O4Ubdy “HE ED.. STATE OF FLORIDA een . AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003007386 AHCA No.: 2003003531 Vv. Return Receipt Requested: 7000 2410 0001 4237 3400 RENOP, LLC d/b/a RENOVA 7000 2410 0001 4237 3417 HEALTH CENTER, 7000 2410 0001 4237 3424 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 Renop, LLC d/b/a Renova Health Center (hereinafter “Renova Health Center”) pursuant to 28-106.111, Florida Administrative Code and Chapter 120, Florida Statutes hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $5,000.00 pursuant to Section 400.23(8) (b), Florida Statutes [AHCA No.: 2003003531]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23({7) (b), Florida Statutes [AHCA No. 203007386]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4, Venue lies in Palm Beach County, pursuant to Section 120.57 and Section 400.121, Florida Statutes and Chapter 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Renova Health Center is a nursing home located at 750 Bayberry Drive, Lake Park, Florida 33403 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RENOVA HEALTH CENTER FAILED TO PROVIDE SERVICES TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER AND/OR TO PROMOTE HEALING OF PRESSURE ULCERS SECTION 400.022(1),(L), FLORIDA STATUTES RULE 59A-4.106(2) (4)r, FLORIDA ADMINISTRATIVE CODE TITLE 42 SECTION 483.25(c), CODE OF FEDERAL REGULATIONS AS INCORPORATED BY RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Renova Health Center participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. a. Section 483.25(c) provides that: (c) Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that — (1)) A vresident who enters the facility without pressure sores does not develop pressure sores _ unless the individuals’ clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. b. Because Renova Health Center is licensed by the State of Florida it must also comply with Chapter 400, Florida Statutes and Rule 59A-4.106, Florida Administrative Code. Section 400.022(1) (1), Florida Statutes provides: (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provision of that statement. The statement shall assure each resident the following: (1) The right to receive adequate and appropriate health care and protective ad 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. Cc. Rule 59A-4.106(2), (4) (r, Florida Administrative Code provides: (2) Each nursing home facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility. (4) Each facility shall maintain policies and procedures in the following areas: (r) Nursing; 9. During a standard survey conducted on August 19, 2003 through August 22, 2003, Agency surveyors determined that the facility failed to provide adequate care and services, to prevent the development of a pressure ulcers, and to promote healing of pressure ulcers, for 3 of 19 residents sampled (residents #10, #12 #13). The findings include the following. RESIDENT #10 a) Resident #10 had a diagnosis of: Congestive heart failure, Peripheral vascular disease, Cerebrovascular accident, Hemiplegia, Dementia, Cataracts, Anemia, Conjunctivitis (MRSA), Aphasia, Aneurysm, and Failure to Thrive and was on Hospice care. b. During the initial tour on 8/19/03 at 9:18 a.m. resident #10 was observed sitting up in a hi-back wheelchair, beside the bed in his/her room (#27) with bilateral soft heel protectors on. The resident was observed at, 9:00 a.m., 9:30 a.m., 10:00 a.m., 10:20 a.m., 10:45 a.m., 11:30 a.m., 1:30 p.m., 2:00 p.m. and 2:30 p.m., to be sitting up in the hi-back wheelchair, in the same position (on his/her buttocks), beside the bed. The resident's position did not change, nor had the wheelchair been moved during observation. c. On 8/20/03 at 8:10 a.m., an Agency surveyor observed the resident sitting up in the hi-back wheelchair, again beside the bed, with bilateral soft heel protectors on (physician had a ordered multipodus for right foot). The resident was also observed at 9:00 a.m., 9:20 a.m., 9:40 a.m., 10:15 a.m., 11:10 a.m., 11:50 a.m., 1:00 p.m., 1:30 p.m., and 2:35 p.m. The resident’s position did not change while in the wheelchair, and he/she had continued to sit on his/her buttocks the entire time. d. On 8/21/03 at 9:30 a.m., the resident was again sitting up in the hi-back wheelchair, in his/her room by the bed. The surveyor approached the nurse, and requested to do a skin observation on resident #10. The resident was placed on the bed by a CNA and a nurse, and the surveyor conducted a skin an observation at 10:04 am. The surveyor requested the soft heel protector to be removed off the right foot, and the heel was examined, and was found to be free from pressure. The outer- lateral aspect of the right foot, near the small toe, however, was observed to have an area of black eschar approximately the size of a dime. The right foot was swollen, with 3+ pitted edema. The surveyor showed this area to the nurse, and asked if he/she was aware of this pressure area, and the nurse stated, "NO". The left foot was observed and was found to be without pressure. The resident’s buttocks were observed, and a covering of Exuderm had partially rolled up, and had to be removed by the nurse. The skin under the Exuderm was observed, to be opened, had red edges, with a white center. It was approximately the size of a quarter, stage III. On 8/22/03 at 9:18 a.m., the surveyor observed resident #10 in the dinning room during activities, with a multipodus boot on the right foot, and a heel protector on the left foot. e. Review of resident #10 clinical record revealed nurses documentation on 3/26/03 at 0130 as follow, "Dressing on right hip saturated with urine". The next nurses documentation was on 5/26/03 at 10:30 p.m., “Resident has a open area to right buttock stage IT, 3X2 cm., treatment orders obtained and treated.” f. on the Wound Evaluation Flow Sheet, recording of a pressure ulcer was documented on 5/26/03, right buttock. The measurements for the pressure ulcer, right buttock (documentation from Wound Evaluation Flow Sheet is as follows: 5/26/03 3.0 X 2.0 cm 5/31/03 2.5 X 2.0 cm 6/07/03 2.0 X 1.5 cm 6/13/03 2.0 X 1.0 cm 6/20/03 2.5 X 1.0 cm 6/27/03 3.0 X 1.0 cm 7/03/03 3.0 X 1.0 cm 7/12/03 3.0 X 1.0 cm 7/19/03 2.5 X 1.0 cm 71/26/03 2.5 X¥ 1.0 cm 8/07/03 3.0 X 2.0 cm 8/18/03 2.0 X¥ 1.5 cm g. Physicians orders dated 6/6/03 were noted as "D/C(discontinue) hydrogel to right cleanser and apply exuderm dressing needed to right buttock. NO AGGRESSIVE TREATMENT". h. Lab Values were as follows 5/05/03 HEMATOLOGY WBC (white blood count) 20.3 HIGH Reference Range 4.0-10.8 RBC (red blood count) 3.63 LOW Reference Range 4.00-7.00 Hemoglobin 12.5 LOW Reference Range 13.0-18.0 Hematocrit 37.3 LOW Reference Range 40.0-54.0 MCV 103 HIGH Reference Range 80-95 MCH 34.4 HIGH Reference Range 27.0-33.0 Bloody Exudate Bloody Exudate Bloody Exudate Bloody Exudate Red Exudate Red Exudate Beige Exudate Red Exudate Red Exudate Red Exudate Beige Exudate Beige Exudate the first Stage Stage Stage Stage Stage Stage Stage II Stage Stage Stage Stage Stage I Il Il II It for the on the follow: buttock, cleanse with wound , change every 3 days and as RDW 20.0 HIGH Reference Range 11.0-18.0 Lymphocytes 5.1 LOW Reference Range 25.0-33.0 6/24/03 HEMATOLOGY WBC (white blood count) 6.3 NORMAL RBC (red blood count) 3.56 LOW Reference Range 4.00-7.00 Hemoglobin 11.8 LOW Reference Range 13.0-18.0 Hematocrit 34.5 LOW Reference Range 40.0-54.0 MCV 97 HIGH Reference Range 80-95 MCH 33.2 HIGH Reference Range 27.0-33.0 CHEMISTRY: Pre-albumin 11.0 LOW Reference Range 17.0-42.0 Glucose 58 LOW Reference Range 70.0-120 BUN 24 HIGH Reference Range 6.0-22.0 i. The surveyor reviewed the resident’s clinical record, for turning and repositioning of resident #10. The nurses’ notes documented the following dates for turning/positioning: From 12/3/02 (Skin break down). There was no documentation for turning/repositioning in the clinical record except on the following dates: 2/13/03 Turn and position every 2 hours. 5/3/03 Turn and position every 2 hours 7/29/03 Turn and position every 2 hours 8/11/03 Turn and position every 2 hours The "Turning Schedule" was reviewed for 8/2, 8/3, 8/4, 8/5, 8/8, 8/9,8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, and 8/17. The schedule was set-up to turn and position the resident every two hours, and to be signed off by the person, who had positioned the resident. Based on turning and position record review for a total of 14 days, the resident had to be turned a total of 336 times, the facility staff turned and repositioned the resident, "78" times, this left 258 times that resident #10 was not turned and repositioned off of his/her buttocks. j. The facilities own care plan dated, 5/26/03 noted, "Staffing to reposition patient every 2 hours". Observation during the survey revealed there was no wheelchair cushion, (Gel and or air cushion) to help relieve pressure on the buttocks. The care plan called for the resident, to have a hand roll, but there was no hand roll in the residents' hand (right hand is contracture). k. The Minimum Data Set (MDS) for 5/28/03 for resident #10 revealed: short/long term memory problem, severely impaired for decisions of daily living, Total care for all activities of daily living-with one assist, unable to walk, unable to set or stand with physical assistance, unable to fed self, requires assistance of one for bed mobility, does not understand, nor is understood; Partial loss of voluntary movement, with limitation to arm and hand and limitation on both sides to legs and feet. Full loss of voluntary movement to one arm and hand. 1. The MDS for 9/9/02 revealed resident #10 weighed, "118 pounds, 69" in height"; 3/10/03 MDS revealed residents weight as, "104 pounds, 69" in height"; 5/29/03 MDS resident #10 weighed, "111 pounds, 69" in height". The resident had gained 7 pounds, between March and May 2003. (There were no other weights, for this resident in the clinical record.) RESIDENT #13 10. The Admission Assessment and Interim Care Plan dated 08/03/03 documented that the resident was admitted with a callous to the right heel. Routine skin observation of resident #13 during survey on 08/20/03 revealed the resident had developed pressure sores (black eschar) to both heels. a. On 8/20/03 nursing administration revealed that they were unaware the pressure sores had developed and had not obtained orders to aggressively treat the pressure sores. Subsequent to the interview, AHCA surveyors noted that the Wound Evaluation Assessment and Flow Sheet dated 08/20/03 documented the pressure sores and new orders for wound treatment. The surveyor did not observe heel protector on the resident on 8/19/03. 10 RESIDENT #12 11. with diagnoses that included Status Post Cerebral Vascular Accident, Right Hemiplegia, Urinary Retention and Diabetes Mellitus, Type II and Dysphagia. The resident was observed during his/her back in a semi-fowler's position in bed and facing the door. a. medication pass on 8/20/03 at 9:40 am in room 32 to be on Observation of the resident revealed the following: 1. On 8/20/03 at 9:40 am, the resident was in bed on his/her back in a semi fowler's position. The resident was placed on a = non- pressure relieving mattress (a regular bed mattress) with a sheet and bed pad covering the mattress. The resident did not have heel protectors on either heel. The resident's wheel chair was next to the TV without a pressure- relieving cushion noted on the chair. The CNA reported it was the resident's wheelchair. This observation was done with a Staff Nurse present. 2. 8/20/03 at 10:40 am the resident was noted to be in the same place and position as noted at 9:40 AM. This observation was done with a CNA present while she was passing ice water. 3. 8/20/03 at 1:20 pm, the resident was in the same position and place, as noted at 10:40 and 9:40 am. The resident was found to be feeding self with left hand with a CNA present assisting with the lunch meal. 4, 8/20/03 at 2:05 pm the resident was positioned on his/her back in a semi fowler's position in bed with the TV on and volume high. This observation was done with the Speech Therapist present. Resident # 12 was admitted to the facility on 11/11/02 5. 8/20/03 at 2:15 pm the resident was on his/her back in semi-fowler's position. This observation was done in the presence of another surveyor, a staff nurse and a certified nurse aide. The surveyor requested the resident be turned from his/her back for a skin assessment. 6. A skin assessment was conducted at 2:15 pm, in the presence of another surveyor. A staff nurse and a CNA who assisted with turning the resident. The resident's brief was removed and the resident was found incontinent of stool and to have a Foley catheter in place. The coccyx was observed to be red approximately 1-% inches in diameter with skin intact. The Staff nurse present stated she would identify the coccyx area, as a Stage I and treatment would be to apply a barrier cream to the area after cleaning the skin with normal saline. 7. 8/21/03 at 8:50 am revealed the resident was on his/her back in a semi-fowler's position in bed and facing the door. A CNA was feeding the resident breakfast. 8. 8/21/03 at 9:30 am the resident was in the same position and same place with his/her spouse visiting at the bedside. The surveyor conducted a family interview at that time. 9. 8/21/03 at 11:40 am the resident was in the same position and place with the TV turned on. The surveyor requested a skin check on this resident at this time. The staff nurse and a CNA attended to the resident and turned the resident to the right side and to then to the left side. The resident was cleaned and repositioned to his/her right side facing the wall. 10. On 8/21/03 a second skin assessment of the resident was conducted. The coccyx was found to have an approximate 4 -inch area of redness surrounding an open area. The surveyor requested the open area measured and the staff nurse did finding it to be 2 cm X 1 cm with depth minimal, noted as an abrasion. The skin was cleaned with normal saline, a brief was applied 12 and the resident was turned to the right side. Based on record review the nurse then notified the physician for further orders. 11. 8/22/03 at 8:35 am, AHCA attempted to see the resident but the resident was not in the room. It was later discovered he had been admitted to the hospital on the evening of 8/21/03. 12, On 8/22/03 at 8:45 AM, the director of nursing reported to AHCA surveyors that the facility did not have written policy or procedures for pressure ulcers but were to notify the physician of any skin changes. 13, Record review, done on 8/21/03 at 10:45 am, documented the last nursing entry of 8/18/03 of the medical record. The observation of a Stage I pressure ulcer was not documented on the current medical record, nor was there any notification in the medical record to the physician of the resident's acquiring a Stage I pressure ulcer prior to it becoming a Stage II. on 8/22/03 an entry was noted as a "late entry for 8/20/03." It documented the resident had abdominal pain and the skin was noted as Stage I pressure sore on coccyx, but there is no documentation that the physician was notified until the resident was noted with a Stage II to the coccyx. 14, Further record review documents the resident was admitted on 11/11/02. The initial Admission Assessment and Interim Care Plan, dated 11/11/02, notes the resident was admitted with ecchymotic area on the left arm and slight redness 13 at the coccyx area. A Pressure Ulcer Risk Assessment was done on 11/11/02 with the resident obtaining a score of 11. The Risk Assessment form states, "Total score of 8 or above represents HIGH RISK." The staff continued reassessments on 2/8/03, with the resident scoring 12, and on 5/8/03 with the resident scoring 12. There was no further reassessment documented for the next quarterly review, which should have been documented as 8/8/03. 15. The initial Minimum Data Set (MDS), with an assessment date of 11/17/02, documents no ulcers and no abrasions or bruises. It also documents for the use of pressure relieving device for bed and chair, turning /repositioning program and other preventative or protective skin care. An MDS for significant change was done on 2/11/03. The coding documented that no ulcers were present. The RAP Summary (resident assessment protocol), dated 2/11/03 was triggered for pressure ulcers. The RAP summary states, "Pressure ulcers is triggered and will proceed with current care plan. Resident is high risk for skin breakdown due to limited mobility, incontinence and diabetes mellitus." The most recent MDS, done on 8/11/03 as a quarterly, documents no ulcers and the same with preventative care, as noted initially. 16. The care plan, with a review date of 8/1/03 and target date of 10/30/03, listed appropriate care issues and approaches as: 14 a. Provide skin care and perineal care after every incontinent episode. b. Provide proper hydration and nutrition. Cc. Keep resident clean and dry every shift. d. Pressure relieving device on bed and wheelchair. e. Apply protective - preventive skin ointment after every incontinent episode. f. Weekly skin audits. g. Observe and document any skin problems noted, i.e. skin redness, skin breaks, tears, bruises, abrasions, erythema, etc. he Notify MD for any skin problem to ensure proper treatment. i. Monitor pertinent lab and notify MD of any abnormalities. 3. Dietary consult, as needed. k. Assist in turning and repositioning with one person. Ll. Check resident feet daily for changes in color, signs of breakdown, presence of edema. m. Podiatry consult, as needed. n. Check feet when rendering care, and report any changes or discoloration. Oo. Heel protectors on in bed to prevent’ skin breakdown. 17. Review of the lab results include: a. Albumin = 3.3 g/dl done on 6-10-03. b. BUN = 31 on 6/10/03. c. Hemoglobin/Hematocrit = 10.6/30.3 mg/dl done on 7/23/03. d. White Blood Count = 14.4 on 7/29/03. e. Complete blood count = within normal range done on 8/6/03. 18. The last weekly skin check was done with the last documentation noted 8/19/03 with skin intact and no~- skin impairments noted. 19. Review of the nutrition quarterly assessment record documents the following recorded weights: a. Weight on 11/11/02 = 106 lbs and height of 62 inches. b. Weight on 2/7/03 = 101.6 lbs. c. Weight on 5/5/03 = 99.8 libs. d. Weight on 8/4/03 = 101.4 lbs. e. Nutritional Progress Notes document on 8/4/03, "Weight is stable, no signs or symptoms of dehydration, skin breakdown, or constipation noted. Blood sugar within normal level, hemoglobin/hematocrit improved..will follow, as needed." 20. Further record review documents the resident was placed on Vitamin C 500 mg twice a day, Megace 400 mg twice a day, Feosol Sulfate 325 mg three times a day, Folic Acid 1 mg daily and was given an additional 200 cc's of water with each medication pass. 21. During the observation period, 8/20/03 from 9:40 am through 2:15 pm, (see above) the resident was not repositioned off his/her back, a pressure-relieving device for bed or wheelchair was not utilized for the resident, heel protectors were not applied to the resident's heels when observed in bed, and the physician was not notified of the Stage I on 8/20/03 for treatment orders for the resident, as documented on the care plan. This resulted in an avoidable Stage I pressure ulcer, noted son the coccyx on 8/20/03, to advance to a Stage II pressure ulcer on the coccyx, observed on 8/21/03. 22. Additionally, based on observation, record review and interview it was determined that resident #12 did not receive the required consistency of thickened liquids as ordered. 16 23. Resident # 12's diagnosis when admitted included Dysphagia. The resident was observed during medication pass on 8/20/03 at 9:40 AM in room 32. 24, During the observation period the nurse was observed to measure and pour 200 cc of water into a plastic cup, carry it into the resident's room along with all the resident's other morning medications. She did not add or mix thickener to the water while she was at the medication cart, nor was thickener noted in the resident's room. 25. Record review, done on 8/20/03, documented a physician's order, dated 8/4/03, to change diet to no concentrated sweets (NCS), puree with honey-thickened liquids. The Medication Administration Record, dated for the month of August 2003, documented, "Thickened liquids to honey consistency." The current care plan documented the diet of NCS, pureed with honey-thickened liquids. Record review documented a video swallow was done on 8/21/02 with recommendations for honey consistency liquids. 26. The nurse was interviewed on 8/20/03 at 10:15 am reported she overlooked the order to thicken the liquids. 27. Resident # 12 was observed on 8/20/03 at 10:40 an, while a certified nurse aide (CNA) was passing fresh ice water on the unit. On the left side of the resident a large pink cup, with a straw placed into the opening through the cup lid, was placed on the bedside. 28. The CNA was interviewed on 8/20/03 at 10:40 am and reported she had just placed fresh ice and water at the resident's bedside and within reach of the resident's left hand. She stated the resident was able to give him/herself water with the left hand. 29, The speech therapist was interviewed on 8/20/03 at 2:05 PM. She stated, "Un-thickened water should be away from the resident. "She went into the room and removed the pink cup of un-thickened water from the bedside table". "Anyone NPO or with aspiration precautions is not to have a pitcher of un- thickened water at the bedside." 30. Review of the facility's policies document, "Each resident will be provided with a pitcher of water, which is filled with fresh water at the beginning of each shift and as needed, except for those with restrictions e.g....aspiration precautions." 31. Resident # 12 was observed on 8/21/03 at 8:20 am, while a certified nurse aide (CNA) was feeding breakfast to the resident. A cup of thin water with ice cubes was observed on the resident's tray, along with thin prune juice and thickened whole milk. 32. The surveyor interviewed the CNA at 8:25 am on 8/21/03. She stated, "I tried one teaspoon of the ice water, but the resident didn't do well with it, so I didn't give anymore." 33. Resident # 12 was admitted to the facility on 11/11/02 with diagnoses that included Status Post Cerebral Vascular Accident, Right Hemiplegia, Diabetes, Hypertension, and Urinary Retention. 34. Based on the foregoing, Renova Health Center violated Section 400.022(1) (1), Florida Statutes, Rule 59A-4.106(2) (4)r, Florida Administrative Code and Section 483.25(c), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8)(b), Florida Statutes, which carries, in this case, an assessed fine of $5,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. The fine in this case has been doubled because the facility was previously cited for a Class II on September 19, 2002, which was upheld by AHCA Final Order No. 2002048119/2002048109 entered on February 11, 2003. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Renova Health Center shall post the license in a prominent place that 19 is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” 20 EXHIBIT “A” Conditional License License #4720952; Certificate No.: Effective date: 08/22/2003 Expiration date: 08/19/2004 21 10577 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. 2. Assess against Renova Health Center an administrative fine of $5,000.00 for the one (1) Class II violation on Count I as cited above. 3. Assess against Renova Health Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. 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 Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. 22 RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. OLba) . Bodiwayc, L Alba M. Rodriguez, Esq. Assistant General Counsel Agency for Health Care Administration 8355 NW 537% Street Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration Manchester Building 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 23 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Romeo D. Montese, Administrator, Renova Health Center, 750 Bayberry Drive, Lake Park, Florida 33403; Renop, LLC, 750 Bayberry Drive, West Palm Beach, Florida 33403; Ron Ostroff, 7491 W. Oakland Park Blvd., Ft. Lauderdale, Florida 33319 on this 13°" day of November, 2003. Alba M. Rodriguez, read 0s 24

Docket for Case No: 04-000024