STATE OF FLORIDA nD AGENCY FOR HEALTH CARE ADMINISTRATIONS NOV ~g py \ Me ; 18 AGENCY FOR HEALTH CARE ADR NSS | ADMINISTRATION, HINISTR A je EARINGS |" Petitioner, é | 1 \ a AHCA No. 2004001615 vs. AHCA No. 2004001011 CROSS CREEK HEALTH CARE Certified Article Number ASSOCIATES, LLC dib/a SD 2075 UNIVERSITY HILLS HEALTH AND TAO 4575 LEM Se REHABILITATION, SENDERS RE Respondent. 7003 2260 ooo? 2ou0 5583 / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA’ or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against CROSS CREEK HEALTH CARE ASSOCIATES, LLC dib/a UNIVERSITY HILLS HEALTH AND REHABILITATION (‘Respondent’), pursuant to Sections 420.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose conditional licensure status upon Respondent, pursuant to Section 400.23(7)(b), Florida Statutes; administrative fines totaling FIFTY THOUSAND DOLLARS ($50,000), upon Respondent, pursuant to Section 400.23(8)(a), Florida Statutes; and a survey fee of SIX THOUSAND DOLLARS ($6,000), upon Respondent, pursuant to Section 400.19(3), Florida Statutes. Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 1 of 16 JURISDICTION AND VENUE 2. AHCA, and the Division of Administrative Hearings upon a request for formal hearing, have jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. PARTIES 4. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part ll, Florida Statutes, and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. Respondent, CROSS CREEK HEALTH CARE ASSOCIATES, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, UNIVERSITY HILL HEALTH AND REHABILITATION (“Facility”), is a 120-bed nursing home located at 40040 Hillview Road, Pensacola, Florida 32514. Respondent is licensed as a skilled nursing facility license #SNF1 111096, effective August 29, 2003. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNT! CLASS } PATTERNED VIOLATION FOR FAILURE TO IMPLEMENT AN EFFECTIVE SYSTEM OF MONITORING AIR TEMPERATURES IN RESIDENTS’ ROOMS, COMMON AREAS AND DINING ROOMS Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 2 of 16 42 CFR 483.15(h)(6); Section 400.23(7)(b), Florida Statutes Section 400.23(8)(a), Florida Statutes Rule 59A-4.106(4)(n), Fla. Admin. Code Rule 59A-4.122(2)(f), Fla. Admin. Code Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provisions of the Code of Federal Regulations and Florida Administrative Code that are pertinent to this alleged violation, read as follows: 42 CFR 483.15 Quality of Life. A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. tie (h) Environment. The facility must provide— (6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71-81degrees Fahrenheit. Rule 59A-4.106 Facility Policies. (4) Each facility shall maintain policies and procedures in the following areas: (n) Loss of power, water, air conditioning or heating. Rule 59A-4.122 Physical Environment. | (2) The facility shall provide: ee (f) Comfortable and safe temperature levels. 8. AHCA surveyors conducted an annual survey of Respondent's lity on January 12 through 16, 2004, which revealed the following: The facility failed to monitor and implement a plan to correct air temperatures in residents’ rooms, dining areas, bathrooms and common areas routinely and during brief episodes of unseasonably cold weather. The cumulative effect of these failures resulted in temperatures below 71 degrees Fahrenheit, placing residents at risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and colds. This represents an immediate jeopardy to residents’ health and safety. There were 9 semi-private rooms occupied by residents, 4 private rooms occupied by 3 residents; a total of 21 residents were affected by the below 71 degree temperatures. Three of five patient care areas were affected by the low temperatures. Specific findings were: Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 3 of 16 monit a). Interview with family member on 1/13/04 at 10:00 a.m. revealed that they have complained numerous times to the staff concerning the heat temperature in the residents’ room as being too cool (69 degrees). A thermometer is hung on the residents’ wall near the doorway. The family member stated that this past weekend when the temperatures fell below freezing, this room was cold. The family member stated he/she walked down the hall where the facility thermostat is located and noticed the facility temperature was also 69 degrees. b). Interviews with residents and staff throughout the facility during the length of the survey revealed complaints of the facility being cold. A staff member stated during the night of 1/11-1/12/04 the facility temperature was 62 degrees. Further interview with staff indicated corporate was aware and has been aware of the heating units being down. c). Interview with service vendor repairing heating units on 1/13/04 at 12:40 p.m. stated he/she had been working on the units for over a year and that some parts were no long available. Interview with staff indicated that 5 units of 22 were not working as of 1/12/04. d). Interview with the maintenance man on 1/12/04 at 4:15 p.m. revealed the issue with the low temperatures and estimates to correct were brought to the administrator's attention and the Regional Vice President’s attention beginning with the August- September 2003 timeframe. e). Interview with staff on 4/12/04 indicated the facility had 92 blankets for 120 residents. f). Review of the Maintenance Daily Log Sheets lacked evidence of temperatures being monitored. g). Review of the Facility Policy and Procedures lacked a policy and procedure for monitoring air temperatures. Further review of the policy and procedures indicated a monthly monitoring check sheet would be conducted, including checking the heating/air conditioning unit. Surveyor requested this information, but it was not provided. h). Interview with the Risk Manager, Nurse Consultant and Director of Nursing on 4/16/04 at 1:40 p.m. revealed issues related to heat temperatures, broken beds and non functioning call bells were brought to stand up morning meetings with the administrator. They stated no investigations were conducted, monitoring implemented or plan of correction developed to resolve the issues. 9. Respondent's failure to implement an effective system of coring air temperatures in residents’ rooms, common areas and dining rooms is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.15(h)(6). 10. Respondent's failure to implement an effective system of monitoring air temperatures in residents’ rooms, common areas and dining Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 4 of 16 rooms is a violation of Rules 59A-4.106(4)(n) and 59A-4.122(2)(f), Fla. Admin. Code. 41. AHCA classified the nature and scope of this violation as a class | “patterned” violation. Pursuant to Section 400.23(8)(a), this classification constitutes grounds for the imposition of an administrative fine of TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500). A class | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility's non-compliance has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care ina facility.” 12. | Respondent's failure to implement an effective system of monitoring air temperatures in residents’ rooms, common areas and dining rooms constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). COUNT II CLASS | PATTERNED VIOLATION FOR FAILURE TO ENSURE RESIDENTS’ ENVIRONMENT REMAIN AS FREE OF ACCIDENT HAZARDS AS IS POSSIBLE 42 CFR 483.25(h)(1) Section 400.23(7){b), Florida Statutes Section 400.23(8)(a), Florida Statutes Rule 59A-4.106(4)(cc), Fla. Admin. Code Rule 59A-4.1288, Fla. Admin. Code 43. | AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 44. | The regulatory provisions of the Code of Federal Regulations and Florida Administrative Code that are pertinent to this alleged violation, read as follows: Administrative Comptaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 5 of 16 42 CFR: 483.25 Quality of care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being, in accordance with the comprehensive assessment and plan of care. (h) Accidents. The facility must ensure that— (1) The resident's environment remains as free of accident hazards as is possible. 59A-4.106 Facility Policies. wee (4) Each facility shall maintain policies and procedures in the following areas: (cc) The reporting of accidents or unusual incidents involving any resident, staff member, volunteer or visitor. This policy shall include reporting within the facility and to the AHCA. 15. AHCA surveyors conducted an annual survey of Respondent's facility on January 12 through 16, 2004, which revealed the following: The facility failed to ensure residents’ environment remained as free of accident hazards as possible by allowing equipment to remain in disrepair. Specifically, the facility failed to repair or replace 26 beds identified by maintenance staff to be broken and posing a great danger to residents in August-September 2003; the beds were allowed to remain in the facility with 18 of these beds still being actively used by residents in January 2004; a broken closet door that went without repair for at least one week fell off the closet and hit a resident (#23), inflicting a head injury requiring an emergency room (ER) visit and sutures to the head. This represents an immediate jeopardy to residents’ health and safety. Specific findings were: a). Review of the record for Resident #23 revealed as documented in the nursing notes dated 11/18/03 4:30 p.m., “called to room by certified nursing assistant (CNA). Closet door caused laceration to forehead, approximate size 2 inches length, 0.5 centimeters width. Emergency Medical Services in the building dropping off new admit and was able to transport resident to a local hospital for evaluation.” Investigation by the facility documented, “on 11/18/03 at 4:30 p.m. resident was in his/her room when closet door slid down, hitting resident on the right side of the forehead. CNA was getting the resident up for the evening meal and had used the mechanical lift. As he/she was slowly backing the lift out, the lift hit the closet door, which was propped against the wail, causing the door to fall and strike the resident on the forehead.” Interview with a staff CNA on 4/15/04 at 8:15 a.m. revealed he/she made out a maintenance work requisition at least a week before the accident while the door hinges were loose and the door still remained on the closet. He/She placed the request in the work log as required. At some point, the door fell off the closet and was propped against the wall in Resident #23’s room. The date and time this occurred was unknown by the staff person. interview with maintenance staff on 1/13/04 at 3:10 p.m. revealed the maintenance department never received a work request for the closet door in the room of Resident #23. The staff member indicated CNAs had stated varying lengths of time the door had actually been off the hinges and propped against the wall in the resident's room. The times reported ranged from two days to two weeks. b). Interview with maintenance staff on 1/13/04 at 3:10 p.m. revealed 26 beds were identified to be broken in the August-September 2003 timeframe. One resident's bed had collapsed and in the process of repairing it, it was found that a steel component was not Administrative Complaint 2004001615 & 2004001011 Cerlified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 6 of 16 anchored to the bed and it could possibly spear through the mattress, having the potential to cause injury or death to the resident in the bed. There was a bed with a broken steel component that went through the mattress, but there was no patient in the bed at the time. This broken part could not be repaired and the beds needed to be replaced. After the identification of the one bed, the maintenance staff checked all of the beds in the facility and found 26 to have the broken part. The maintenance staff notified the administrator and regional vice president of the findings. On 1/13/04 at the time of the survey the maintenance staff was requested to identify how many of these beds were still being used by residents after surveyors could only identify 17 of the initial 26 beds still in use. A list identifying 18 broken beds still in use by residents was provided after another bed assessment was conducted on 1/14/04 at 9:15 a.m. Interview with the administrator on 1/14/04 at 3:10 p.m. revealed a request for 32 new beds was approved on 12/5/03 and was expected to received in the facility during the second week of February. Eighteen leased beds were ordered and all of the residents’ broken beds replaced by 5:00 p.m. on 1/16/04. Several requests were made of maintenance staff to review work requisitions and preventative maintenance logs for the beds and were not provided. Interview with risk manager on 1/16/04 at 1:20 p.m. revealed he/she was aware of the broken beds that were discussed in the management stand up meeting, often on a daily basis. No alternative systems or bed replacement, other than the new beds expected in February 2004, were planned as a part of an interim corrective action plan. 16. Respondent's failure to ensure residents’ environment remain as free of accident hazards as is possible is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.25(h)(1). 17. Respondent's failure to ensure residents’ environment remain as free of accident hazards as is possible is a violation of Rule 59A-4.106(4)(cc), Fla. Admin. Code. 18. AHCA classified the nature and scope of this violation as a class | “patterned” violation. Pursuant to Section 400.23(8)(a), this classification constitutes grounds for the imposition of an administrative fine of TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500). A class | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility's non-compliance has caused, or is likely to cause, serious injury, harm, impairment or death toa resident receiving care in a facility.” Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 7 of 16 49. Respondent's failure to ensure residents’ environment remain as free of accident hazards as is possible constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). COUNT III CLASS | PATTERNED VIOLATION FOR FAILURE TO MAINTAIN A PROPERLY FUNCTIONING COMMUNICATION SYSTEM FROM THE NURSING STATION TO RECEIVE RESIDENT CALLS FROM THEIR ROOMS AND BATHROOM FACILITIES 42 CFR 483.70(f)(1)&(2) Section 400.23(7)(b), Florida Statutes Section 400.23(8)(a), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code 20. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 21. The regulatory provision of the Code of Federal Regulations that is pertinent to this alleged violation, reads as follows: 42 CFR: 483.25 Physical environment. The facility must be designed, constructed, equipped, and maintained to protect the health and safety of resident, personne! and the public. (f) Resident call system. The nurse’s station must be equipped to receive resident calls through a communication system from-- (1) Resident rooms; and (2) Toilet and bathing facilities. 22. AHCA surveyors conducted an annual survey of Respondent’s facility on January 12 through 16, 2004, which revealed the following: Residents had no consistent means of directly contacting the nurse’s station from their rooms since August 2003. This represents an immediate jeopardy in facility's failure to prevent neglect by not implementing compensatory measures after identifying a non- functioning call system. Specific findings are: a). Observations of the first day of the survey, 1/12/04 during the initial tour beginning at approximately 9:00 a.m. revealed residents’ call systems that had no light and no sound at the nursing station for rooms 200, 204 A&B, 217, 250 A&B, and 254 A&B. Continued observations found bathroom call lights in room 204 without lighting capabilities and bathroom in room 228 without a call light cord attached for use in case of emergency. Further observations revealed residents’ call systems that had no sound at the nursing station to include rooms 200, 201 A&B, 202A, 203 A&B, 205B, 208 A&B, 209 A&B, 210 Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 8 of 16 A&B, 211 A&B, 212 A&B, 214 A&B, 215 A&B, 216A (and includes bathroom light), 226A, 227A, 228A, 229A, 231A, 251 A&B, 252 A&B, 253 A&B, 254B, 255 A&B, 256 (entire call bell broken and could not be used), and 256B. b). Interview with the Administrator, upon entrance conference on 1/12/04 at approximately 9:00 a.m. found he readily admitted the facility's call bell system had not been properly functioning since at least August/September 2003. Continued interview found Administrator had notified the Corporate Regional Vice President of the non-functioning call light system and, around September 2003, obtained and submitted a bid for repair/replacement of the system without approval. Interview with the vendor at 42:10 p.m. on 1/13/04 confirmed a proposal of repair/replacement had been submitted to the administrator and a copy sent to the Corporate Regional Office without receiving a response. Interview with maintenance staff at 2:45 p.m. on 1/12/04 found he too had notified the Corporate Regional Vice President for the facility in the August/September 2003 timeframe, alerting the manager to the fact that the systems had progressed to past the repair stage without a corrective action plan provided to handle the situation. c). Review of policies and procedures revealed availability of a checklist for documentation of monthly maintenance inspections. However, upon request to review any documentation of preventative maintenance logs, none were provided. d). Interview with Risk Manager, Director of Nurses, and Corporate Nurse Consultant on 4/16/04 at 1:20 p.m. revealed the non-functioning call bell system had been discussed in their management meeting, also known as “stand up meetings’, without any directives to put an alternative system in place for residents to be able to access nursing staff in case of emergencies or for any needed assistance. 23. Respondent's failure to maintain a properly functioning communication system from the nurses’ station to receive residents’ calls from their rooms and bathroom facilities is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.70(f). 24. AHCAclassified the nature and scope of this violation as a class | “patterned” violation. Pursuant to Section 400.23(8)(a), this classification constitutes grounds for the imposition of an administrative fine of TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500). Aclass | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility’s non-compliance has caused, or is likely to cause, serious injury, harm, impairment or death toa resident receiving care in a facility.” Administrative Complaint 2004001615 & 20040010114 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 9 of 16 25. Respondent's failure to maintain a properly functioning communication system from the nurses’ station to receive residents’ calls from their rooms and bathroom facilities constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). COUNTIV CLASS | PATTERNED VIOLATION FOR FAILURE OF ADMINISTRATION TO USE ITS RESOURCES EFFECTIVELY AND EFFICIENTLY 42 CFR 483.75, 42 CFR 483.75(0)(2)&(3) Section 400.23(7)(b), Florida Statutes Section 400.23(8)(a), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code 26. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 27. The regulatory provision of the Code of Federal Regulations that is pertinent to this alleged violation, reads as follows: 42 CFR: 483.75 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (0) Quality assessment and assurance. (2) The quality assessment and assurance committee— (i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary, and (ii) Develops and implements appropriate plans of action to correct identified quality deficiencies. 28. AHCA surveyors conducted an annual survey of Respondent's facility on January 12 through 16, 2004, which revealed the following: The facility was not administered in a manner conducive to appropriate resource utilization. This resulted in failure to ensure staff was appropriately trained and resources utilized effectively and efficiently to develop and implement an effective system for monitoring and maintaining a safe and comfortable resident environment. An immediate jeopardy situation was identified as a result of these findings. Specific findings are: a). The facility failed to maintain comfortable and safe resident room temperatures and aiso failed to use staff resources available to them to monitor the temperatures and put Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 10 of 16 an alternative plan in place for temperatures below 71 degrees. Interviews with residents and staff confirmed this finding. b). The facility failed to maintain resident beds in safe working order and to put an alternative plan in place to temporarily replace the unsafe beds until them could be replaced permanently. c). The facility failed to maintain a nurse call system whereby the residents could obtain help and to put an alternative communication system in place until the call system could be repaired/replaced. Interviews with residents and staff confirmed this finding. d) The facility failed to develop and implement plans of action to correct identified deficiencies found within the facility on an ongoing basis. The Failure to formulate corrective action plans in the approximately four (4) months after the deficiencies were identified led to situations which involved inadequate air temperatures, inadequate equipment and inadequate call bell system. Specific findings are: Review of the facility Risk Management and Quality Improvement Program reveals the facility will review other information that may be necessary to minimize risk. Interview with the Risk Manager, Director of Nursing and the Nurse Consultant on 1/16/04 stated when problems arise in the facility, these issues are discussed in stand up meetings with the administrator. There is no documentation maintained on the investigations related to the issues. Surveyor asked if inadequate air temperatures related to an ongoing problem with heating/air conditioning units since 8/9/03, inadequate equipment related to 26 broken beds with 18 residents in them since 8/9/03 and inadequate call bell system since 8/9/03 were brought up in stand up meetings and the answer was yes. Staff further stated there is no investigation/documentation, monitoring related to the above or a corrective action plan in place to bring about resolution of the problems. e) The facility failed to follow its Risk Management Quality Improvement plan, which requires the facility to develop a corrective action plan when quality deficiencies are identified. Issues 1, 2, and 3 above were discussed in the daily stand up meeting as far back as August-September 2003, as identified in interviews with the risk manager, director of nursing and corporate nurse consultant. f) Interview with the maintenance man on 1/12/04 at 4:15 p.m. revealed the issue with the low temperatures and estimates to correct were brought to the administrator's attention and the Regional Vice President's attention beginning with the August-September 2003 timeframe. 29. Respondent's failure of administration to use its resources effectively and efficiently is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.75. 30. Respondent's failure to develop and implement plans of action to correct identified deficiencies is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.75(0)(2)&(3). Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 11 of 16 Sal 31. AHCA classified the nature and scope of this violation as a class | “patterned” violation. Pursuant to Section 400.23(8)(a), this classification constitutes grounds for the imposition of an administrative fine of TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500). A class | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility’s non-compliance has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility.” 32, Respondent's failure of administration to use its resources effectively and efficiently constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). CLAIM FOR RELIEF Loe WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Counts | through V. 2. Uphold the imposition of conditional licensure status. 3. imposition of administrative fines as follows: Count 1, TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500), Count Il, TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500), Count Ill, TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500), Count IV, TWELVE THOUSAND FIVE HUNDRED DOLLARS ($12,500), for a total of FIFTY THOUSAND DOLLARS ($50,000). Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 12 of 16 4. Imposition of a 6-month survey cycle fee of SIX THOUSAND DOLLARS ($6,000). 5. Such other relief as this Court deems is just and proper. DISPLAY OF LICENSE Pursuant to Section 400.23(7), Florida Statutes, University Hills Health and Rehabilitation shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “A”. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 420.569 and 120.57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308. RESPONDENT !S FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 13 of 16 AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. St ao, a Respectfully submitted this 21 day of _DSFTEM EAA , 2004. Joanna Daniels, Asst. General Counsel Fla. Bar No. 0118321 Agency for Health Care Administration 2727 Mahan Drive, Building #3, MSC #3 Tallahassee, FL. 32308 (850) 921-5873 (office) (850) 413-9313 (fax) CERTIFICATE OF SERVICE | hereby certify that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail, return receipt requested, to: Mr. Jerry Banks CT Corporation System Administrator Registered Agent for University Hills Health and Rehabilitation Cross Creek Health Care Associates, LLC 10040 Hillview Road 1200 South Pine Island Road Pensacola, FL 32514 Plantation FL 33324 (Certified # 7106 4575 1294 2050 2075) (Certified # 7003 2260 0007 2000 5583) onthis 21° day of SEPTEMBRE RO, 2004. JOANNA DANIELS Administrative Complaint 2004001615 & 2004001011 Certified Numbers 7106 4575 1294 2050 2075 & 7003 2260 0007 2000 5583 Page 14 of 16 LED 04 NOV -g PH Us 18 DN VIS ADMINIS TA iy HEAR! hee Exhibit “A”

Docket for Case No: 04-004052