STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE O 7 . .) lo U 7 ADMINISTRATION, Petitioner, . AHCANos. 2006010011 (Fine) . 2006010012 vs. (Conditional License) IHS ACQUISITION NO. 103, INC., D/B/A HORIZON HEALTHCARE CENTER AT DAYTONA, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through undersigned counsel, and files this administrative complaint against IHS ACQUISITION NO.103, INC., D/B/A HORIZON HEALTHCARE CENTER AT DAYTONA, (hereinafter “facility” or “Respondent”), pursuant to Chapter 400, Part II, and Sections 120.569 and 120.57, Florida Statutes (2006). NATURE OF THE ACTION 1. This is an action to impose administrative fines in the amount of thirty-seven thousand five hundred dollars ($37,500) and a survey fee in the amount of six thousand dollars ($6,000), based upon Respondent being cited for one isolated Class I deficiency, pursuant to Section 400.022(1)(1), Florida Statutes (2006), one widespread Class I deficiency, pursuant to Section 400.022(1)(0);, Florida Statutes (2006) and one patterned Class I deficiency, pursuant to Section 400.102(1)(a), Florida Statutes (2006) (AHCA No. 2006010011). Additionally, this is an action to impose a conditional licensure rating from October 14, 2006, through November 15, 2006, pursuant to Section 400.23(7)(b), Florida Statutes (2006) (AHCA No, 2006010012). JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to Sections 120.569, 120.57, 120.60, and 400.062, Florida Statutes (2006). 3. Venue lies in Volusia County, pursuant to Rule 28-106.207, Florida Administrative Code (2006). PARTIES 4. The Agency is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part IL, Florida Statutes (2006), and Chapter 59A-4, Florida Administrative Code. 5. Respondent operates a skilled nursing facility located at 1350 S. Nova Road, Daytona Beach, Florida 32114, having been issued license number 1164095. Respondent was at all times material hereto a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNTI RESPONDENT FAILED TO PROVIDE ADEQUATE AND APPROPRIATE CARE AND SERVICES TO RESIDENTS SECTION 400.022(1)(), FLORIDA STATUTES (2006) ISOLATED CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That on or about October 14, 2006, the Agency conducted an annual survey at Respondent’s facility. 8. Based on resident and facility nursing staff interviews, observation, and record review, Respondent failed to provide adequate and appropriate care and services to protect the health and ensure no deterioration in condition for Residents #11, #10, and #6 (3 of 20 sampled residents). Specifically, there was a failure to follow physician orders for insulin coverage and a failure to notify the physician of blood sugars over 350, which is essential to diabetic management, that poséd a direct threat to the health and safety for Resident #11. Also, the Respondent provided documentation on 10/ 13/06 of missed accuchecks for Resident #3, as well as four unsampled residents. There was also a failure to safely and correctly administer necessary medications ordered by the physician for Resident #10, which posed a direct threat to health and safety. The Respondent also failed to provide physician-ordered protection to the ankles of Resident #6 as treatment for a Stage 4 pressure sore to the left ankle, a pressure ulcer that developed in the facility. Additionally, the following findings were noted, including: a. Resident #11 had a physician order for insulin coverage based on a sliding scale dose dependent on the results of the Resident's accucheck, with the physician to be notified of a result of 350 or above. A review of the Medication Record and Profiles of August and September, 2006 for Resident #11 revealed the following entries: 8/2/06 Blood sugar 283- no coverage documented; 6 units ordered. 8/4/06 6 a.m. accucheck (blood sugar test) blood sugar signed as done with no results recorded. 8/5/06 6 a.m. and 4 p.m. accucheck signed as done with no results recorded. 8/6/06 6 a.m. and 4 p.m. accucheck signed as done with no results recorded. 8/9/06 6 a.m. blood sugar 295; 9 units charted as given when 6 units was ordered for 295 results. 8/10/06 4 p.m. accucheck signed as done with no results recorded. 8/11/06 4 p.m. blood sugar 331-no Insulin coverage charted as given (8 units ordered). 8/12/06 4 p.m. blood sugar 367; documentation of 8 units Insulin given (the order of 716/06 states that blood sugars over 350 were to be called to the physician) 8/12/06 revealed no documentation of a call to the physician. 8/13/06 4 p.m. accucheck was done with no results charted. 8/14/06 4 p.m. accucheck was done with no results charted. 8/15/06 4 p.m. blood sugar 395-no Insulin coverage charted and no nurses’ notes documented physician notification for blood sugar over 350. 8/20/06 6 a.m. accucheck signed as done with no results recorded. 8/21/06 6 a.m. accucheck not signed as done; 4 pan. blood sugar recorded was 334-no Insulin was recorded as given. 8/23/06 4 p.m. 351 blood sugar recorded with 15 units of Insulin coverage; No physician order for the 15 units was noted in the clinical record. 8/24/06 6 a.m. accucheck signed as done with no results recorded. 8/25/06. 4 p.m. blood sugar recorded as 308; 6 units of Insulin charted as given with 8 units was ordered for blood sugars between 300 to 350. 8/26/06. 4 p.m. blood sugar 355 with 8 units of Insulin charted as given. The physician order of 7/6/06 stated to call the physician for blood sugars over 350. No documentation of a physician call was noted in the nurses’ notes. 8/27/06 Accuchecks for 6 a.m. and 4 p.m. were not signed as done. 8/30/06 4 p.m. accuchecks were not signed as done. 8/31/06 6 a.m. accucheck was signed as done with no results documented; 4 p.m. results were not charted as done. 9/4/06 4 p.m. blood sugar of 350 with no Insulin administration recorded. 9/6/06 4 p.m. blood sugar documented at 218 with 1 unit administered in the LA (left arm); there was no order for Insulin coverage below 250. 9/9/06 4 p.m. blood sugar 395; 8 units Insulin recorded as given when the physician was to be notified. 9/12/06 4 p.m.-blood sugar 341; no coverage was charted when 8 units of Insulin were ordered. 9/13/06 6 a.m. accucheck signed as done with no results documented. 9/18/06 4 p.m. blood sugar 426; 8 units of Insulin were given when the physician was to be called. 9/19/06 4 p.m. blood sugar 344- no Insulin was charted as given when 8 units were ordered. 9/20/06 4 p.m. blood sugar 318- no Insulin was charted as given when 8 units were ordered. 9/23/06 4 p.m. blood sugar 330- documentation for administration of 10 units Insulin; 8 units of Insulin were ordered for blood sugars between 301-350. 9/24/06 6 a.m. accucheck was charted as done with no results documented. A review of the clinical record revealed a physician progress note dated 9/20/06 documenting that the resident's Diabetes Mellitus was still out of control; a physician otder was noted 9/20/06 expanding the sliding scale accucheck Insulin coverage for 351- 450 and notification of the physician with blood sugars over 450. History and physical notes for Resident #11 dated 2/16/06 documented a diagnosis of Diabetes Type II requiring Insulin. A review of the care plan for Resident #11 revealed the resident was at tisk for hypo- and hyperglycemic reactions, and that accuchecks were to be done as ordered in order that the resident's "blood sugars will become more WNL (within normal limits) for him/her, thereby requiring minimal to no need for sliding scale coverage.” ‘An interview with the Assistant Director of Nursing on 10/14/06 at 11:25 a.m. revealed that there was no nursing policy and procedure for emergency treatment of hypoglycemia or hyperglycemia treatment with parameters for treatment or notification of the physician. Resident #11 was observed in bed on 10/11/06 at 7:30 pm. When asked whether dinner had been served, the resident stated "they have already given me my insulin shot and I still have not been served dinner. I am feeling a little lightheaded and shaky." Resident stated that the dinner hour has been changed and now her/his insulin regimen does not coincide with her/his medications. b. Resident #10 was observed on 10/12/06 at 8:10 am sitting on the edge of the bed waiting for breakfast. Observation of the bed table revealed a 1-ounce plastic cup which contained 7 different medications. The resident stated "the nurse leaves these here for me and I take them when I get ready to." An interview with the Licensed Practical Nurse (LPN) on 10/12/06 at 8:15 am revealed that she had given the medications to Resident #10 together in a plastic cup, and she does that often so the resident can take them when she/he wants to. c. Resident #6 was admitted with a left hip dislocation and had current October 2006 physician orders for heel protectors to be worn when in bed. The resident also had a stage IV pressure ulcer to the left ankle revealed by the 8/30/06 significant change Minimum Data Set and 8/23/06 plan of care. The resident was observed lying in bed on 10/10/06 at 3:30 pm without the heel protector on the left foot. The day shift nurse confirmed that they were not in place although it was a physician order. The resident's current Kardex (used by the CNAs to direct care) did not indicate that the resident was to have the heel protector on while in bed. The resident had a new order on 10/10/06 for a sponge block to be on the resident's left lower extremity after each dressing change. The resident was observed on 10/11/06 at 1:40 pm lying in bed without the sponge block in place. The attending nurse verified that it was not in place and should be. This new intervention was not on the resident's Kardex as care to be provided by CNA. 9. The above constitutes a violation of Section 400.022(1)(1), Florida Statutes (2006), which includes residents’ rights to receive adequate and appropriate health care and protective and support services. Failing to notify a physician as ordered when blood sugar spikes, failing to administer medications properly, and failing to follow physician orders relating to treatment of an area of the body near a stage IV pressure ulcer can have serious consequences for residents. subjected to such neglect. 10. The above constitutes an isolated class J deficiency, for which a fine of $10,000 is authorized pursuant to Section 400.23(8)(a), Florida Statutes (2006). COUNT II RESPONDENT FAILED TO PROVIDE A SAFE ENVIRONMENT, FREE OF PHYSICAL, VERBAL AND MENTAL ABUSE SECTION 400.022(1)(0), FLORIDA STATUTES (2006) WIDESPREAD CLASS I DEFICIENCY 11. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. That on or about October 14, 2006, the Agency conducted an annual survey at Respondent’s facility. 13. Based on a family interview, staff and resident interviews, observations, and review of the abuse investigation log and the grievance log, the Respondent failed to provide a safe environment, free of physical, verbal, and mental abuse, and free of unprescribed physical restraints for each of the facility residents, including sampled Residents #2, #4, #11, and seven unsampled residents. The Respondent failed to thoroughly investigate all allegations of abuse, report the allegations, protect residents from further abuse during investigations, and take corrective actions to ensure the abuse did not continue or reoccur. These circumstances created an environment that placed ail residents of the Respondent’s facility at risk for abuse, and resulted in a direct threat to the health and safety of the residents. The findings include: a. During the survey on 10/11/06 at 10:00 a.m., a family member for Resident #12 approached a surveyor regarding a witnessed incident. The incident involved Employee #11. This family member alleged overhearing Employee #11 say to Resident #4 on 10/10/06, "[i]f you don't shut up about those glasses, I will push you out of that wheelchair." The family member also stated that the incident was reported to the Director of Nursing (DON), the Social Worker, and the Unit Manager on 10/10/06, and stated that they were told by the DON and the Unit Manager to "keep it under wraps until we get to it.” At 9:55 am on 10/12/06, a CNA came to a surveyor to report that the family member for Resident # 12 had wanted her to speak to the surveyors about the incident to be sure that someone heard and responded to the concern. The CNA stated, "[mJany of [the] CNAs don't want to go to the DON or the Unit Managers because they are friends with Employee #11 and nothing gets done. I have personally heard this CNA (Employee #11) abuse the residents, and she is still working here." A teview of the Respondent's abuse investigation log, as well as the Respondent's abuse investigations on 10/12/06 revealed no evidence that an allegation of abuse regarding this incident had been reported or that an investigation had begun. Furthermore, the abuse prevention coordinator stated she had no knowledge of this allegation. The incident of alleged verbal abuse was not investigated or reported, and no measures were put in place to protect residents, and the employee was observed to be working at the Respondent’s facility with residents on 10/13/06 at 1:00 PM. A review of Employee #11's personnel file on 10/12/06 revealed an allegation of abuse alleging that the employee was observed choking a resident on 1/5/05 during breakfast. Two different staff members documented the witnessed event and stated that the resident was crying and repeating "help me, help me.” When the investigation for this incident was requested by surveyors, the abuse prevention coordinator, who has held this position for nine years, stated that she had never heard of this incident and that she had shredded all the 2005 investigations. Employee #11, who is alleged to have been physically and verbally abusive to residents, continues to work at the facility even after the January 2005 witnessed incident of choking. This employee is a CNA and has direct contact with the residents, placing them at risk for abuse and mistreatment. On 10/13/06 at 1:00 pm, Employee #11 was observed working with the residents of the facility. b. A review of the facility's policy and procedures for abuse prevention was done on 10/12/06. The policy states that "[a]ll allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property, are reported immediately to the Administrator of the facility, the State Survey Agency and, to other officials in accordance with State law.” The policy further states that "all allegations of abuse, neglect, and exploitation/misappropriations, including injuries of unknown source, are thoroughly investigated” and to "suspend suspected employee(s) pending outcome of the investigation." The policy was not followed in that investigations were not done and the "suspected employees were not suspended pending the outcome of the investigation". A review of the Respondent’s records on 10/12/06 revealed the following: 01/23/06: An allegation of abuse stating a CNA "snatched the call bell out of the resident's hand with one hand and twisted the wrist with the other hand." 02/1/06: An allegation stating a resident requested a bed pan for a bowel movement and was told to "wait until his/her CNA came back from lunch." The resident couldn't wait and was incontinent of bowel. 03/01/06: An allegation that "daughter came in facility at about 4:30 pm to take a ; resident to the dining room and the resident was still in [his/her] nightgown. CNA's put a blue denim jumper and a sweater over the gown and a yellow sweater." None of these items belonged to the resident. 03/20/06: An allegation by Resident #11 requesting a pain pill was told "[t]he nurse stated you will get pain pill when I give it to you.” 03/21/06: Resident #11 made-an allegation of verbal abuse. When resident requested assistance turning was told by CNA "[i]f you want to get the hell out of here, you will do it yourself." 03/23/06: Resident #11 made an allegation that at 6:30 pm, a CNA said "[I’d] better tell her everything I needed/wanted now because she wasn't coming back in the room the rest of the night." 08/4/06: An allegation that the resident requested pain medicine at 8:30 pm on 8/3/06 and at different times throughout the night. The resident did not receive any pain medication until the 7 am - 3 pm shift on 8/4/06. 08/10/06: An allegation that at 1:30 pm, the resident stated to staff "I have not had my diaper changed since yesterday and I have been asking them to do it since 2:30 thismorning.” Physical-Therapy staff found-his/her sheets soaked from the knees to the neck. 08/23/06: An allegation that a resident requested a shower and the staff "just walked out and didn't say anything.” A review of the above allegations indicated no evidence of thorough investigation and actions to prevent reoccurrences. c. Resident #2 was observed lying in bed on 10/10/06 at 2:15 pm with full side rails up on the bed. At lunch time, the left full side rail was lowered and the resident sat up at the side of the bed and was observed eating the meal. Full side rails were again observed to be up on Resident #2's bed while the resident was lying in it on 10/11/06 at 9:30am. The resident was unable to lower the side rail by him- or herself when asked. Resident #2 was admitted to the sub-acute unit on 7/19/06. The resident's Minimum Data Set (MDS) assessment reference date of 7/26/06 revealed that no side rails were used by the resident. A side rail data and collection assessment was partially completed on 7/19/06 indicating that the resident requests side rails to help the resident turn. It did not indicate if quarter, half, or full side rails were to be used. The Unit Manager of the sub- acute unit was interviewed on 10/10/06 at 2:15 pm and asked what type of side rail was being used by the resident. The Unit Manager went to the resident's room and returned and said that full side rails were up. She then checked full side rails on the 7/19/06 side rail data collection and assessment form. The facility's side rail data collection and assessment form had Full (Restraint only) under "Type of side rail to initiate." A significant change MDS assessment reference date of 8/15/06 revealed that 1/2 side rails were to be used daily. The resident was transferred to the nursing center unit on September 12, 2006. When interviewed on 10/10/06 at 2:15 pm, the Restorative Nurse stated that there were full side rails on the bed when the resident transferred from the other unit. The Restorative Nurse stated that the full side rails were not considered a restraint because the resident used it for bed mobility. The full side rails were not assessed as a restraint or care-planned in the resident's medical record, although it prevented the resident from sitting at the side of the bed and the resident could not lower them. The Restorative Nurse had placed a work order for maintenance to replace 20 full side rails with 1/2 side rails on 7/22/06. The MDS Coordinator stated that the resident only had 1/2 side rails when she did the last assessment when the resident was on the sub- acute unit. The MDS Coordinator stated on 10/11/06 at 9:30 am that the facility is switching out full side rails for 1/2 side rails for the whole facility. It was not until 10/11/06 that 32 half side rails were ordered to replace any of the full side rails. 14. The above constitutes a violation of Section 400.022(1)(0), Florida Statutes (2006), which ensures that facility residents have the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized on writing by a physician for a specified and limited period of time or as are necessitated by an emergency. It is clear from the above findings that residents of the Facility have been subjected to verbal and physical abuse, bullying, intimidation, humiliation, neglect resulting in bowel/bladder incontinence incidents, and neglect in administering pain medications resulting in resident(s) suffering needlessly. It is also clear that policies and procedures designed to report, investigate, document, and respond appropriately to allegations of abuse and neglect have not and do not function and are not followed at Respondent’s facility. 15. The above constitutes a widespread class I deficiency, for which a fine of $15,000 is authorized pursuant to Section 400.23(8)(a), Florida Statutes (2006). COUNT III RESPONDENT FAILED TO PROVIDE AND MAINTAIN A SAFE AND SECURE ENVIRONMENT AND TO MEET THE DAILY NEEDS OF ALL RESIDENTS, MATERIALLY AFFECTING THE HEALTH OR SAFETY OF THE RESIDENTS SECTION 400.102(1)(a), FLORIDA STATUTES (2006) PATTERNED CLASS I DEFICIENCY 16. | The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 17. That on or about October 14, 2006, the Agency conducted an annual survey at Respondent’s facility. 18. Based on observations, record reviews, group interviews, staff and resident interviews, the Respondent's facility failed to provide and maintain a safe and secure environment and to meet the daily needs of all facility residents and specifically nine of twenty sampled residents (#4, #7, #8, #10, #11, #12, #13, #18, and #19), and three unsampled residents (#R8, #R10, and #R11). The facility failed to maintain a building that was secure and safe from intruders. The facility also failed to provide the appropriate foods and supplements to ensure nutritional health for the residents. Additionally, the facility failed to consult the residents before changing their meal times, which resulted in dinner being served too late in the evening for multiple residents, which resulted in not all residents having an evening meal prior to bedtime, thus extending the time between meals from lunch until breakfast the next morning. The lack of a safe environment and failure to provide adequate nutrition created a sense of anxiety, stress, and fear of future harm for the residents, which constituted an immediate threat to the health and safety of all residents. The findings include: a. On 10/11/06 at 10:00 am, a group meeting was conducted with nine female residents from the facility who were alert and oriented. All nine residents stated they were fearful and anxious about strangers entering the building in the evenings and on weekends. They stated, "the front doors are locked all weekend and in the evenings, but people are in the facility that we do not know. They should at least wear name tags so -we would know who they are.” These residents also stated they were unhappy with the meal times and the menu. They indicated that a new Certified Dietary Manager had just been hired at the facility and was changing the menu and the meal times without consulting the residents. They stated that their breakfast is always slow and late, and their dinner is now being served between 6:30 pm and 7:00 pm. It was also stated that many nights in the past two weeks, the evening meal was late and they did not receive their dinner until after 7:30 pm. They also voiced concer about not receiving a snack at bedtime. b. During an evening visit to the facility on 10/11/06 at 6:30 PM, three surveyors followed the instructions on the sub-acute entrance/exit door and were able to disarm and reset the alarm and enter the building without any facility personnel observing them. The instructions for disarming the alarm were attached in plain sight on the door of the sub-acute unit, which presented an opportunity for unauthorized individuals to enter the facility at any hour of the day or night without supervision. The front doors of the facility were locked at night and weekends with a sign posted to re-route people to the sub-acute door for entrance. A large printed sign in plain sight advised individuals to enter the sub-acute door, then disarm and reset the alarm system by pushing the yellow button three times. The sub-acute door opened into a resident hallway with seven rooms that were not observable from the nurse's station. c. On 10/11/06 at 8:00 PM, the front door of the facility was observed to have a folded newspaper between the doors which prevented the doors from locking and allowed unmonitored access and egress to the front of the building. d. A review of the medical record of Resident #8 on 10/11/06 revealed a form titled "Food Preference Record" which was blank. An interview with this resident on 10/11/06 at 7:05 pm revealed "I don't like what they serve." There was nothing to indicate that anyone had attempted to determine the resident's food preferences in order to allow the resident to maintain a healthy nutrition status. e. A review of Resident #19's diet card on 10/13/06 revealed the resident was to receive fortified oatmeal with his/her breakfast. An observation on 10/14/06 at 8:17 am in the restorative dining-room, revealed the resident did not eat the oatmeal. An interview with the staff on 10/14/06 at 8:18 a.m. assisting Resident #19, stated the resident "Doesn't eat oatmeal, doesn't like it." There was nothing to show that any other measures had been tried to increase the resident's intake. f. A review of Resident #18's diet card revealed the resident was to receive coffee and juice as part of his/her breakfast. An observation of breakfast on 10/14/06 at 8:45 a.m. revealed the resident did not receive coffee or juice on the breakfast tray. g During a breakfast observation on 10/12/06 at 8:40 am, unsampled resident #R8 was observed being served thickened liquids with the thickener settled to the bottom of his/her juice and water. His/her diet card called for regular beverages. Resident R8 was observed to have a staff feeding him/her. An observation on 10/13/06 at breakfast (8:45 am) revealed the resident's diet card called for the resident to receive 8 oz of skim milk, 1 cup of decaf coffee, and 6 oz of juice for the day. The resident was observed served with 2 glasses of water and no coffee, milk, or juice. h. During meal observation on 10/10/06 at 12:30 PM, Resident #12 was observed stating in a loud voice "Why am I sitting here? I want to sit at my regular table!" An unidentified Certified Nursing Assistant (CNA) was heard replying, "[t]hey changed the seating, you have to sit there.” During an interview with the Director of Nursing on 10/10/06 at 3:30 PM concerning the change in seating, she stated the change was so all the "feeders" would be in one area so it would be easier for staff to assist with feeding. i. In an interview with unsampled resident #R10 on 10/14/06 at 8:30 AM, it was stated the resident did not feel well because she/he had to eat dinner the night before at 6:30 PM, which the resident felt was "ridiculous". The resident further stated, "We never know when the meals are going to come and it feels awful to eat late in the evening.” j. A review of resident records revealed that Residents #7 and #13 did not have their food likes and dislikes form filled out. The facility-generated form was in each chart but had not been filled out. SECTIONS 400.19(3) AND 400.23(7)(b), FLORIDA STATUTES (2006) 21. The Agency re-alleges and incorporates paragraphs (1) through (20) as if fully set forth herein. 22. Based upon Respondent’s three cited State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or with rules adopted by the Agency, a violation subjecting it to assignment of conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes (2006). - 23. Due to the presence of three Class I deficiencies, a conditional license certificate number 13950 was issued to Respondent with an effective date of October 14, 2006. Respondent was issued a standard license certificate number 13951 with an effective date of November 15, 2006 (Exhibit 1 and 2). 24. Respondent has been cited for three Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000, pursuant to Section 400.19(3), Florida Statutes (2006). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, Count I, Count II, and Count IV; (B) Recommend administrative fines against Respondent in the amount of $10,000 for Count I, $15,000 for Count II, $12,500 for Count II, and $6,000 as a survey fee pursuant to Section 400.19(3), Florida Statutes (2006), for a total of $43,500; (C) Assess attorney’s fees and costs; and 15 (D) Grant all other general and equitable relief allowed by law. 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 Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this 5 “day of January 2007. orraine M. Novak, Esquire Fla. Bar. No. 0023851 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that-a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7004 1160 0003 3739 3694 to: Registered Agent CT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 and by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 3700 to: Facility Admipistrator Susan L. Hein, 1350 S. Nova Road, Daytona Beach, FL 32114, on “© 2007: Coraine M. Novak, Esquire Copy furnished to: Nancy Marsh, FOM

Docket for Case No: 07-000647