurses' note shows, "Nursing to monitor behaviors." During interview with administrative staff on March 25, 2003 at approximately 9:15 PM, staff stated, " I guess we should have staffed the unit first". 2. During initial tour by a second surveyor, on March 24, 2003 at approximately 9:30A.M., no staff were observed in the third floor Memory Support Unit. The only staff person that was seen, other than the staff person touring, was the nurse passing out medication. There were no other staff identified to take care of the residents and to monitor the unit. The residents that were in their rooms were still in bed. Some of them were asleep and some were awake. After the medications had been passed out, the nurse exited the Memory Support Unit to the other side of the closed double doors where the medications and clinical records for the residents residing on the Memory Support Unit were located. Staff were observed giving care and helping residents in the other portion of the dementia care unit, outside of the Memory Support Unit. All of the nurses at the time were observed to be on the other side of the closed double doors, outside of the Memory Support Unit. During the tour, there were approximately twenty-five residents on the side of the double doors referred to as the Memory Support Unit. During the observation of the noon meal on March 24, 2003 at 11:45 AM, residents left the Memory Support Unit to eat their meal in the other portion of the dementia care unit, where all the staff were observed to be located. There were no staff observed on the Memory Support Unit where residents were observed to be eating in their rooms with no staff present to supervise/monitor the residents. On the second day of the survey, March 25, 2003, during observation of the Memory Support Unit at 9:00 AM, there was no staff member located on the Memory Support Unit. Observation identified a resident having difficulty getting into the restroom with his/her walker. There were residents still in bed, but there was no staff member observed to be monitoring the residents or the unit. 3. During an interview conducted on March 25, 2003 at approximately 6:30 PM, an Administrative staff member stated that the intent for the Memory Support Unit was that it would not be a "locked unit" but rather a "secured unit", meaning that the staff, public, and other residents would be able to enter this unit without a code, but residents wearing a wander- guard bracelet would trigger an alarm system, that would prevent the doors from opening if they came within a few feet of the door. Staff further stated that once this system was in effect, the code system for third floor elevators would be removed. Staff then stated that the Memory Support Unit was not actually a separate unit of the third floor, but that the rest of the resident population would be in rooms outside the secured doors. A review of the facility's policy and procedure for the Memory Support Unit, dated May 30, 2002 and signed by an 8 Administrative staff and the Medical Director, revealed that the Admission Criteria included the following philosophy statement for two (2) of the seventeen (17) admission requirements: "The Memory Support Unit is a therapeutic residence...a separate, specialized residence within our facility where the focus is on "wellness" and success in activities of daily living. Although there is nursing staff on the unit 24 hours per day, the focus is not medical in nature." "Resident must have a primary diagnosis of Dementia Disease or related untreatable dementia..." "...Resident must be independent in mobility or be able to ambulate and transfer with one assist. May be aided by assistive devices to enable independence." 18. The above actions or inactions are a violation of 42 CFR 483.30(2002) which requires the facility to maintain sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The above actions or inactions are also a violation of 42 CFR 483.30(a) (1) &(2) (2002), which requires the facility to provide services by sufficient numbers of each of the following types of personnel, on a 24-hour basis, to provide nursing care to all residents in accordance with resident care plans: Except when waived under paragraph (c) of this section, licensed nurses; and other nursing personnel. Additionally, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 19. Pursuant to Section 400.23(8) (a), Florida Statutes, the foregoing is a “patterned” class I deficiency and as such, presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the Agency, is required for correction. 20. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 21. Respondent was provided a mandated correction date of March 29, 2003. 22. A civil penalty is authorized and warranted in the amount of $12,500, as this violation constitutes a “patterned” Class I deficiency. 23. During the annual survey of June 30, 2002, Respondent was cited for Tag F309, an “isolated” class II deficiency. Therefore, pursuant to Section 400.23(8) (a), Florida Statutes (2002), the fine amount is doubled to $25,000. 24. Pursuant to Section 400.19(3), Florida Statutes (2002), the agency shall assess a one-time fine, in the amount of $6,000, for each facility that is subject to the six-month survey cycle. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $36,000 civil penalty against RESPONDENT; c. Assess costs related to the investigation and prosecution -of this case pursuant to Section 400.121(10), Florida Statutes (2002); and d. Grant any other general and equitable relief as appropriate. NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. ( ( RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Katrina D. Lacy, Esquire AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0007 8499 6294 to Robert N. Bianco, Administrator, Westminster Towers, 70 West Lucerne Circle, Orlando, FL 32801,on the O/s¢ day of August, 2003. Katrina D. Lacy, Sodaize Copies furnished to: Robert N. Bianco, Administrator Westminster Towers 70 West Lucerne Circle Orlando, FL 32801 (U.S. Certified Mail) Henry T. Keith Registered Agent for Westminster Towers 80 W. Lucerne Circle Orlando, FL 32801 (U.S. Mail) 12 hae_-™ C EXHIBIT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION TIES, INC. db/a WESTMINSTER TOWERS Ref. # 2003003638 Cert. # 10260 / 4{1Je3 Pursuant to and in compliance with s. 400.23(7), Florida Statutes, the Agency for Health Care Administration (“the Agency”) the Agency surveyed! investigated the above- identified nursing home facility on OF about March 28, 2003, to make a determination as to the degree of compliance of the facility with Chapter 400, Part iL, Florida Statutes, and ay plicable rules for assigning licensure status. The report(s) of that gurvey/investigation includes the report that constitutes the most recent inspection report that the Agency evaluated, and upon which the Agency determined its assignment of conditional licensure status to the facility effective and commencing on or about March 28, 2003. The Agency evaluated the facility in accordance with the statute and applicable rules and made a substantial compliance with criteria established under Part II or rules of the Agency. © Section 400.23(7) provides that conditional licensure means that a facility is “not in substantial compliance at the time of the survey” if such non-compliance is tdue to the presence of one or more class 1 or class Il deficiencies, or class ti deficiencies not corrected within the time established by the Agency.” The survey(s) pertinent to this assignment is/are attached hereto. The factual basis for the Agency's evaluation and determination of licensure status includes, put is not limited to, facts set forth in the referenced survey! inspection report(s)- This Notice of Assignment constitutes notice of final Agency action. Bach licensee shall post its license in 2 prominent place that is in clear and unobstructed public view at or neat the place where residents are peing admitted to the facility. The facility has @ right, pursuant to 5.120.569, Florida Statutes, to request an administrative hearing as to the assignment of conditional licensure status by the Agency: These specific options are set out in the attached Agency form for “Blection of Rights for Administrative Hearing Regarding Assignment of Conditional Licensure Status.” This form may be used to request a hearing, but alone will not serve as 4 legally sufficient request for a formal hearing. Any request for a hearing must be received within twenty- one (21) days of the receipt py the facility of this Notice of Assignment of Conditional Licensure Status. Long Term Care Unit Agency for Health Care Administration (03-03) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used with Election of Rights for Assignment of Conditional Licensure Status) In response to the material facts contained in the Notice of Assignment of Conditional Licensure Status issued by the Agency for Health Care Administration (“Agency”), please make one of the following elections on the Election of Rights form and return it fully executed to the address listed on the form. OPTION 41. If Respondent. does not dispute the material facts contained in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation reports(s) (you consent to the assignment) and elects to waive the right to be heard, Respondent should select OPTION 1 on the Election of Rights form. The material facts and the related survey/investigation report(s) attached with the Notice of Assignment of Conditional Licensure will be deemed admitted. This constitutes notice of final agency action. OPTION 2. ‘If Respondent does not dispute the material facts contained in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation reports(s) (you admit to all of the material facts), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present written and/or oral evidence regarding any lawful basis for the agency to withdraw the assignment of conditional licensure status. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. If the Respondent disputes any material facts as set forth in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation report(s) (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent's request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent’s original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Notice of Assignment of Conditional Licensure Status. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: PRESBYTERIAN RETIREMENT CASE NO: 2003003638 COMMUNITIES, INC. a/b/a WESTMINSTER TOWERS ELECTION OF RIGHTS FOR ADMINISTRATIVE HEARING FOR ADMINISTRATIVE HEARING . REGARDING ASSIGNMENT OF CONDITIONAL LICENSURE STATUS PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) __ Respondent does not dispute the material facts contained in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation agency action. OPTION TWO (2) ___ Respondent does not dispute, and admits, the material facts contained in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation OPTION THREE (3) ___. Respondent does dispute the material facts contained in the Notice of Assignment of Conditional Licensure Status and the related survey/investigation reports(s)and Respondent requests a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an In order to preserve Respondent’s right to a hearing, Respondent’s original Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date Respondent receives the Notice of Assignment. Respondent (Licensee) ooo eee Address: License, No. and facility type: Phone No. ee es PLEASE RETURN YOUR COMPLETED FORM To: Attention: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg. #3, MS #3, Tallahassee, FL 32308. Telephone Number: (850) 922-5873 FLORIDA AGENCY FOR HEALTH CARE ADMINGTRATION JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY July 2, 2003 WESTMINSTER TOWERS 70 WEST LUCERNE CIRCLE ORLANDO, FL 32801 Dear Administrator: The attached license is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Séttion, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 License Status Change to Conditional incerely, Agency for & Care Administration Division of Health Quality Assurance Enclosure ce: AHCA Area Office 07 Long Term Care Section file Medicaid Contract Management Certificate of Need 2727 Mahan Drive Mail Stop #33 Visit AHCA Online at www fdhe.state fl. us Tallahassee, FL. 32308 ! "| LICENSE #: SNFI6di0961 State of Florida _ AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE SKILLED NURSING FACILITY. CONDITIONAL inistration, authori licensee is authorized to operate “WESTMINSTER TOWERS 70 WEST LUCERNE CIRCLE ORLANDO, FL 32801 TOTAL: 120 BEDS Sat: 120 BEDS STATUS CHANGE ACTION EFFECTIVE DATE: 03/28/2003 ‘LICENSE EXPIRATION DATE: 02/29/2004 at ary, Division of Health Quality Assurance Po fons KEVISED: “FESSION ra WD. LIC CBE we a]o3 , ‘ < ioe RECOMMENDA‘..JN FOR SANCTION - entral Office (FDAU) Use Only Enf. Complaint #: £203 0d Case #: "3633 Board Indicator Set (date): 6-Month Cycle in FRAES: Other ID (opt): Instructions: Complete this form to impose sanctions by Administrative Complaint. Attach a copy of the Statement of Deficiencies and other supporting documents as necessary. Al] RFSs with their supporting documentation should be sent via interoffice mail to the Central Office Facility Analysis Data Unit (Mailstop 47) for tracking in FRAES. Please number pages at bottom of form. Each survey done (complaint versus recert, etc) must have a separate RFS. However, multiple RFS forms for surveys completed on or about the same time must be attached together as legal will produce one case / Administrative Complaint (see Multiple RFS item 12). 1. FIELD OFFICE: 07 2. Facility type: X] Nursing Home [[] Assisted Living Facility [_] Hospital [_] Home Health Agency [_]Other: 3. Licensee Name: PRESBYTERIAN RETIREMENT COMMUNITIES If unlicensed, check here [_] and INC Provide prior licensee name if applicable: 4. Licensed Beds: # 120 5. Facility Name: WESTMINSTER TOWERS. 6. Facility License #.: 16010961 7. Address: 70 WEST LUCERNE CIRCLE 8. City: ORLANDO 9. Date of Visit Resulting in Sanction: 3/28/03 13. Survey Type (check one): . - XJ Annual [_] Complaint [_] Other 10. FRAES Inspection #: 35956 (_] Follow-up, indicate original survey date: & Original survey type: 11. Mandated Correction Date: 4/21/03 - F324 (J Annual/ biennial 3)29[03- F3s3 [_] Complaint 12. If Multiple RFS, thisisRFS_ of ___ [_] Other: [74-Name(s) of Surveyor(s) involved: MARY_ANNE PEARCE, JANE WOODSON, IRENE HAYES- OLIVERAS LORRAINE HENRY, DOUGLAS METCALFE & MARK FORONDA a Sanctions Imposed (check a! yy: Cone # 2200300 3638 ines x} Conditional License ting Home Only) (Check only i the facility is going from a Standard license to a Conditional license as a result of this survey.) [1] Moratorium (check if this visit resulted in the imposition of an Immediate Order of Moratorium) Date of Order: AHCA # on Order: e.g.: 04-01-234 NH) (] Revocation - Indicate statutory grounds for revocation: L_] Suspension - Indicate statutory grounds for suspension: 16. Nursing Home 6-Month Survey Cycle Facility qualifies for 6-month survey cycle (see 400.19, F.S.) for (check all that apply): x[_] Cited for a Class I deficiency (_] Cited for two or more Class II deficiencies arising from separate surveys or investigations within a 60-day period, date of prior Class II: (Three or more substantiated complaints within a 6 month period, each resulting in at least one Class I or II deficiencies, dates of two prior complaints: and: Note to legal: The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. EXHIBIT STATE OF FLORIDA j 3 AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA Nos.: 2003003638 2003002543 Petitioner, DOAH Nos.: 03-2811 03-3315 vs. PRESBYTERIAN RETIREMENT COMMUNITIES, INC., d/b/a WESTMINSTER TOWERS, Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Petitioner, Agency for Health Care Administration (hereinafter the “Agency") through their undersigned representatives, and Presbyterian Retirement Communities, Inc., d/b/a Westminster Towers (““Westminster"), pursuant to Sec. 120.57(4), Florida Statutes (2003), each individually, a "party", collectively as "parties," hereby enter into this Stipulation and Settlement Agreement ("Agreement") and agree as follows: WHEREAS, Westminster is a skilled nursing facility licensed pursuant to Chapter 400 Part II, Florida Statutes (2003), and Rule 59A-4, Florida Administrative Code, (2003); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes; and WHEREAS, the Agency served Westminster with an Administrative Complaint on August 23, 2003, notifying the party of its intent to impose a civil penalty for $36,000.00 (AHCA Case No. 2003002543). and WHEREAS, the Agency served Westminster with a Notice of Assignment of Conditional Licensure Status on July 14, 2003, imposing a conditional license effective March 28, 2003 through February 29, 2004 (AHCA Case No. 2003003638), and: TLHI\HEALTHISS664.1 1682330013 DT dma 8/22/02 WHEREAS, Westminster requested a formal administrative hearing, for the fine case, in a Petition for Formal Administrative Hearing filed by Karen Goldsmith, Esquire and received by the Agency on September 18, 2003; and WHEREAS, Westminster requested a formal administrative hearing, for the conditional license case, in a Petition for Formal Administrative Hearing filed by Karen Goldsmith, Esquire and received by the Agency on August 6, 2003; and WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: L. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Westminster agrees to a withdrawal of its Petition for Formal Administrative Proceedings; agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. Provided, however, that no agreement herein, shall be deemed a waiver by either party of its right to judicial enforcement of this stipulation. 4. The parties agree to the following terms: TLHI\HEALTHSS664.1 416833/0C13 DT dma 8/22/02 a. Count I-Tag 324 will remain an “Isolated” Class II Deficiency. The fine amount will be $2,500: b. Count Il-Tag 353 will be reduced from a “Patterned” Class I Deficiency to a “Patterned” Class II Deficiency. The fine amount will be $5,000; and c. The conditional license rating will be imposed upon Westminster from March 28, 2003 to May 7, 2003. 5. Westminster shall pay the Agency Seven Thousand Five Hundred ($7,500.00) Dollars within thirty days (30) of the rendition of the Final Order in this case. 6. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 7. Westminster neither admits nor denies the allegations in the Administrative Complaint. The Agency agrees that it will not impose any further penalty against Westminster as a result of the survey conducted on March 24-28, 2003. However, no agreement made herein shal] preclude the Agency from imposing a penalty against Westminster for any deficiency/violation of statute or rule identified in a future survey of Westminster, which constitutes a “repeat” deficiency from the survey of March 24-28, 2003. 8. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 9. Each party shall bear its own costs and attorney fees. 10. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 11. Westminster, for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s 3 TLHTHEALTH55664.4 16833/00 12. DT dma 8/22/02 actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Westminster or related facilities. 12. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph ten (10) of this Agreement. 13. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 14. This Agreement contains the entire understandings and agreements of the parties. 15. This Agreement supercedes any prior oral or written agreements between the parties. 16. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement by Westminster or related facilities, its successor or any resulting organization, shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. Abed - Ope PE Lon Elizabeth Dudek KAREN L. LE Fp, ESQUIRE Deputy Secretary, GOLDSMITH, GROUT & LEWIS, P.A. Managed-Care and 2180 Park Avenue North, #100 Health Quality Assurance Post Office Box 2011 Agency for Health Care Administration Winter Park, FL 32790-2011 a e 407/740-0144 DATED: E// LOY Attorneys for Respondent Florida Bar No. 274534 DATED: EL 2, Boog TLHT\HEALTH\S5664.1 168320013 DT dma 8/22/02 Valda Clark Christian General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee FL 32308 DATED: om, Le ‘aL VA He j £003 03636 AUCH Me 2003 M254 TLH1\HIEALTHISS664 1 168330013 DT dma 8/22/02

Docket for Case No: 03-002811