STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Nos. 2002034851, 2002036821, 2002042271, 2002039431, 2002045371 DOAH Nos: 02-4277, 02-4278, 02-4749, vs ot eben ~ - 5 Cy CYPRESS MANOR HEALTH CARE CSH « NO. Aecf 03- 05sec - ASSOCIATES, LLC., d/b/a CYPRESS N “ nari COMMUNITY CARE CENTER, . ON Respondent. ‘ . 2 _/ . m aN FINAL ORDER Having reviewed the Administrative Complaints dated April 25, May 30, June 04, and June 28, 2002, attached hereto and incorporated herein (Ex's. 1 & 5), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 6), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 1 2. A fine of $3,375.00 is hereby imposed upon the Respondent. The fine is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this Case number, should be sent directly to Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, Mail Stop # 14 Tallahassee, Fl. 32308. 4. Unpaid fines will be subject to statutory interest, and may be collected by all methods legally available. 5. The Conditional license will be effective for the time period of June 15, 2002 until July 12, 2002. 2 DONE and ORDERED this / day of Be centt __, 2003, in Tallahassee, Leon County, Florida. A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.” Copies furnished to: Donna Holshouser Stinson, Esquire Broad & Cassel 215 S. Monroe Street, Ste. 400 Tallahassee, Florida 32301 (U. S. Mail) Carolyn S. Holifield Administrative Law Judge Division of Administrative Hearings 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Eileen O'Hara Garcia, Esq. Senior Attorney ~ Agency for Health Care Administration 525 Mirror Lake Dr. N. #330D St. Petersburg, FL 33701 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bidg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the 4 day of. Septem RE 2003. c (4 —- Lealdnd McCharen, Agency Clerk ~ Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 EXHIBIT STATE OF FLORIDA 3 AGENCY FOR HEALTH CARE ADMINISTRATION 3 / STATE OF FLORIDA, AGENCY FOR HEALTH ~ CARE ADMINISTRATION, Petitioner, AHCA NO:.2002034851 vs. CYPRESS MANOR HEALTH CARE ASSOCIATES, Lh, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against CYPRESS MANOR HEALTH CARE ASSOCIATES, LL, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Five Thousand Dollars ($5,000) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes. The amount of the fine constitutes a doubling of the fine for an isolated class II deficiency pursuant to § 400.23(8) (b) Fl. Stat. (2001). The facility was previously cited for a Class II deficiency during the last annual inspection of 5/17/01. 2. The Respondent was cited for the repeat deficiency during the annual survey conducted on or about April 25, 2002. Jurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. _ 4. venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A.C. Parties 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS. VIOLATING Fl. Admin Code R.59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.25 (h) (2) & § 400.022(1) (1) Fl. Stat. (2001) REPEAT CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based on resident record reviews, observations and interviews the Respondent failed to ensure that 2 (Residents #2 and #7) of 18 active surveyed residents received adequate supervision and assistive devices to prevent accidents resulting in one of the resident's falling and experiencing a fracture of the superior and inferior pubic rami (pelvis). 9, The findings of the surveyors include the following: a. Resident #2 was admitted to the facility 3/6/02. Her admission data on 3/6/02 identified her as having an unsteady gait. Her fall risk assessment identified her as high risk for falls. Her Care Plan of 3/13/02 identified her to be at risk for falls, and having a history of falling. The approaches on her Care Plan were anticipate her needs, answer call light quickly, keep area free of clutter, keep floor clean and dry, PT/OT evaluation, and monitor side-effects of medication. On 3/17/02, she was found on the floor and x-rays revealed the fractures. There was no recommendation or discussion’ of protective devices in her chart. There was no re-evaluation after the fall. b. Resident #7 was observed on 4/23/02 at 10:40 A.M. and 2:10 P.M., to be sitting in a wheelchair unsupervised without a lap buddy in the West Wing day room. On 4/24/02 at 1:30 P.M., resident was observed to be sitting in the facility courtyard in a wheelchair, without supervision or lap buddy. Interview on 4/24/02 at 1:30 P.M., with the Director on Nursing, confirmed Resident #7 was sitting in her wheelchair, unsupervised and without a lap buddy. Record review for resident #7 revealed a falls care plan updated on 2/3/02, with "lap buddy" as an intervention and a physician order dated 2/6/02, "lap buddy when out of bed in wheelchair..Release during meals, supervised activities, toileting, and repositioning." 10. The above action or inactions are violations of 42 CFR 483.25 (h) (2) which requires each resident receive adequate supervision and assistive devices to prevent accidents and § 400.022(1) (1) Fl. Stat. (2001) which provides that the resident has a right to receive adequate and appropriate health care and protective and support services. 11. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under Sections 400.022(3), 400.102(1) (a,d), 400.121(1), and 400.23(8) (b), Florida Statutes. WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a doubled fine of Five Thousand Dollars ($5,000) for the violation cited in Count I, against the respondent under Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes; c. Assess costs of the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2001) D. All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. Eileen O'Hara Gar¢ia, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive North, 330D St. Petersburg, Florida 33701 I HEREBY CERTIFY that a copy hereof has been furnished to CT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7002 0510 0003 3404 1334 and to Administrator, Cypress Community Care Center, 7173 Cypress Drive S.W., Fort Myers, FL 33907, Return Receipt No. 7002 0510 0003 3404 1341 by U.S. Certified Mail, on October 10, 2002. Eileen O'Hata Gakcia, Esquire Copies furnished to: Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O'Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 310L St. Petersburg, Florida 33701 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO:2002036821 vs. CYPRESS MANOR HEALTH CARE ASSOCIATES, LL, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against CYPRESS MANOR HEALTH CARE ASSOCIATES, LL, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: Nature of the Action 1. This is an action to impose a conditional licensure status effective April 25, 2002 pursuant to Sections 400.23(7) (b) and 400.23(8) (b). 2. The Respondent was originally cited for the repeat deficiency during the annual survey conducted on or about April 25, 2002. Jurisdiction and Venue 3. The Agency has jurisdiction over the Respondent pursuant to’Chapter 400, Part II, Florida Statutes. 4, Venue lies in Lee County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. Parties 5. AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I EFFECTIVE April 25, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO CYPRESS COMMUNITY CARE CENTER BASED UPON THE DETERMINATION THAT CYPRESS COMMUNITY CARE CENTER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF A CLASS II DEFICIENCY AT THE MOST RECENT SURVEY OF APRIL 22-25, 2002. § 400.23(7), Fla. Stat. 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based on resident record reviews, observations and interviews the Respondent failed to ensure that 2 (Residents #2 and #7) of 18 active surveyed residents received adequate supervision and assistive devices to prevent accidents resulting in one of the resident's falling and experiencing a fracture of the superior and inferior pubic rami (pelvis). 9. The findings of the surveyors include the following: a. Resident #2 was admitted to the facility 3/6/02. Her admission data on 3/6/02 identified her as having an unsteady gait. Her fall risk assessment identified her as high risk for falls. Her Care Plan of 3/13/02 identified her to be at risk for falls, and having a history of falling. The approaches on her Care Plan were anticipate her needs, answer call light quickly, keep area free of clutter, keep floor clean and dry, PT/OT evaluation, and monitor side- effects of medication. On 3/17/02, she was found on the floor and x-rays revealed the fractures. There was no recommendation or discussion of protective devices in her chart. There was no re-evaluation after the fall. b. Resident #7 was observed on 4/23/02 at 10:40 A.M. and 2:10 P.M., to be sitting in a wheelchair unsupervised without a lap buddy in the West Wing day room. On 4/24/02 at 1:30 P.M., resident was observed to be sitting in the facility courtyard in a wheelchair,without supervision or lap .buddy. Interview on 4/24/02 at 1:30 P.M., with the Director on Nursing, confirmed Resident #7 was sitting in her wheelchair, unsupervised and without a lap buddy. Record review for resident #7 revealed a falls care plan updated on 2/3/02, with "lap buddy" as an intervention and a physician order dated 2/6/02, "lap buddy when out of bed in wheelchair..Release during meals, supervised activities, toileting, and repositioning." 10. The Agency seeks to impose a Conditional Licensure Status effective April 25 , 2002, based on one repeat Class II deficiency as authorized under Sections 400.23(7) (b), 400.23(8) (b) and 400.022(3), Florida Statutes. WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Recommend that the change of licensure status effective April 25, 2002, from Standard to Conditional be upheld; and c. 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 Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. 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. spectfully submitted tal Hora Eileen O'Hara Garcia, AHCA - Senior Attorn¢y 525 Mirror Lake Drive North St. Petersburg, Florida 33701 F HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7002 0510 0003 3404 1358 and to 7173 Cypress Drive Administrator, Cypress Community Care Center, S.W., Fort Myers, FL 33907, Return Receipt No. 7002 0510 0003 3404 1365 by U.S. Certified Mail, on October 10, 200 Eileen 0o' a Garcia, Esquire Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330D St. Petersburg, Fl 33701 CERTIFICATE #: 8640 LICENSE #: _SNF11160961 "' State of Florida AGENCY FOR HEALTH CARE ADM DIVISION OF MANAGED CARE AND HEALTH QUALITY SKILLED NURSING FACILITY | CONDITIONAL This is to confirm that_CYPRESS MANOR HEALTH CARE ASSOCIATES, LL_ has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: CYPRESS COMMUNITY CARE CENTER 7173 CYPRESS DRIVE S.W. FORT MYERS, FL 33907-2994 with _120 beds. Change In Status ACTION EFFECTIVE DATE: 04/25/2002 ivision of Managed Care and Health Quality; LICENSE EXPIRATION DATE: _11/30/2002 Deputy Secretary, UVES ES AAI Se UL 8 IM Ba UN ea A ea Me ge K is STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXHIBIT STATE OF FLORIDA, 3 AGENCY FOR HEALTH CARE ADMINISTRATION, tabdles* Petitioner, AHCA NO: 2002042271 vs. CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Two Thousand dollars ($2,000) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (c), Florida Statutes. 2. The Respondent was cited for the uncorrected deficiency during the follow-up survey conducted on or about June 3-4, 2002. The original mandated correction date for the deficiency was 5/25/02. The fine for the deficiency is doubled because the facility was cited for a Class II deficiency as a result of the April 2002 survey. ‘ Jurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A.C. Parties 5. AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO KEEP RESIDENTS FREE FROM UNNECESSARY DRUGS. FL. ADMIN CODE R.59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.25(1) (1) UNCORRECTED CLASS III DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about April 25, 2002 an annual survey was conducted at the facility. 9. At that time, it was determined, based on record review and staff interview, that 2 of 21 residents sampled were not free from unnecessary drugs. Resident #9 received psychoactive medication without adequate monitoring and Resident #17 received hypnotic medication for 10 days without a risk benefit statement or assessment of the drug’s effectiveness. 10. On or about June 4, 2002 a revisit survey was conducted at the facility. Based on resident record review and staff interview, one (resident #17) of 13 active residents was not free from unnecessary drugs. This is evidenced by resident #17 being given Ativan without clinical documentation that the medication was needed. 11. The above referenced violation constitutes the grounds for the imposed uncorrected Class III deficiency and for which a fine of Two Thousand dollars ($2,000) is authorized under Sections 400.102(1) (a) (a), 400.121(1), and 400.23(8) (c), Florida Statutes. WHEREFORE, AHCA requests this Court to order the following ‘relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of Two Thousand Dollars ($2,000) for the violation cited in Count I, against the respondent under Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8)(c), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121 Fl. Stat. (2001) ‘ D. All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Acministration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. pectfully submitted, . \ Eileen O’Hara Garcia, AHCA - Senior Attorney/ 525 Mirror Lake Drive North, 330D St. Petersburg, Florida 33701 I HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7099 3400 0002 2450 7781, by U.S. Certified Mail and to Administrator, Cypress Community Care Center, 7173 Cypress on No Drive S.W., Fort Myers, FL 33907, -S. Mail, 2002. Eileen O’ Hara ye Esquire 4 Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXHIBIT STATE OF FLORIDA, j Y AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO:-2002039431 vs. CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT ‘COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Five Thousand Dollars ($5,000) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes and a survey fee of Six Thousand Dollars ($6,000). The fine amount represents a doubling of the fine due to a Class II deficiency citation on the annual survey of April 25, 2002. 2. The Respondent was cited for the Class II deficiency during Pa the Complaint Survey conducted on or about May 30, 2002. Jurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearirgs, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A.C. Parties 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROVIDE SUFFICIENT PREPARATION AND ORIENTATION TO RESIDENTS TO ENSURE SAFE AND ORDERLY TRANSFER OR DISCHARGE FROM THE FACILITY. VIOLATING 59A-4.1288 FL. ADMIN. CODE INCORPORATING BY REFERENCE 42 CFR 483.12(a) (7). CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. A complaint investigation was conducted at the facility on May 30, 2002. ; 9. On that date, based on resident medical record review, interview with staff, review of records received by an Assisted Livine Facility and review of hospital records, the facility failed to ensure appropriate and complete discharge planning as evidenced by failure to ensure medical equipment was_ordered and delivered to an Assisted Living Facility (ALF) prior to the discharge of 1 of 3 (Resident #3) sampled discharged residents, who required nebulizer treatments every 6 hours and oxygen at 2 liters as needed for shortness of breath. 10. The findings include: A./ Review of the medical record for Resident #3 revealed the resident was admitted to the facility on 2/20/02 and discharged to an ALF on 5/28/02. His admitting diacnosis included Compensatory Emphysema and Hypertension. During his 3 month stay at the skilled nursing facility, he was hospitalized twice with respiratory distress. B./ His latest re-admission to the nursing home was on 5/3/02. The resident record indicated the resident was received oxygen via nasal cannula at 2 liters as needed and Duoneb treatments every 6 hours to help facilitate his breathing as he had frequent episodes of shortness of breath. The last documented nebulizer treatment was noon on 5/28/02. The resident was discharge to an ALF on 5/28/02 and arrived prior to 3:30 P.M. c./ Social Services notes indicate that the Social Worker arranged for the resident to have a tour of the ALF on 5/24/02. The notes also state that she arranged for-the Department of Elder Affairs (DOEA) Form 1823 (Health Assessment Form for Assisted Living Facility), to be taken to the resident's physician for completion on the day the resident was discharged from the facility (5/28/02). D./ Nursing notes for 5/28/02 in the resident record stated, "PM, discharged to ALF via van. Ambulated to van.” The record did not contain documentation of any discharge summary or information, which accompanied the resident to the ALF, E./ Interview with the Director of Nursing (DON) revealed the facility considered the DOEA Form 1823 a sufficient document for obtaining any medical needs and orders for residents going to ALF's. The DON further stated, the resident did not use his oxygen véry much, "he used it sparingly." She further indicated the resident was very anxious to leave the facility. F./ Interview with the Social Worker revealed, she gave the van driver the DOEA Form 1823 for the resident. Further interview revealed, she did not review the DOEA Form 1823 for complete orders or signatures that would allow the resident to receive the services needed at the ALF. Review of the DOEA Form 1823 on 5/28/02, revealed the physician's signature was unreadable and it did not include the physician's name, phone number or license number as required when using the DOEA Form 1823 as valid physician's orders. This lack of information prevented the ALF from having enough information to obtain the needed durable medical equipment for the resident's immediate use. Further interview with the Social Worker revealed if a resident was going to their own home, she would make arrangements for their medical needs such as home health or medical equipment. She further stated she does not do this when residents are going to an Assisted Living Facility. G./ Interview with the skilled nursing facility nursing staff present when Resident #3 was discharged, revealed they did not send any oxygen equipment or nebulizer with the resident when he was discharged. H./ Review of the paper work received by the ALF for Resident #3 revealed, the DOEA Form 1823 was the only information received at discharge. The physician's signature was unreadable and it did not include the physician's name, phone number or. license number as required. The ALF was unable to get oxygen or a nebulizer treatment for the resident since no complete orders or prescriptions accompanied the resident. At approximately 9 P.M. on 5/28/02, the resident complained of shortness of breath and difficulty breathing. The ALF staff called 911 and the resident was transferred to the hospital. Review of the EMS transport record revealed a O02 stat of 60 (normal 98) at 9:48 P.M. I./ Follow up at the hospital on 5/31/02, revealed treatment at the ER included updraft xl hour (nebulizer). Bypap attempted, but failed, not tolerated. The resident was admitted to the Intensive Care Unit on 02 at 4 liters, with diagnoses of respiratory failure, pneumonia, chronic obstructive pulmonary disease and history of atrial fibrillation on 5/28/02 and was still hospitalized as of the date of the survey. 11. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under Sections 400.022(3), 400.102(1) (a) (d), 400.121(1), and 400.23(8) (b), Florida Statutes. ADDITIONAL FEE UNDER §400.19(3), FLORIDA STATUTES 12. The Respondent has been cited for a Class II deficiency and the amount of sanction is doubled because of a previous Class II deficiency within a 60-day period: 4/25/02 survey - tag 324. Therefore, the Respondent is subject to a survey fee of Six Thousand dollars ($6,000) pursuant to Section 400.19(3), Florida Statutes. 13. Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of Five Thousand Dollars ($5,000) for the violation cited in Count I, against the Respondent under Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of ‘ this case pursuant to Section 400.121 Fl. Stat. (2001) D. Impose a survey fee in the amount of Six Thousand Dollars ($6,000). E. All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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. ypectfully submitted, Oty la. Eileen O’Hara Garcia, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive North, 330D St. Petersburg, Florida 33701 I HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, FL 33324, Return Receipt No. 7002 0510 0003 5504 4864 by U.S. Certified Mail, and to Administrator, Cypress Community Care Center, 7173 Cypress Drive S.W., Fort Myers, FL 33907, by U.S. Certified Mail, on December & 7, 2002. 4 yo rs bos - Aa. Eileen O'Hara Garcia, Esquire ¢ Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Certified Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXHIBIT tabbies" STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO:- 2002045371 vs. CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against CYPRESS MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Five Thousand dollars ($5,000) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8)(b), Florida Statutes. This amount of sanction represents a doubled fine because the facility was previously cited for a Class II violation (F324) on the annual survey of 4/22-25/02. 2. The Respondent was cited for a Class II deficiency during ‘ the complaint survey conducted on or about June 28, 2002. Jurisdiction 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 F.A.C. Parties 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 7173 Cypress Drive S.W., Fort Myers, Florida 33907. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROVIDE THE CARE AND SERVICES NECESSARY TO MAINTAIN RESIDENT #1 AT THE HIGHEST PRACTICABLE PHYSICAL AND MENTAL WELL-BEING, FAILED TO PROMPTLY NOTIFY RESIDENT #1'S RESPONSIBLE PARTY AND PHYSICIAN OF THE CHANGE IN HER CONDITION WHEN SHE STOPPED EATING FOR ONE WEEK PRIOR TO BEING ADMITTED TO THE HOSPITAL. VIOLATING 59A-4.106(4) (q) AND 59A-4.1288 FL. ADMIN. CODE INCORPORATING BY REFERENCE 42 CFR 483.25 CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. ‘ 8. On or about 6/28/02 a complaint investigation was conducted at the respondent’s facility. 9. On that date, based on staff interviews, one of one resident records reviewed, facility and hospital records reviewed, the facility did not provide the care and services necessary to maintain Resident #1 at the highest practicable physical and mental well-being, failed to promptly notify Resident #1's responsible party and physician of the change in her condition when she stopped eating for one week prior to being admitted to the hospital. 10. The findings regarding this violation include: a./ RA review of Resident #1's medical record from the facility revealed she was admitted to the facility on 7/12/01. She was discharged to an Assisted Living Facility on 6/10/02, however, did not seem to meet the criteria for an Assisted Living Facility (ALF) and was sent back to the nursing home the same day. In an interview the Social Worker stated she was very weak. b./ The medical records show prior to 6/10/02, a data sheet showing the amount of food she ate for each meal revealed as approximately 25% to 75% of her meals. After 6/10/02, the data sheet revealed she either refused to eat her meals, the amount of food eaten was zero or the box was left blank. Of the 42 meals offered from 6/10 to 24/02, at only two meals documentation showed a meal consumption of 25%, 14 meals were marked with a "R" for refused, 5 meals were marked "0", and 21 meals lacked any documentation. The PM snack documentation from 6/10 to 24/02 showed only 1 documented refusal, and 13 opportunities lacked documentation. Fluid documentation for 6/10 to 24/02 revealed 28 shifts with 16 of 28 showing fluids offered. No fluid consumption is noted. c./ Interview with staff stated she was refusing to eat and stopped eating. Interview with Resident #1 family member revealed the family member and a staff nurse had conversed about the refusal to eat and felt the residents was displaying manipulative attention seeking behavior. ad./ A review of her weights showed on 5/18/02 she weighed 172.2 pounds. On 6/13/02, she refused to be weighed and on 6/17/02 she weighed 147.8 pounds. A nutrition note on 6/26/02 revealed there was a 14% weight loss since readmission (6/10/02). According to the nurse's notes on 6/10/02 the resident returned to the facility from the ALF. - On 6/11/02, there were family concerns and these issues would be brought up to the Social Worker. The next nurse's note was 6/18/02. It revealed the resident refuses to get out of bed, won't speak to the staff, refuses food and possible depression. e./ Interview with the DON revealed no documentation was found to show the physician was notified of the change in the resident from 6/10 to 6/18 until asking for an order for a Psychological Consult. On 6/21/02, the Psychologist ordered Effexor and Zyprexa. These medications were documented as given 1 time from 6/21 to 6/24, and ‘refused all other times. On 6/21/02, Resident #1 continues to refuse to get out of bed, is incontinent of bowel and bladder, "primarily dependent in care tasks," she does not assist with her activities of daily living skills and "often refused to be toileted." She is lethargic and catatonic at times. She had a decline in overall function in the past 10 days. The nurse's notes on 6/22/02 revealed she refused her medications. A review of her Medication Administration Record revealed she refused her medications on 6/21, 6/22 and 6/23/02. Attempts were made to seat an IV on 6/23/02, without success. She was then sent to the emergency room in the early hours on 6/24/02. £./ Blood was collected on 6/23/02 and the results were printed on 6/24/02. The following are the result: - Sodium level was 152 (high) - normal range 137 - 145. - Potassium was 8.4 (critical factor) - normal range 3.6 - 5.0. ~ Chloride 116 (high) - normal range 98 - 107. - C02 below 5.0 - normal range 22 - 30. - BUN 398 (high) - normal range 7 - 17. - Creatinine 17.7 (high) - normal range .7 - 1.2. serum glucose - 141 (high) - normal range 70 - 105. calculated serum osmolality - 470 (high) normal range 285 - 295. ‘ q./ Interview with facility staff stated they did not notify the family of this change in the resident's condition until she went to the hospital. Interview with another facility staff stated she was not able to find any type of documentation in Resident #1's chart or anywhere else that the family was notified of this change between 6/11/02 and 6/18/02. Interview with the DON revealed no documentation was found to show the physician was notified of the change in the resident -frorm 6/10 to 6/18 until asking for an order for the psychiatric consult. Family stated they were notified Resident #1 was at the hospital on 6/24/02. 11. The above actions or inactions constitute a violation of Fl. Admin Code R. 59A-4.106(4) (q) which require that 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. 12. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under Sections 400.022 (3), 400.102 (1) (a,d), 400.121(1), and 400.23(8) (b), Florida Statutes. WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of Five Thousand dollars ($5,000) for the violation cited in Count I, against the respondent under Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121 Fl. Stat. (2002) D. All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention cf Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr., St. Petersburg, Florida, 33701. 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, Kernel . Sn AL Eileen O’Hara Gatcda, Esquire AHCA - Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) «- (727) 552-1440 It HEREBY CERTIFY that a copy hereof has been furnished to cT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 Return Receipt No. 7002 0510 0005 5504 4871 and to Administrator, Cypress Community Care Center, 7173 Cypress Drive S.W., Fort Myers, FL 33907, U.S. Mail, on December / , 2002. Copies furnished to: C T Corporation System Registered Agent for Cypress Community Care Center 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Administrator Cypress Community Care Center 7173 Cypress Drive S.W. Fort Myers, FL 33907-2994 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330D a St. Petersburg, Florida 33701 EXHIBIT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 6 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. Case No. 02-4277 CYPRESS MANOR HEALTH CARE ASSOCIATES, 02-4278 LLC, d/b/a CYPRESS COMMUNITY CARE CENTER, 02-4749 03-0358 Respondent. 03-0160 / STIPULATION AND SETTLEMENT AGREEMENT Petitioner, Agency for Health Care Administration (hereinafter the "Agency”) through its undersigned representatives, and Cypress Manor Health Care Associates, LLC, d/b/a Cypress Community Care Center, (hereinafter referred to as "Respondent") pursuant to Sec. 120.57(4), Florida Statutes each individually, a "party", collectively as "parties," hereby enter into this Stipulation and Settlement Agreement ("Agreement"), and agree as follows: WHEREAS, Respondent , is a nursing home licensed pursuant to Chapter 400 Part IT, Florida Statutes (2001), and Rule 59A-4, Florida Administrative Code, (2001); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Respondent pursuant to Chapter 400, Part II, Florida Statutes, and WHEREAS, the Agency served Respondent with two Administrative Complaints notifying Respondent of its intent to impose a conditional license and a fine of $5,000 based upon a class II deficiency identified during a survey conducted on April 25, 2002; and WHEREAS, the Agency served Respondent with an Administrative Complaint notifying Respondent of its intent to impose a $5,000 fine based upon a class II deficiency identified in a survey conducted on May 30, 2002; and, TLH1\HEALTHY62897.1 31187/G001 DMA dma 4/14/03 WHEREAS, the Agency served Respondent with an Administrative Complaint notifying Respondent of its intent to impose a $2,000 fine based upon an uncorrected class II! deficiency identified in a survey conducted on June 4, 2002; and, WHEREAS, the Agency served Respondent with an Administrative Complaint notifying Respondent of its intent to impose a $5,000 fine based upon a class II deficiency identified in a survey conducted on June 28, 2002; and, WHEREAS, Respondent requested a formal administrative hearing in Petitions for Formal Administrative Hearing for each of the Administrative Complaints filed by AHCA; and, WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of these disputes would avoid the expenditure of substantial sums to litigate the dispute; and; WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding. NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties. 3. The Agency agrees that the deficiency described under Tag F324 from the April 25, 2002 survey report (described in Count I of both of Petitioner’s Administrative Complaints, DOAH case Nos. 02-4277 and 02-4288) is not a situation in which Respondent compromised a resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being. Instead, the Agency agrees that the deficiency presents a situation that will result in no more than minimal physical, mental, or psychosocial discomfort to a resident or . TLHI\HEALTH\62897.1 31157/0001 OMA dma 4/14/03 only has the potential to compromise a resident’s ability to maintain or reach his or her highest practical mental or psychosocial well-being. Accordingly, the Agency agrees that the state class rating for the deficiency should be and is hereby changed from a class II to a class III deficiency. Because of these changes, the Agency hereby rescinds the Conditional rating it imposed against Respondent, replaces it with a Standard rating beginning April 25, 2002 and continuing until June 15, 2002, rescinds the $5000 fine and withdraws both of its Administrative Complaints. 4. The Agency agrees that the deficiency described under Tag F204 from the May 30, 2002 survey report (described in Count I of Petitioner’s Administrative Complaint, DOAH case No. 03-0358) is not a situation in which Respondent compromised a resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, Instead, the Agency agrees that the deficiency presents a situation that will result in no more than minimal physical, mental, or psychosocial discomfort to a resident or only has the potential to compromise a resident’s ability to maintain or reach his or her highest practical mental or psychosocial well-being. Accordingly, the Agency agrees that the state class rating for the deficiency should be and is hereby changed from a class II to a class III deficiency. Because of these changes, the Agency hereby rescinds the $5000 fine and withdraws its Administrative Complaints, 5. The Agency agrees that, because of its agreements in Paragraphs 3 and 4 above to reduce the cited deficiencies from class II to class III deficiencies, there is no longer any basis to “double” any fine cited in the June 28, 2002 survey. Accordingly, the Agency agrees that the fine for the class II deficiency from the June 28, 2002 survey is $2,500, not $5,000 as asserted in its Administrative Complaint. (DOAH Case No. 03-0160) TLHI\HEALTH\62897.1 31157/0001 DMA dma 4/14/03 6. Respondent hereby agrees to pay the Agency an administrative assessment of $3375 dollars in settlement of the issues in these cases, which shall be due and payable within thirty days after the complete execution of this Agreement by the parties. The parties also agree that Respondent’s licensure rating for the time period of June 15, 2002 until July 12, 2002 is Conditional, and that, beginning July 13, 2002, its licensure rating is Standard. 7. Upon full execution of this Agreement, Respondent agrees to a withdrawal of its Petitions for Formal Administrative Hearing; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. Provided, however, that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Stipulation. 8. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 9. By executing this stipulation, Respondent does not admit the validity of the allegations raised in the Administrative Complaints referenced herein. By executing this Stipulation, the Agency asserts the validity of the allegations raised in the Administrative Complaints referenced herein except to the extent that they have been modified by this Stipulation, including, without limitation, those modifications set forth in Paragraphs 3 and 4 above. The Agency agrees that it will not impose any other penalty against Respondent as a result of the surveys completed April 24, 2002, May 30, 2002, June 4, 2002 and June 28, 2002, however, no agreement made herein shall preclude the Agency from “doubling” a future fine rg TLH1\HEALTH\62897.14 31157/0001 DMA dma 4/14/03 pursuant to Chapter 400.23(8), Florida Statutes based upon the class II deficiency from the June 28, 2002 survey. Provided, however, that if the Agency hereafter doubles a future fine based upon the class I deficiency from the June 28, 2002 survey, the facility reserves the right to challenge that penalty and the class II deficiency from the June 28, 2002 survey supporting it in an administrative appeal. 10. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 11. Each party shall bear its own costs and attorney fees in the above- numbered cases. 12. This Agreement shall become effective on the date upon which it is fully executed by all the parties, 13. Cypress Manor Health Care Associates, LLC, d/b/a Cypress Community Care Center for itself and for its related or resulting organizations, its successors or transferees, attomeys, heirs, and executors or administrators, does hereby discharge the Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Cypress Manor Health Care Associates, LLC, d/b/a Cypress Community Care Center or related facilities. 14. The Agency for Health Care Administration, does hereby discharge Cypress Manor Health Care Associates, LLC, d/b/a Cypress Community Care Center and its agents, ‘ TLH1\HEALTH\62897.1 31157/0001 DMA dma 4/14/03 representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Cypress Manor Health Care Associates, LLC, d/b/a Cypress Community Care Center, or related facilities, excepting actions based on “repeat”, “uncorrected,” or cumulative fines, as referenced in paragraph six (6). 15. | This Agreement is binding upon all party's herein and those identified in the aforementioned paragraphs nine and ten of this Agreement. 16. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 17. This Agreement contains the entire understandings and agreements of the parties. 18. This Agreement supercedes any prior oral or written agreements between the parties. 19. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. The parties agree that a facsimile signature suffices for an original signature. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. TLHIHEALTH\62897.1 31157/0001 DMA dma 4/14/03 EAL YUAEM arcsce Hebel neger Fire om Elizabeth Dudek Donna Holshouser Stinson Deputy Secrétary, Broad and Cassel Managed Care and 215 S. Monroe Street, Ste. 460 Health Quality Assurance Tallahassee, FL 32301 Agency for Health Care Administration DATED: i / DATED: Wau 23, 2003 fislla. tek ff Valda Clark Christian General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee FL 32308 DATED: Loz loz TLHISHEALTH\62897.1 31157/0001 DMA dma 4/14/03

Docket for Case No: 03-000358