= Centified Md Bate 6 | -U AYO (7004 180 9683,5 37309 ‘ FA ts 94 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION! Di ea STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . AHCA NOS.: 2007007541 (Fines) vs. ; ; 2007007542 (Cond.) 2007007543 (Fines) PRESBYTERIAN RETIREMENT COMMUNITIES 2007007544 (Cond.) INC. d/b/a WESTMINSTER OAKS, ; Respondent. ~ ee / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION © (“AHCA’), by and through the undersigned counsel and files this Administrative Complaint against Presbyterian Retirement Communities Inc. d/b/a Westminster Oaks (“Westminster Oaks, pursuant to Section 120.569, and 120.57, Fla. Stat. (2006), alleges: NATURE OF THE ACTION . . 1. — This is an action to impose four (4) administrative fines in the amount of Six Thousand Dollars ($6,000.00), against Westminster Oaks for four (4) class III deficiencies, pursuant to Sections 400.23(8)(c), 400.022(1)(I), Fla. Stat. (2006), and Rule 594-4, Fla. Admin. Code (2006). The Agency also intends to impose a. conditional rating effective February 19, 2007 through September 30, 2007, pursuant to Section 400.23(7), Fla. Stat. (2006) case nos. 2007007542, 2007007544. JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 400, Part Il and Sections 120.569 and 120.57, Fla. Stat. (2006). 3:. Venue lies in Leon County, Tallahassee, Florida, pursuant to Section 120.57 Fla. Stat. (2006); Rule 59A-4, Fla. Admin. Code (2006), and Section 28,.106.207, Fla. Stat. (2006). PARTIES 4. AHCA, is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing home facilities pursuant to Chapter 400, Part IT, Fla. Stat. (2006), and Chapter 59A-4, Fla. Admin. Code (2006). 5. . Westminster Oaks is a for-profit corporation, whose 120-bed nursing home facility is located at 4449 Meandering Way, Tallahassee; Florida. Westminster Oaks is licensed as nursing home license #SNF1599096; certificate number #14592, effective May 7, 2007 through September 30, 2007. Westminster Oaks was at all times material hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNTI WESTMINSTER OAKS FAILED TO FOLLOW THE PHSICIAN’S ORDER FOR ADMINISTERING MEDICATION FOR TWO (2) OF FIFTEEN (15) SAMPLED RESIDENTS (#15 AND 9). STATE TAG N054-FOLLOW PHYSICIAN ORDERS Section 400.23(8)(c), Fla. Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Rule 59A-4.107(5), Fla. Admin. Code (2006) PHYSICIAN SERVICES 6. AHCA rte-alleges and incorporates paragraphs (1) through (5) as if fully set “forth herein. | 7. On or about February 19, 2007, AHCA conducted an unannounced follow- up survey at the Respondent’s facility: AHCA cited the Respondent based on the findings below, to wit: | a.) On or about January 11, 2007, Westminster Oaks failed to‘endire that all provided services met professional standards of quality, specifically in ‘regards to the physician orders being carried out, for 5 of 30 sampled residents (Resident’s #8, #12, #13, #21 and #23). b.) During an unannounced follow-up survey on or about February 19, 2007, Westminster Oaks failed to follow the -physician’s order for administering medication for two (2) of fifteen (15) sampled residents (Resident’s #14 and #8). The Findings include: . 1. Resident # 14 was given one (1) Folic Acid 2 milligram (mg) tablet. Review of the ' ‘physician's order revealed an order for Folic Acid 2 mg, two (2) tablets for to be - administered. An. interview was conducted. with the medication nurse on 2/19/07 at approximately 10:30 am. The medication nurse acknowledged the physician's order stated two (2) Folic Acid tablets were to be administered instead of the one (1) tablet. 2. A record review of resident #8 was conducted on 02-19-2007 at approximately 2 p.m. The record review revealed a.consultant pharmacist communication dated 01- 31-2007. with a recommendation from the pharmacist for the physician to discontinue Zoloft. A further review revealed a response by the physician on the consultant pharmacist communication dated 02-14-2007 to discontinue the Zoloft. A continued review revealed a notation by the RN’ dated 02-14-2007 on the consultant pharmacist communication in response to the physician's order to discontinue the Zoloft A review of the medication record on 02-19-2007 at approximately 2:30 PM for resident #8 fot. 02-01-2007 through 02-28-2007 revealed that the Zoloft had continued to be given to the resident on 02-14-2007 through 02-19-2007. An interview with the charge nurse for the north. hall on 02-19-2007 at approximately 2:35 p.m. confirmed that the facility had failed to follow physician orders and to discontinue the Zoloft. 8. The regulatory provisions of the. Fla. Stat. (2006) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential. to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or 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 $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class 1 or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. * * * _ 59A-4.107 Follow Physician Order (5) All physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that’shift. ek oe 9. The violation alleged herein constitutes an uncorrected class II] deficiency, and warrants a fine of $1,000.00. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000.00. COUNT II WESTMINSTER OAKS FAILED TO FOLLOW WRITTEN CARE PLANS FOR 2 OF 15 SAMPLED RESIDENTS (RESIDENT'S #8, AND #11). STATE TAG N201-RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE Section 400.23(8)(c), Fla. Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; ; LICENSURE STATUS ee Section 400.022(1), Fla. Admin. Code (2006) RESIDENT’S RIGHTS 10. AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. On or about February 19, 2007, AHCA conducted an unannounced follow: - up survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about January 11, 2007, Westminster Oaks failed to follow written care plans for 5 of 30 sampled residents (Resident’s #8, #12, #13, #18 and #21). b.) During an unannounced follow-up survey on or about February 19, 2007, Westminster Oaks failed to follow written care plans for 2-of 15 sampled residents (Resident’s #8, and #11). The findings include: 1. A record review for resident # 8 was conducted on 02-19-2007. Review of the resident's care plan up-dated date of 01-03-2007 revealed a "Problem Onset" that the resident has short term memory problems, impaired decision making skills, a diagnosis of Parkinson's, can hear, can speak clearly, can make needs known, and can understand others. Further review of the resident's care plan up-dated date of 01-03-07 revealed in the "Approach" that when talking to the resident to approach them from the left side because of a right side neck contracture. Observations of resident # 8 while sitting in their wheelchair at the dining table at the 140 hall buffet on 02-19-2007 at 12:53 pm failed to reveal the CNA assisting with lunch to be approaching the resident from the left side, All dining assistance was provided from the right side. An interview with the charge nurse on the East hall on 02-19-2007 at 2:45 p-m. confirmed that the care plan stated to approach the resident from the'left side. 2. An observation of resident # 11 on 2/19/07 at approximately 11:00 a.m. revealed resident lying in bed with a brief and insert in place. Review of the current:care plan for resident # 11 revealed the following approach, “when out of bed in chair, use brief and insert. While in bed use brief only, leave brief open". An interview was conducted with the Unit Manager on 2/17/07 at approximately 11:00 a.m. The Unit Manager acknowledged the care plan stated the insert was to be used only when out of bed. 12. The regulatory provisions of the Fla. Stat. (2006) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 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 citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a’class III deficiency is corrected within __ the time specified, no civil penalty shall be imposed. 400.022 Follow Physician Order (1)@) The right to receive adequate and appropriate health care and protective and support. services, including social services; mental health services, if available; planned tecreational activities; and therapeutic and rehabilitative. services consistent with the resident. care plan, with established’ and recognized practice standards within the community, and with rules as adopted by the agency. eee . 13... The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $1,000.00. WHEREFORE, AHCA demands the following relief: 1, Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000.00. COUNT I WESTMINSTER OAKS FAILED TO FOLLOW THEIR PRESENTED PLAN OF - CORRECTION AND FAILED TO ENSURE ALL PHYSICIAN ORDERS ARE FOLLOWED AS PRESCRIBED, AND IF NOT FOLLOWED, THE REASON RECORDED IN THE RESIDENT’S MEDICAL RECORD DURING THAT SHIFT FOR 2 OF 5 (#3 & #5) SAMPLED RESIDENTS. STATE TAG N054-FOLLOW PHYSICIAN ORDERS Section 400.23(8)(c), Fla. Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Rule 59A-4.107(5), Fla. Admin. Code (2006) PHYSICLAN SERVICES 14. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. | On or about April 5, 2007, AHCA conducted an unannounced 2™ follow- up survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: -a.) During an unannounced 2™ follow-up to a full survey on or about April 5, 2007, Westminster Oaks failed to follow their presented Plan of Correction and failed to ensure all physician orders are followed as prescribed, and if not followed, the teason recorded in the resident's medical record during that shift for 2 of 5 (#3 & #5) sampled residents. | The findings include: 1. An observation of the facility's medication pass was conducted on 04/05/2007. During the medication pass it was observed that the medication nurse crushed a Toprol XL 25 mg. tablet prior to administering the Toprol XL 25mg. tablet to sampled resident #3 and then administered the crushed medication to the resident. A review of sampled -resident #3's physician's orders was conducted on 04/05/2007. During this review it was revealed that sampled resident #3. had an order for: , Toprol XL 25mg - Take 1 tablet by mouth every day **DO NOT CRUSH** A telephone interview with the facility's contracted pharmacy's pharmacist was conducted on 04/05/2007. During this interview the pharmacist acknowledged that the Toprol XL should never be crushed prior to administration and instead an order to change the medication should be requested to the prescribing physician. A review of the facility's policies and procedures for medication administration was conducted on 04/04/2007. During this review it was documented in Section VI, ‘ page 6.1 - Refer to "Do Not Crush List" prior to crushing any medication. A review of the facility's "Do Not Crush List" for medications revealed that Toprol XL was listed as a medication that was not to be crushed prior to administration. (Note: This is not done (crushing this medication) due to the fast absorption of the medication and the ill effects that this may have on the user’s blood pressure and cardiac output) 2. A review of sampled resident #5's clinical record was conducted on 04/05/2006. During this record review it was documented that sampled resident -#5 was to be "NPO" (Nothing by mouth). Sampled resident #5 was to be fed by tube and had aspiration precautions. An observation with the Assistant Director of Nursing (ADON) was conducted in reference to follow-up survey requirements. During this observation: the ADON acknowledged that sampled resident was to be NPO. A facility staff nurse taking care of sampled resident #5 on the day of the survey and also interviewed on 04/05/2007 at approximately 3:30 p.m., acknowledged that the resident was to be NPO and that all medications administered by him/her and other nurses are given via the resident's G-Tube. A review of the physician's orders (signed and dated on 04/04/2007 by the physician for 04/01/2007 - 04/30/2007) for sampled resident #5 was conducted on 04/05/2007, During this review it was revealed that the following listed medications were ordered to be given by mouth: Fludrocoritisone 0.1mg tab - Take one tab by mouth every other day Gabapentin 100mg - Take one capsule by mouth 3 times a day Loratadine 10mg OTC- Take one tablet by mouth every day Cyclobenzaprine 10mg - Take **One-Half** tablet by mouth at bedtime Diphenoxylate/Atropine 2.5mg/0.025mg - Take 1 tablet by mouth four times a day as needed for diarrhea Further review of the physician's orders documented: "These orders are in effect for the next 60 days unless otherwise specified." Continued review of sampled resident #5's clinical chart revealed there were no other orders for the above listed medications - to be given via G-Tube, could be found in the residents chart. An interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) was conducted. on 04/05/2007 at approximately 5:06 p.m. During this interview the DON and the ADON were asked, are there any orders that you have to show that the medications listed (see above) are to be given by G-Tube? The ADON stated, "No, these should have been updated." The DON stated, "We'll get new orders tight now for these." and also answered "No" to the facility being able to produce any documentation (physician's orders) that the medications being given by mouth could be given via G-Tube as stated by the medication nurse. 16. The regulatory provisions of the Fla. Stat. (2006) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(c) A class HI deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident - or has the potential to compromise the resident's ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty. of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 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 Il deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. 59A-4.107 Follow Physician Order (5) All physician orders shall be followed as prescribed, and if not followed, the reason shall be, recorded on the resident’s medical record during that shift. a 17. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $2,000.00. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $2,000.00. COUNT IV WESTMINSTER OAKS FAILED TO ENSURE THAT EACH RESIDENT RECEIVED ADEQUATE AND APPROPRIATE HEALTH CARE, THERAPEUTIC AND REHABILITATIVE SERVICES, CONSISTENT WITH THE RESIDENT CARE PLAN, WITH ESTABLISHED AND RECOGNIZED PRACTICE STANDARDS WITHIN THE COMMUNITY, AND WITH RULES AS ADOPTED BY THE AGENCY FOR 2 OF 5 (#3 & #5) SAMPLED RESIDENTS. ~~ STATE TAG N201-RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE Section 400.23(8)(c); Fla. Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 400.022(1), Fla. Admin. Code (2006) RESIDENT’S RIGHTS 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set - forth herein. 19. On or about April 5, 2007, ANCA conducted an unannounced 2" follow- up survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: 10 a.) During an unannounced 2™ followup to a full survey on or about April 5, 2007, Westminster Oaks failed to ensure that each resident received adequate and appropriate health care, therapeutic and rehabilitative services, consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency for 2 of 5 (#3 & #5) sampled residents. The findings include: 1. An observation of the facility's medication pass was conducted on 04/1 05/2007. During the medication pass it was observed that the medication nurse crushed a Toprol XL 25 mg. tablet prior to administering the Toprol XL 25mg. tablet to sampled resident #3 and then administered the crushed medication to the resident. A review of sampled resident #3's physician's orders was conducted on 04/05/2007. During this review it was revealed that sampled resident #3 had an order for: ; : Toprol XL 25mg - Take 1 tablet by mouth every day **DO NOT CRUSH** A telephone interview with the facility's contracted pharmacy's pharmacist was conducted on 04/05/2007. During this interview the pharmacist acknowledged ~ that the Toprol XL should never be crushed prior to administration and instead an order to change the medication should be requested to the prescribing physician. A review of the facility's policies and procedures for medication administration was conducted on 04/04/2007. During this review it was documented in Section VI, page 6.1 - Refer to "Do Not Crush List" prior to crushing any medication. A review of the facility's "Do Not Crush List" for medications revealed that Toprol XL was listed as a medication that was not to be crushed prior to administration. (Note: This is not done (crushing this medication) due to the fast absorption of the . medication and the ill effects that this may have on the user’s blood pressure and cardiac output) , : 2. A review of sampled resident #5's clinical record was conducted on 04/05/2006. During this record review it was documented that sampled resident #5 was to be "NPO" (Nothing by mouth). Sampled resident #5.was to be fed by tube and had aspiration precautions. An observation with the Assistant Director of Nursing (ADON) was conducted in reference to follow-up survey requirements. During this observation the ADON acknowledged that sampled resident was to be NPO. A facility staff nurse taking care of sampled resident #5 on the day of the survey and . also interviewed on 04/05/2007 at approximately 3:30 p.m., acknowledged that the resident was to be NPO and that all medications administered by him/her and 1 other nurses are given via the resident's G-Tube. A review of the physician's orders (signed and dated on 04/04/2007 by the physician for 04/01/ 2007 - 04/30/2007) for sampled resident #5 was conducted on 04/05/2007. During this review it was revealed that the following listed medications were ordered to be given by mouth: Fludrocoritisone 0.1mg tab - Take one tab by mouth every other day Gabapentin 100mg - Take one capsule by mouth 3 times a day - Loratadine 10mg OTC- Take one tablet by mouth every day Cyclobenzaprine 10mg - Take **One-Half** tablet by mouth at bedtime Diphenoxylate/Atropine 2.5mg/0.025mg - Take 1 tablet by mouth four times a day as needed for diarrhea : ; Further review of the physician's orders documented: "These orders are in effect for the. next 60 days unless otherwise specified.” | Continued review of sampled resident #5's clinical chart revealed there were no other orders for the above listed medications - to be given via _G-Tube, could be found in the residents chart. Ain interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) was conducted on: 04/05/2007. at approximately 5:06 p.m. During this interview the DON and the ADON were asked, are there any orders that you have to show that the medications listed (see above) are to be given by G-Tube? The ADON stated, "No, these should have been updated." The DON stated, "We'll get new orders tight now for these." and also answered "No" to the facility being able to produce any documentation (physician's orders) that the medications being given by mouth could. be given via G-Tube as stated by.the medication nurse. 20. The regulatory provisions of the Fla. Stat. (2006) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status (8)(c) A class III deficiency is a deficiency that the agency determines will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident's ability to maintain or reach his ot her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for°a patterned deficiency, and $3,000 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 imspection or any: inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. ; 12 400.022 Follow Physician Order (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. x ok ® 21. The violation alleged herein constitutes an uncorrected class III deficiency, and warrants a fine of $2,000.00. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $2,000.00. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I, II, III and Count IV. 2. Assess against Westminster Oaks an administrative fine in the amount of $6,000.00 for the violations cited above. 3. Assess against Westminster Oaks a conditional license in accordance with Section 400.23(7), Florida Statutes (2006). 4. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2006). Specific options for administrative action are set out in the attached Election of Rights (oné 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 the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael ©. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully Submitted this ant ay of Busvst_ 2007, Leon County, Tallahassee, Florida. MALAI Michael O. Mathis, Esquire Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive 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 certified mail on QT day of Buses + , 2007 to Shannon. Ewing Sauls, Westminster Oaks, 4449 Meandering Way, Tallahassee, FL 32308. IN Michael O. Mathis, Esquire 14 SUONONSU| 10} BS43ABY BBG | P asn VvVidis dou | [WOo'SdSI’ MMM Je ayISGoM INO PSIA UOHeUOjU! ALaANap 404 (papiaoid abesanog aout ‘Aug [ley onsauieg) idlndsuY WW GalsaiLYdsd HQ@IAIBS [B}SOd “S'f} TbTb bEZE ENOO OFTT hood SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ™@ Print your name and address on the reverse so that we can return the card to you. ™@ Attach this card to the back of the mailpiece, or on the front if space permits. ORME GS, Squdad fps cwoner snes” So Does keninshyy Qealks UY Myeanadmuins Wes Tatiarnress, FL'3 0308 —— a \yasbrrinaben Qalks [aCertified Mail 0 Express Mail © Registered © Return Receipt for Merchandise O Insured Mail =O 6.0.0. 4, Restricted Delivery? (Extra Fee) 2. Article Number. (Transfer from service label) 7004 11bD O003 3739 9191 PS Form 3811, August 2001 , Domestic Return Receipt 102595-02-M-1035

Docket for Case No: 07-004380