WU : YU STATE OF FLORIDA rc i” aad DP AGENCY FOR HEALTH CARE ADMINISTRATION § tf 401 STATE OF FLORIDA, AGENCY FOR . OO MAY TL AMID: 5g HEALTH CARE ADMINISTRATION, - DNISION F ADMINISTRA ye Petitioner, . HEARINGS | ¥S. : AHCA NO: 02-00-011-NH WAKULLA MANOR, 00-/ 9 6 b Respondent. , / ADMINISTRATIVE COMPLAINT 7 YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $4,500.00 upon Wakulla Manor. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part II, Florida Statutes. 2. . Respondent, Wakulla Manor, is licensed by the Agency to operate a nursing home at 4679 Crawfordville Highway, Crawfordville, Florida 32326 and is obligated to operate the nursing home in compliance with Chapter 400 Part II, Florida Statutes, and Rule 59A-4, Florida Administrative Code. 3. A recertification survey was conducted from December 20-23, 1999 by the Agency’s Area 2 Office. During this survey, nine (9) Class III deficiencies were cited. VU VU 3A. Pursuant to 42 CFR §483.15(h)(1), the facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This requirement was not met as evidenced by the following observations: 3B. (1) At the group interview all cognitively intact residents indicated water temperatures to be too cold. (2) Surveyor observations during the survey revealed hot water temperatures as follows: Room 101 was 94F Room 108 was 94F Room 115-was 95F Room 128 was 94F. (3) Based on resident interviews and surveyor observations, it was determined that the facility violated Rule 59A-4.130(2)(a), F.A.C., for again failing to maintain water temperatures in resident’s rooms and in bathing rooms that were warm enough for residents. Pursuant to 42 CFR §483.70(f), the nurses’ station must be equipped to receive resident calls through a communication system from resident rooms, and toilet and bathing facilities. This requirement was not met as evidenced by the following observations: (1) The nurse calls in rooms 108 bed 4, 110 bed 1, and rooms 128, 131, 136 and 153 did not activate the nurse system when the nurse call button was depressed. (2) On December 20, 1999 at 11:20 a.m., the bathroom with entrance off of the hallway by nurse’s station #2 was unlocked, giving access to residents, with no nurse call system installed. (3) _ Based on surveyor observations, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing to equip the nursing stations to receive resident calls from all areas of the facility. 3c. pursue to National Fire Protection association (NEPA) 101 Standard, Life Safety Code 31-4.1.1, there is in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire and for their evacuation to areas of refuge and from the building when necessary. This requirement was not met as evidenced by the following observations: (1) The facility did not have an approved fire/disaster plan in place for training of staff. (a) The plan was submitted on several occasions with the Wakulla County Sheriffs Office and on each occasion, the representative of the Sheriff's office has requested correction to be made to the plan. . (b) The last request was made by the Wakulla County Sheriff's Office on May 19th, 1999, requesting current/updated transfer agreements, current staff call-out, water supply issues and generator issues. This request has not been addressed by statement given to the surveyor at the time of survey on December 20, 1999, (2) Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Code 31-4.1.1, for failing to have an approved fire/disaster plan that would enable the staff to be trained to perform life safety measures in the event of a fire or emergency situations, endangering the occupants of the facility. 3D. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 31-4.1.3, fire drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and shall be aware that drills are part of the established routine. Responsibility for planning and conducting drills shall be assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 p.m. and 6 a.m., a gn U U coded announcement may be used instead of audible alarms. This requirement was not met as evidenced by the following observations: 3E. (1) The facility had not recorded and performed all fire drills on each shift for each quarter within the past year, December 1998 through the date of the survey, December 20, 1999. (2) (a) The 7 to 3 shift had only documented fire drills for September 25, 1999, October 22, 1999, November 1, 1999, November 30, 1999 and December 20, 1999. (b) The 3 to 11 shift had only documented one fire drill for the year September 22, 1999. (c) The 11 to 7 shift had only documented fire drills for September.10, 1999, November 03, 1999 and December 03, 1999. (d) The facility did not have an approved fire plan in place to train personnel in the event of a fire, and there was no staff member assigned to conduct the fire drills. Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and Life Safety Code 31-4.1.3, for failing to have a trained ’staff member to perform life safety measures in the event of a fire, endangering the occupants of the facility. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Codes 13-3.4.2, 13-3.4.3 and 13-3.4.4, a fire alarm system, not a presignal type, with approved component devices or equipments shall be installed to provide effective warning of fire in any part of the building. Pull stations in patient sleeping areas may be omitted at exits if located at all nurse’s stations, are visible and continuously accessible and travel distances of 7-6.2.4 are not exceeded. Required sprinklers, detectors, etc. are arranged to activate the fire alarm system and operate devices such as dampers, door holders, etc. Fixed extinguishment protective systems protecting commercial cooking equipment in kitchens, protected by a complete automatic sprinkler system, need not initiate the building fire alarm system. The fire alarm system is U UY connected to automatically transmit an alarm to summon the local fire department. This requirement was not met as evidenced by the following observations: 3F. (1) The dialer for the fire alarm panel to the central station had only one phone line with jumpers to the second phone line position for the facility burglar alarm to keep it from going into trouble/phone line failure. Actuation of the fire alarm only responded as a burglar alarm at the central station. (2) Based on observation, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Codes 13-3.4.2, 13-3.4.3 and 13-3.4.4, for failing to comply with NFPA 72 4-3.3.2.2, in the event of a failure of equipment at a station or the communication Channel to a central station, a backup line shall operate within 90 seconds. This deficiency would impede in the facility’s ability to notify the proper emergency forces,in the event of a fire, endangering occupants of the facility. : Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 31-1.3, the fire alarm system shall be tested monthly. This requirement was not met as evidenced by the following observations: 3G. (1) The facility did not have written documentation of monthly fire alarm testing from December 1998 through the date of the survey, December 20, 1999. In an interview, the Maintenance Director stated he was not aware of the requirement of the monthly fire alarm test. (2) Based on record review and interview, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Code 31- 1.3, for failing to test the fire alarm system monthly. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 13-3.5.1, there shall be an automatic sprinkler system of a standard approved type to provide complete coverage for all portions of the facility. This requirement was not met as evidenced by the following observations: (1) _ The facility has not conducted and recorded all quarterly fire sprinkler testing from December 1999 through the date of survey, December 20, 1999. The only documented quarterly testing was for June 30, 1999 and September 30, 1999. W . ww) (2) Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and Life Safety Code 13-3.5.1, for the lack of testing could leave the fire ‘sprinkler system unreliable during the event of a fire, endangering occupants of the facility. 3H. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 13-3.2.4, the design, installation and use of commercial cooking equipment shall meet the requirements of NFPA 96 (Standard for the Installation of Equipment for the Removal of Smoke and Grease-Laden Vapors from Commercial Cooking Equipment). Pursuant to NFPA 96-8-2.1, six month service testing shall be required for the fire suppression system. These requirements were not met as evidenced by the following observations: (1) The facility is using vegetable fat in their deep fat fryer on the cooking line under the dry chemical pre-engineered fire suppression system within the kitchen. HCFA and Underwriters Lab have determined that. any facility using vegetable fat in their deep fat fryers shall have an approved wet agent pre-engineered fire suppression system installed for protection of the cooking equipment on the cooking line within the kitchen, or do not use vegetable fat, or do not use do deep fat frying. (2) The facility did not have documentation of all testing for the fire suppression for the kitchen fire suppression system. The system was tested in December 1998 and then in November 1999. (3) Based on observation and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Codes 13-3.2.4 and 96-8-2.1, for failing to install the correct commercial cooking equipment that meets the requirements of NFPA 96 and for the lack of testing of the fire suppression system. 31. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 70 500-5, electrical equipment shall not be in close proximity of flammable gases or vapors. Division II electrical equipment shall not be within 15 feet of flammable gases or vapors. This requirement was not met as evidenced by the following observations: YU UY (1) The LP gas feed water heater’s point of exchange of flammable gases and vapors are within 15 feet of the main electrical panels located in the service room where both electrical panels and LP gas feed water heaters are installed. (a) This condition could cause an explosion in this service room, endangering the occupants of the facility. (2) Pursuant to NFPA Life Safety Code 70 400-8, extension cords or cables shall not be used as (1) a substitute for fixed wiring of a structure, (2) run through holes in walls, ceiling, or floors, (3) run through doorways, windows, or similar openings, (4) attach to building surfaces, (5) concealed behind buildings walls, ceilings, or floors, or (6) where installed in raceways. , (a) In the east dining room/dayroom there was an electrical cord running between the ceiling tile and the grid of the ceiling tile into the crawl space above the ceiling tile. (b) The cord could chaff and then energize the metal grid and /or cause a fire to the combustible ceiling tile, endangering occupants of the facility. (3) Pursuant to NFPA 110 6-3.4 , 6-4.1 and 6-4.2, a written record of inspection, tests, exercising, operation, and repairs shall be maintained on the premises. Level 1 generators shall be inspected weekly and exercised under load at intervals of not more than 30 days. Level 1 generators shall be tested under operating temperature conditions and at a capacity not less than fifty percent of total connection load at least once a month for a minimum of thirty minutes. (a) The facility did not have written documentation of the monthly load testing from December 1998 through September 1999. The facility did not have written documentation of an annual load bank and transfer switch test from December 1998 through the date of the survey, December 20, 1999. (b) The lack of testing could leave the generator unreliable in the event of an emergency, endangering the occupants of the facility. (4) Based on observation and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C., NFPA Life Safety Codes 70 500-5, 70 400-8, 110 6-3.4, 6-4.1 and 6-4.2, endangering the occupants of the facility. 4. On san 24, 2000, a survey team from the aency’s Area 2 Office conducted a follow-up to the Life Safety Code portion of the recertification survey. During this survey, nine (9) Class III deficiencies were cited. 4A. Pursuant to 42 CFR §483.15(h)(1), the facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal “belongings to the extent possible. This requirement was not met as evidenced by the following observations: (1) ‘Surveyor observations of water temperatures that were taken at 3:30 p.m. revealed the following: no hot water in the bathtubs or whirlpools in the three shower rooms. (a) The water temperature from the showers in shower rooms #1 and #2 was 90 degrees. The temperature of the water in shower room #3 was 100 degrees. (2) ‘Three individual resident interviews conducted from 4 p.m.-4:15 p.m. revealed that they prefer having baths rather than showers. Staff interviews revealed that no residents are bathed in the bathtubs. (3) One resident interview indicated that her shower is cold. Several other residents indicated that the water is hot enough or at least warmer now, but it has been cold in the past. (4) The following resident rooms had water temperatures that were out of the 105-115 degree range (the acceptable range indicated on the facility's plan of correction): Room 101-100 degrees Room 108-104 degrees Room 115-104 degrees Room 128-104 degrees (5) Based on resident interviews and surveyor observations, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for failing to maintain water temperatures in resident’s rooms and in bathing rooms that were warm enough for residents. 4B. U Pursuant to 42 CFR §483.70(f), the nurses’ station must be equipped to receive resident calls through a communication system from resident rooms, and toilet and bathing facilities. This requirement was not met as evidenced by the following observations: 4c. (1) The nurse calls in rooms 108 bed 4, 110 bed 1, 131 bed 2 and 136 bed 1, did not activate the nurse system when the nurse call button was depressed. (2) Based on surveyor observations, it was determined that the facility violated Rule 59A-4.1288, F.A.C., for again failing to equip the nursing stations to receive resident calls from all areas of the facility. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 31-4.1.1, there is in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire and for their evacuation to areas of refuge and from the building when necessary. This requirement was not met as evidenced by the following observations: (1) On the date of the follow-up survey, the facility has not received the approval from Wakulla County Sheriff’s Office for the Disaster Plan. (2) The facility did not have an approved fire/disaster plan in place for’ training of staff. (a) The plan was submitted on several occasions with the Wakulla County Sheriff's Office and on each occasion, the representative of the Sheriff's office has requested correction to be made to the plan. (b) The last request was made by the Wakulla County Sheriff's Office on May 19th, 1999, requesting current/updated transfer - agreements, current staff call-out, water supply issues and generator issues. This request has not been addressed by statement given to the surveyor at the time of survey on December 20, 1999. (3) Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Code 31-4.1.1, for failing to have an approved fire/disaster plan that would enable the staff to be UY trained to perform life safety measures in the event of a fire or emergency situations, endangering the occupants of the facility. 4D. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 31-4.1.3, fire drills are to be held at unexpected times under varying conditions, at least quarterly on each shift. The staff shall be familiar with procedures and shall be aware that drills are part of the established routine. Responsibility for planning and conducting drills shall be assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 p.m. and 6 a.m., a coded announcement may be used instead of audible alarms. This requirement was not met as.evidenced by the following ‘observations: (1) | As of the follow-up date, the facility is still without an approved fire plan for training. The facility has assigned the Maintenance Director to conduct the fire drills. The Maintenance Director was unavailable to question his knowledge in conducting the fire drills. (2) The facility had not recorded and performed all fire drills on each shift for each quarter within the past year, December 1998 through the date of the survey of December 20, 1999. (a) The 7 to 3 shift had only documented fire drills for September 25, 1999, October 22, 1999, November 1, 1999, November 30, 1999 and December 20, 1999. : ’ (b+) = The 3 to 11 shift had only documented one fire drill for the year, September 22, 1999. (c) The 11 to 7 shift had only documented fire drills for September 10, 1999, November 03, 1999 and December 03, 1999. (d) ‘The facility did not have an approved fire plan in place to train personnel in the event of a fire, which would leave the staff member assigned to conduct the fire drills, untrained to perform life safety measures in the event of a fire, endangering the occupants of the facility. 10 U VY (3) Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and Life Safety Code 31-4.1.3, for again failing to have a trained staff member to perform life safety measures in the event of a fire, endangering the occupants of the facility. 4E. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Codes 13-3.4.2, 13-3.4.3 and 13-3.4.4, a fire alarm system, not a presignal type, with approved component devices or equipments shall be installed to provide effective warning of fire in any part of the building. Pull stations in patient sleeping areas may be omitted at exits if located at all nurses stations, are visible and continuously accessible and travel distances of 7-6.2.4 are not exceeded. Required sprinklers, detectors, etc. are arranged to activate the fire alarm system and operate devices such as dampers, door holders, etc. Fixed extinguishment protective systems protecting commercial cooking equipment in kitchens, protected by a complete automatic sprinkler system, need not initiate the building fire alarm system. The fire alarm system is connected to automatically transmit an alarm to summon the local fire department. This requirement was not met as evidenced by the following observations: (1) The facility still has failed to show this surveyor that they have phone lines to be used to call central station in the event of a fire, and that central would receive the signal as a fire signal and not a burglar alarm signal. (2) The dialer for the fire alarm panel to the central station had only one phone line with jumpers to the second phone line position for the facility burglar alarm to keep it from going into trouble/phone line failure. Actuation of the fire alarm only responded as a burglar alarm at the central station. (3) Based on observation, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Codes 13-3.4.2, 13-3.4.3 and 13-3.4.4, for failing to comply with NFPA 72 4-3.3.2.2, in the event of a failure of equipment at a station or the communication Channel to a central station, a backup line shall operate within 90 seconds. This deficiency would impede in the facility’s ability to notify the proper 11 4F. WU YU emergency forces in the event of a fire, endangering occupants of the facility. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 31-1.3, the fire alarm system shall be tested monthly. This requirement was not met as evidenced by the following observations: 4G. (1) — On the date of the follow-up survey, the facility was unable to show this surveyor that the monthly fire alarm test was conducted. The Maintenance Director was unavailable to question his knowledge in conducting the fire alarm test. (2) The facility did not have written documentation of monthly fire alarm testing from December 1998 through the date of the survey on December 20, 1999. In a previous interview, the Maintenance Director stated he was not aware of the requirement of the monthly fire alarm test. (3) Based on record review and interview, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Code 31- 1.3, for failing to test the fire alarm system monthly. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 13-3.5.1, there shall be an automatic sprinkler system of a standard approved type to provide complete coverage for all portions of the facility. This requirement was not met as evidenced by the following observations: (1) On the date of the follow-up survey, the facility did not produce records that the quarterly fire sprinkler testing had been conducted. (2) The facility has not conducted and recorded all quarterly fire sprinkler testing from December 1999 through the date of survey on December 20, 1999. The only documented quarterly testing was for June 30, 1999 and September 30, 1999. (3) Based on record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and Life Safety Code 13-3.5.1, for the lack of testing the fire sprinkler system, which could leave the fire sprinkler unreliable during the event of a fire, endangering occupants of the facility. 12 4H. U Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 13-3.2.4, the design, installation and use of commercial cooking equipment shall meet the requirements of NFPA 96 (Standard for the Installation of Equipment for the Removal of Smoke and Grease-Laden Vapors from Commercial Cooking Equipment). This requirement was not met as evidenced by the following | observations: 41. qd On the date of the survey, the facility still had a dry chemical fire suppression system in its cooking line and the oil being used for cooking was still vegetable oil/fat. (2) The facility is using vegetable fat in their deep fat fryer on the cooking line under the dry chemical pre-engineered fire suppression system within the kitchen. HCFA and Underwriters Lab have determined that any facility using vegetable fat in their deep fat fryers shall have an approved wet agent pre-engineered fire suppression system installed for protection of the cooking equipment on the cooking line within the kitchen. (3) This condition would impede the suppression of a fire on the cooking line, endangering occupants of the facility. (4) Based on observation and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and NFPA Life Safety Codes 13-3.2.4 and 96-8-2.1, for failing to install the correct commercial cooking equipment that meets the requirements of NFPA 96. Pursuant to National Fire Protection Association (NFPA) 101 Standard, Life Safety Code 70 500-5, electrical equipment shall not be in close proximity of flammable gases or vapors. Division II electrical equipment shall not be within 15 feet of flammable gases or vapors. This requirement was not met as evidenced by the following observations: (1) The LP gas feed water heater’s point of exchange of flammable gases and vapors are within 15 feet of the main electrical panels located in the service room where both electrical panels and LP gas feed water heaters are installed. 13 YU VY (a) This condition could cause an explosion in this service room, endangering the occupants of the facility. (b) The wall that was removed to allow for the new water heater, has not been reconstructed. (2) Pursuant to NFPA Life Safety Code 70 400-8, extension cords or cables shall not be used as (1) a substitute for fixed wiring of a structure, (2) run through holes in walls, ceiling, or floors, (3) run through doorways, windows, or similar openings, (4) attach to building surfaces, (5) concealed behind buildings walls, ceilings, or floors, or (6) where installed in raceways. (a) In the east dining room/dayroom there was an electrical cord running between the ceiling tile and the grid of the ceiling tile into the crawl space above the ceiling tile. (b) The cord could chaff and then energize the metal grid and /or cause a fire to the combustible ceiling tile, endangering occupants of the facility. (c) On the date of the follow-up survey, the electrical wire was still in its original place as the date of the December survey.’ (G3) Pursuant to NFPA 110 6-3.4,, 6-4.1 and 6-4.2, a written record of inspection, tests, exercising, operation, and repairs shall be maintained on the premises. Level 1 generators shall be inspected weekly and exercised under load at intervals of not more than 30 days. Level 1 generators shall be tested under operating temperature conditions and at a capacity not less than fifty percent of total connection load at least once a month for a minimum of thirty minutes. (a) The facility did not have written documentation of the monthly load testing from December 1998 through September 1999. The facility did not have written documentation of an annual load bank and transfer switch test from December 1998 through the date of the survey on December 20, 1999. (b) The lack of testing could leave the generator unreliable in the event of an emergency, endangering the occupants of the facility. : (4) Based on observation and record review, it was determined that the facility violated Rule 59A-4.1288, F.A.C., NFPA Life Safety Codes 70 500-5, 70 400-8, 110 6-3.4, 6-4.1 and 6-4.2, and failed to correct these deficiencies, endangering the occupants of the facility. 14 | | eae UY Y 5. Based on the foregoing, Wakulla Manor violated Rule 59A-4.1288, F.A.C., which states that nursing homes that participate in Title XVIII or XIX must follow certification rules and regulations found in 42 CFR 483, Requirements for Long Term Care Facilities, September 26, 1991. 6. Based on the foregoing, Wakulla Manor has also violated the following: (a) Tag K048 incorporates NFPA Life Safety Code 31-4.1.1 (b) | Tag K050 incorporates NFPA Life Safety Code 31-4.1.3 (c) Tag-K05lincorporates NFPA Life Safety Codes 13-3.4.2, 13-3.4.3 and 13-3.44 (d) Tag K052 incorporates NFPA Life Safety Code 31-1.3 (e) Tag K056 incorporates NFPA Life Safety Code 13-3.5.1 (f) Tag K069 incorporates NFPA Life Safety Code 13-3.2.4 (g) | Tag K130 incorporates NFPA Life Safety Codes 70 500-5, 70 400-8, 110 6-3.4,, 6-4.1 and 6-4.2 7. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 4uu.23(d) and Section 4UU. i021 )(aj(d), riorlua Suaiuies, and Rule 59A-4.1288, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of a Nursing Home. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or YU subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: R.S. Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Building 3, Tallahassee,” Florida 32308-5403, with a copy to Christine T. Messana, Esquire. . All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payment of fines should be sent to the Agency for Health Care Administration, Attention: Christine T. Messana, Staff Attorney, General Counsel’s Office, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403. 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. U WY Issued this ve of Q& la) an \ , 2000. m™ Heiberg ( Supervisor, Area 2 - Agency for Health Care Administration Health Quality Assurance 2639 North Monroe Street, Suite 208 Tallahassee, Florida 32303 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Wakulla Manor, 4679 Crawfordville Highway, Crawfordville, Florida 32326 on this S-€tday of Any . ) , 2000. Copies furnished to: Christine T. Messana Staff Attorney Agency for Health Care Administration ; 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308-5403 Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 Lt Christine T. Messana, Esquire Office of the General Counsel Donah Heiberg, Area 2 Office Gloria Collins, Finance & Accounting 17

Docket for Case No: 00-001966