STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2004011396 (Fine) Case No. 2004011600 (Cond. Lic.) OCEAN VIEW NURSING & REHABILATION CENTER, LLC, d/b/a OCEAN VIEW NURSING & Veo TX Tb REHABILATION CENTER, 0 yo Te Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against OCEAN VIEW NURSING & REHABILATION CENTER, LLC, d/bla OCEAN VIEW NURSING & REHABILITATION CENTER (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and alleges: NATURE OF THE ACTION 1. This is an action against Respondent nursing home to (1) impose an administrative fine in the amount of $3,000 (Case No. 2004011396); and (2) assign a conditional licensure status commencing November 23, 2004 (Case No. 2004011600), pursuant to the various citations, statutes, and rules cited in each of the three counts below. 2. In summary, Respondent was cited as follows: Page 1 of 16 October 15, 2004 recertification survey. Respondent was cited for three Class III violations. November 23, 2004 revisit survey. Respondent was cited for three uncorrected Class III violations. JURISDICTION AND VENUE L220 3. This tribunal has jurisdiction over Respondent, pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 4, Venue shall be determined, pursuant to Chapter 28-106.207, Florida Administrative Code (2004). PARTIES 5. Pursuant to Chapter 400, Part II, Florida Statutes (2004), and Chapter 59A-4, Florida Administrative Code (2004), AHCA is the licensing and enforcing authority with regard to nursing facility laws and rules. 6. The Respondent is a nursing facility located at 2810 S Atlantic Ave, New Smyrna Beach, Florida 32169. The Respondent is and was at all times material hereto a licensed nursing facility under Chapter 400, Part II, Florida Statutes (2004), and Chapter 59A-4, Florida Administrative Code (2004), having been issued license number 13860961. COUNTI Respondent failed to follow signed October 2004 Physician Orders for thirteen residents (Resident’s #’s 9, 16, 20 and 23 and residents #’s 2, 6, 17, 23, 28, 29, 30, 21, and 33 later). Additionally, November 2004 physician orders were not updated to reflect current and accurate treatments and services. § 400.022(1)(), Fla. Stat. § 400.23(7)(b), Fla. Stat. § 400.419(2)(c), Fla. Stat. 42 C.E.R. 483.20(kK)(3)( 7. AHCA re-alleges paragraphs 1-6 above. Page 2 of 16 8. On or about October 15, 2004, AHCA conducted a recertification survey at Respondent’s facility. AHCA cited Respondent for a violation, based on the following findings below: a) b) ¢) qd) e) 9. Resident #23 had signed October 2004 physician orders for a criss cross belt when in wheel chair for safety. Observation of this resident during two of the five days of the survey revealed this resident had a shoulder/torso restraint. During interview with the Restorative Nurse on 10/14/2004 at 11:09 a.m., they stated they were following a physician order dated 1/28/2004. Resident #23 had a non-specific and incomplete physician order on their signed October 2004 Physician Orders that stated "may participate in restorative nursing program as indicated". Record review and interview with the restorative certified nursing assistant on 10/14/2004 at 11:30 a.m. revealed this resident was receiving "sit/stand drills 10 reps each holding on to hand rails with assistance" and "range of motion to bilateral lower extremities 5 reps each"; this was part of the restorative nursing program. There was no physician order for this finding. There was no care plan to address these findings. Resident #16 had signed October 2004 Physician Orders for "restorative nursing for ADL (activities of daily living) retraining, transfer, gait training". Observation during four days of survey and medical record review revealed this resident was independent in their ADL's, transfers and ambulation. Investigation revealed this order had originated at the time of this resident's admission on 8/18/2000 and that the resident was not receiving these services as ordered per current signed physician orders. Resident #20 had a Restorative physician order to ambulate independently with a walker 200 feet every day. Review of the activity of daily living care plan, the restorative instructions and the documentation on the ADL sheets revealed that the resident was being assisted to walk 100 feet 3-5 times a week only. Interview with the MDS coordinator and the Restorative CNA on 10/14/04 at 9:55 am stated that they were sure that the physician order was changed but they could not produce the evidence to support their claim up until 3 PM 10/14/04 . The order was on the current physician orders. A record review of Resident #9 on 10/12/04 revealed a physician's order dated 9/30/04 ordering the discontinuation of peanut butter with crackers as the resident's evening snack. Further record review of the resident's Medication Administration Record (MAR) revealed the resident continued to receive peanut butter with crackers as of 10/11/04. Respondent failed to follow physician orders for the above residents. Additionally, November 2004 physician orders were not updated to reflect current and accurate treatments and services, as required by Section 400.022(1){1), F Page 3 of 16 lorida Statutes, and Rule 42 C.F.R. 483.20(k)(3)(i), Code of Federal Regulations, which provide, in pertinent part, as follows: “400.022 Residents’ rights.— (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 provisions of that statement. The statement shall assure each resident the following...(I) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.” § 400.022(1)(1), Fla. Stat. “TITLE 42 -- PUBLIC HEALTH...Part 483 -- REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES--...Sec 483.20 Resident assessment...(k) Comprehensive care plans....(3) The services provided or arranged by the facility must — (i) Meet professional standards of quality; and” 42 C.F.R. 483.20(k)(3)(i) 10, The foregoing violation constitutes a Class III violation due to the nature of the violation and the gravity of its effect on the residents of the facility and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, to wit: s are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines indirectly or potentially threaten the physical or emotional health, safety, or security of facility residents, other than class I or class II violations. A class I violation is subject to an administrative fine of not less than $500 and not exceeding $1,000 for each violation...” § 400.419(2)(c), Fla. Stat. *(c) Class III violation “400.23 Rules; evaluation and deficiencies; licensure status.—...(7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into sideration findings from other official reports, surveys, interviews, investigations, 1 assign a licensure status of standard or conditional ditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial he time of the survey with criteria established under this part or with yy the agency. If the facility has no class I, class Il, or class Ill tandard licensure status may be con and inspections. The agency shal to each nursing home...(b) A con compliance at t rules adopted b deficiencies at the time of the follow-up survey, a S' assigned.” § 400.23(7)(b), Fla. Stat. Page 4 of 16 11. On November 23, 2004, AHCA completed a revisit survey at Respondent’s facility. AHCA cited Respondent for an uncorrected deficiency, based on the findings below, to wit: a) b) c) d) €) Resident #17 had a physician order dated 10/13/04 for "2000-2500 cc PO (oral) fluids qd (every day). There was no documentation of the exact amounts of fluid the resident received or when they received it after 10/16/04. The November 2004 physician orders stated Resident #6 was to receive Fortified Cereal (PO) every morning. This order was discontinued on 8/12/04 per record review. On 11/4/04 the physician wrote an order for 1&O (intake and output) for two weeks. There was no evidence of the amounts of intake and output in the resident's medical record. After discussion with the Director of Nursing (DON) on 11/22/04 at 4:20 p.m., the DON located two Daily Intake-Output Worksheets (11/7/04 and 11/8/04) that addressed specific amounts and totals for 24 hours. Resident #33 had a physician order (on the November 2004 Physicians Orders) for increase fluid intake to 2000-5000 cc H2O (water) daily. Record amount consumed. The MAR stated Increase Fluid Intake to 2000-2500 cc daily. The amount of water consumed daily was not documented. Resident #23 had a physician order (on the November 2004 Physician Orders) for "4 02. House Shake Plus (PO) three times daily. Record amount consumed.” There was documentation of the amounts consumed for 17 servings out of the 63 servings documented as served for the month of November 2004 (11/1-2/2004). Resident #23 had a physician order for "Hydrate with 2500 ML fluid daily." There was no documentation of the specific amounts of fluid this resident consumed. Resident #23 had an order for Ensure Pudding (PO) twice daily with lunch and dinner. Record amount consumed. Record review revealed documentation of amount consumed for eight servings out of 42 servings documented as served for the month of November 2004 (11/1-21/04). A record review of the following residents revealed the physician's order to record the amount of prune juice consumed was not followed: #2 for 22 out of 22 days in November 2004. A record review of the following residents revealed the physician's order to record the amount of food supplements consumed was not followed: #28 for 7 out of 22 days in November 2004 #30 for 5 out of 22 days in November 2004 #31 for 22 out of 22 days in November 2004 #29 for 20 out of 22 days in November 2004 Page 5 of 16 12. The foregoing violation constitutes an uncorrected Class III violation pursuant to Section 400.419(2)(c), Florida Statutes (quoted above), due to the nature of the violation and the gravity of its effect on the residents and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes (quoted above). 13. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Uphold the imposition of conditional licensure status commencing November 23, 2004 and expiring May 31, 2005; 3. Impose a fine in the amount of $1,000 for the referenced violation; and 4. Impose such other relief as this tribunal may find appropriate. COUNT IT Respondent failed to provide a complete and accurate care plan to address the needs of two residents (Residents #’s 6 and 17). § 400.022(1)(D), Fla. Stat. § 400.23(7)(b), Fla. Stat. § 400.419(2)(c), Fla. Stat. 42 C.F.R. 483.20(k)(3)(ii) 14. AHCA re-alleges paragraphs 1-6 above. 15. On or about October 15, 2004, AHCA conducted a recertification survey at Respondent’s facility. AHCA cited Respondent for a violation, based on the following findings below: Page 6 of 16 a) Review of the care plans on 10/12/04 and 10/13/04 on Residents #5, 6, 15, and 17, it was noted that each one had a goal of “will be free of constipation and have a bowel movement (BM's) every three days or less through next review". The approach states to keep accurate records of (BM's) to avoid complications, check every shift for daily (BM's) and urination with resident, and report on resident record. Report to nursing if no BM in two days. The following reflects the facility's failure to communicate the problem of constipation and to initiate their approaches to alleviate the problem: Resident #5's record review showed a past medical history of a paralytic ileus and from September 24, 2004 through day shift of September 29, 2004, the resident had no record of having had a BM. The nurse notes do not indicate the nurse was notified of this problem and the resident does not have an order for a laxative nor was the doctor notified to obtain an order. Resident #6 had several periods of more than two days have gone by without a BM. These are from 8/7, 8/8, 8/9, 8/11, 8/12, 8/13 and part of 8/14, 8/25, 8/26, 8/27, 8/30, 8/31, 9/1, on 9/10 through 9/14, 9/22 through 9/23, and Oct 6, 7, and 8. Resident #6 had an order for Dulcolax 5 mg since 5/10/04 in the morning and the evening which is given as ordered according to the Medication Administration Record (MAR). There is also an order for a Fleets Enema when ever necessary and there is no record of it being administered. Resident #15, whose care plan problem states is prone to constipation/ diarrhea, has no record of a BM on 8/3, 8/4, 8/5, 8/26, 8/27, 8/28, 8/30, 8/31, 9/1, 9/2, 9/21, 9/22, 9/23, 9/24, and on 10/7, 10/8, 10/9 and then was given a laxative 10/9. There were only three recorded of the resident having colace on 8/6 and 8/7, no record of colace given in September or for October as of the survey dates. An interview with the resident on 10/13/04 at 2:30 PM revealed that she/he has a problem with their bowels but lately it isn't quite as bad. The record for the past week shows this resident has had bowel movement on a more regular frequency. Resident #17 is a paraplegic and on standing orders for pain medication. In September, the record shows no BM from 9/19 through 9/22, 9/24 through 9/28, and in October from 10/3 through 10/10/04. There are orders for Lactulose with Milk of Magnesia weekly and on 10/12/04, the order was changed to Milk of Magnesia 60 cc every day and Senekot S one every 12 hours and Magnesium Citrate every week for four weeks. On interviewing the resident on 10/14/04 at 8:30 AM, it was learned she/he had problems with blockages in the past and they would just give him/her a lot of strong laxatives to help clean it out. 16. | Respondent failed to provide a complete and accurate care plan to address the needs of two residents (Residents #’s 6 and 17), as required by Section 400.022(1)(1), Florida Statutes, and Rule 42 C.F.R. 483.20(k)(3)(ii), Code of Federal Regulations, which provide, in pertinent part, as follows: “400.022 Residents’ rights.— (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such Page 7 of 16 facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following...(l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.” § 400.022(1)(1), Fla. Stat. “TITLE 42 -- PUBLIC HEALTH...Part 483 -- REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES--...Sec 483.20 Resident assessment...(k) Comprehensive care plans.... (3) The services provided or arranged by the facility must — (ii) Be provided by qualified persons in accordance with each resident’s written plan of care.” 42 C.F.R. 483 .20(k)(3)(ii) 17. The foregoing violation constitutes a Class III violation pursuant to Section 400.419(2)(c), Florida Statutes (quoted above), due to the nature of the violation and the gravity of its effect on the residents and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes (quoted above). 18. On November 23, 2004, AHCA conducted a revisit to survey at Respondent’s facility. AHCA cited Respondent for an uncorrected deficiency, based on the findings below, to wit: a) On 11/22/04 at 12:20 p.m. the spouse of Resident #23 was observed to be feeding lunch to the resident in their room. No facility staff was in the room. Review of this resident's care plan revealed the following approaches (begin 5/7/03) related to aspiration precautions; instruct (resident) to alternate liquids with solids during meals, instruct (resident) to perform throat clear technique (cough) intermittently during meals to clear food particles from mouth and instruct (resident) to "double swallow" after each bite or sip. These approaches were not complete a regular diet with thin liquids since observed. The diet had been advanced to a 5/7/03. b) Resident #17, who had diagnoses that included constipation and paraplegia, had a non-specific care plan. The care plan for prone to constipation had a goal "will be free of constipation AEB (as evidenced by) bowel movement every three days or less." Non-specific goals included: "administer mediations as ordered and monitor for effectiveness", "encourage adequate protein and fluid intake", increase bulk in diet if ordered by physician”, "check for constipation, change in bowel habits every shift and request bowel regime for pattern of constipation or loose stools" and "keep accurate records of BM's to avoid complications, check every shift for daily BM's and urination with resident and report on daily resident record.” The facility was unable to identify their bowel regime for lack of BM's. The Care Plan Coordinator stated on 11/23/04 at 1:30 p.m. that the facility did Page 8 of 16 not have a policy and procedure to address constipation or a bowel regime and the care plan should state "request bowel regime from the physician.” There was no approach to address when the CNA’s, who document BM's, were to notify the nurse of no BM for so many days. Documentation revealed this resident frequently refused medications to promote BM's. There was no care pan to address this finding. Documentation revealed this resident had no BM for three days 11/5-7/04; six days 11/9-14/04; four days 11/17-21/04. 19. The foregoing violation constitutes an uncorrected Class III violation pursuant to Section 400.419(2)(c), Florida Statutes (quoted above), due to the nature of the violation and the gravity of its effect on the residents and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes (quoted above). 20. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. 2. Enter factual and legal findings as set forth in the allegations of this count; Uphold the imposition of conditional licensure status commencing November 23, 2004 and expiring May 31, 2005; Impose a fine in the amount of $1,000 for the referenced violation; and Impose such other relief as this tribunal may find appropriate. COUNT I Respondent failed to consistently document resident activities in accordance with physician orders for nine residents (Residents # 2, 6, 7, 23, 28, 29, 30, 31 and 33). § 400.23(7)(b), Fla. Stat. § 400.419(2)(c), Fla. Stat. Fla. Admin. Code R. 59A-4.106(4)(p) Fla. Admin. Code R. 59A-4.118(2) 42 C.F.R. 483.75()(1) Page 9 of 16 21. AHCA te-alleges paragraphs 1-6 above. 22. On or about October 15, 2004, AHCA conducted a recertification survey at Respondent's facility. AHCA cited Respondent for a violation, based on the findings below, to wit: ician order dated 7/1/2004 to hydrate with 1000 cc 7-3; 1000 cc 3-11; 500 cc 11-7 and intake and output (I&O) for two months. This was not added to the monthly physician orders for August or September. The October Physician Orders had a hand written entry for "Hydrate with 1000 cc 7- 3; 1000 cc 3-11; 500 cc 11-7". There was no physician order for the continuation past the two months which would have ended on September 1, 2004. The need for the hydration and the I&O was not addressed in the care plan. During interview with the MDS (Minimum Data Set) Coordinator on 10/15/2004 at 11:55 a.m., they stated the hydration was for a urinary tract infection. Review of the I&O records revealed no record of intake or output for 7/11, 7/12, 7/13, and 7/16 through 8/31/2004. a) Resident #23 had a phys b) Resident #23 had signed October 2004 physician orders for a criss cross belt when in wheel chair for safety. Observation of this resident during two of the five days of the survey revealed this resident had a shoulder/torso restraint. During interview with the Restorative Nurse on 10/14/2004 at 11:09 a.m., they stated they were following a physician order dated 1/28/2004 c) Resident #16 had signed October 2004 Physician Orders for "restorative nursing for ADL (activities of daily living) retraining, transfer, gait training". Observation during four days of survey and medical record review revealed this resident was independent in their ADL's, transfers and ambulation. Investigation revealed this order had originated at the time of this resident's admission on 8/18/2000 and that the resident was not receiving these services as ordered per current signed physician orders. 0/12-14/04, it was revealed that Residents #5, #6, #15 d) During record review on 1 owel movements for and #17 had opened areas of uncharted documentation of b August, September and October 2004. Resident #5 had eleven opened shifts of undocumented BM's for this time period. Resident #6 had five uncharted shifts of BM's, Resident #15 had eighteen open uncharted shifts for BM's for this time period and Resident #17 had four between September and October. A record review of Resident #9's weekly weight form (as ordered by the physician on 8/24/04), done 10/13/04 at 8:04 a.m. revealed blank spaces for 9/28/04, 10/5/04 and 10/12/04. e) 23. Respondent failed to consistently document resident activities in accordance with physician orders for the above residents, as required by Rules 59A- Page 10 of 16 4.106(4)(p) and 59A-4.118(2) Florida Administrative Code; and Rule 42 CFR. 483.75(1)(1), Code of Federal Regulations, which provide, in pertinent part, as follows: “59A-4,106 Facility Policies....(4) each facility shal] maintain policies and procedures in following areas: (p) medical records;” Fla. Admin. Code R. 59A- 4.106(4)(p) “59A-4.118 Medical Records....(2) Each medical record shall contain sufficient information to clearly identify the resident, his diagnosis and treatment, and results. Medical records shall be complete, accurate, accessible and systematically organized.” Fla. Admin. Code R. 59A-4.118 “TITLE 42 -- PUBLIC HEALTH...Part 483 -- REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES--...Sec 483.75 Administration. ..(I) Clinical records. (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are --” 42 C.F.R. 483.75(I)(1) 24. The foregoing violation constitutes a Class III violation pursuant to Section 400.419(2)(c), Florida Statutes (quoted above), due to the nature of the violation and the gravity of its effect on the residents and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes (quoted above). 25. On November 23, 2004, AHCA conducted a revisit to survey at Respondent’s facility. AHCA cited Respondent for a repeat deficiency, based on the findings below, to wit: a) Resident #17 had a physician order dated 10;/13/04 for "2000-2500 cc PO (oral) fluids qd (every day)." There was no documentation of the exact amounts of fluid the resident received or when they received it after 10/1 6/04. b) The November 2004 physician orders stated Resident #6 was to receive Fortified Cereal (PO) every morning. This order was discontinued on 8/12/04 per record review. On 11/4/04 the physician wrote an order for 1&O (intake and output) for two weeks. There was no evidence of the amounts of intake and output in the resident's medical record. After discussion with the Director of Nursing (DON) on 1/22/04 at 4:20 p.m., the DON located two Daily Intake-Output Worksheets (11/7/04 and 11/8/04) that addressed specific amounts and totals for 24 hours. Resident #33 had a physician order (on the November 2004 Physician Orders) for increase fluid intake to 2000-2500 cc H2O (water) daily. Record amount consumed. The MAR stated Increase Fluid Intake to 2000-2500 cc daily. The amount of water consumed daily was not documented. ¢) Page 11 of 16 d) Resident #23 had a physician order (on the November 2004 Physician Orders) for "A oz. House Shake Plus (PO) three times daily. Record amount consumed." There was documentation of the amounts consumed for 17 servings out of the 63 servings documented as served for the month of November 2004 (1 1/1-12/04). Resident #23 had a physician order for "Hydrate with 2500 ML fluid daily.” There was no documentation of the specific amounts of fluid this resident consumed. Resident #23 had an order for Ensure Pudding (PO) twice daily with lunch and dinner. Record amount consumed. Record review revealed documentation of amount consumed for eight servings out of 42 servings documented as served for the month of November 2004. (11/1-21/04). e) During a record review of Residents # 2, 28, 29, 30 and 31 on 11/22/04 and 11/23/04, the facility failed to accurately and completely document amounts of food supplements consumed or prune juice consumed as ordered by the physician. Refer to tag 281. 26. The foregoing violation constitutes an uncorrected Class TI violation pursuant to Section 400.419(2)(c), Florida Statutes (quoted above), due to the nature of the violation and the gravity of its effect on the residents and warrants (1) a fine of $1,000; and (2) the assignment of a conditional licensure status, pursuant to Section 400.23(7)(b), Florida Statutes (quoted above). 27. AHCA, in determining the penalty imposed, considered the gravity of the violation, the probability that death or serious harm will result, the uncorrected actions of Respondent and its staff, the financial benefit to the facility of committing or continuing the violation, and the licensed capacity of the facility. WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of this count; 2. Uphold the imposition of conditional licensure status commencing November 23, 2004 and expiring May 31, 2005; 3. Impose a fine in the amount of $1,000 for the referenced violation; and 4. Impose such other relief as this tribunal may find appropriate. Page 12 of 16 DISPLAY OF LICENSE OF oy fo me go f% DISPLAY OF LICENS* Wy ae 28. Until a subsequent standard license is issued, Respondent is required @ Ay ~ ars ed 475 NGEAW Sie t fi post its conditional license in a prominent place that is clear and unobstructed. pubhi a as on” 400.23(7)(d) and (e), Florida Statutes, which reads as follows: “400.23 Rules; evaluation and deficiencies; licensure status.—...(7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home...(d) The current licensure status of each facility must be indicated in bold print on the face of the license. A list of the deficiencies of the facility shall be posted in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to that facility. Licensees receiving a conditional licensure status for a facility shall prepare, within 10 working days after receiving notice of deficiencies, a plan for correction of all deficiencies and shall submit the plan to the agency for approval. (e) Each licensee shall post its license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility” 29. The following licenses are attached hereto as follows: Exhibit “A”: Conditional License Certificate # 12139 with an effective date of November 23, 2004 and an expiration date of May 31, 2005. NOTICE Respondent, OCEAN VIEW NURSING & REHABILATION CENTER, LLC, d/b/a OCEAN VIEW NURSING & REHABILITATION CENTER, is notified that it has aright to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. Page 13 of 16 RESPONDENT IS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. Submitted on this aod day of Calinwareg 2005, TD ime Ce Timothy B. EWtiott, Senior Attorney Fla. Bar No. 210536 Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3, MSC #3 Tallahassee, Florida 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been sent by U.S. Certified Mail, Return Receipt Requested (receipt # 7000 1530 0000 5684 9174) to Ocean View Nursing & Rehabilitation Center, Attention: Administrator, 2810 S. Atlantic Avenue, New Smyrna Beach, Florida 32169. Submitted on this Ancl_ day of Felines 2005. Lipaztlig BCL. ct Timothy B. EMott, Senior Attorney Agency for Health Care Administration Page 14 of 16 USPS - Track & Confirm Page 1 of 1 7000 1530 0000 5684 4174 Track & Confirm Current Status Track & Confirm Enter label number: You entered 7000 1530 0000 5684 9174 Your item was delivered at 3:55 pm on February 04, 2005 in NEW SMYRNA BEACH, FL 32169. U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) WDMINSTRAT VE Restricted Delivery (Endorsement sen Fee, Qb/os WES Alves IAG. 7s) a © fe Street, Apt. MEI or PO Box No. ent To ; = Priat your neme and address on the roverse - 3 80:thatwe caf setum the. card ‘to the’ ae NEW SVewA Beaty Fucks 5169 — me ae =| Ci Registered turn Recalpt for Merchandise Ol insured Mall ~=£0 C.0.D. 4. Restricted Delivery? (Extra Fee) Ol Yes ee 2. Article Number (Transfer from service label} 7 http://trkenfrm 1 .smi.usps.com/netdata-cgi/db2www/cbd 243.d2w/output Postage COMPLA ATT 2 contact us government services Certified Fee ComarT oN ° 12 USPS. All Rights Reserved. Terms of Use Privacy Policy 0 € totum Receipt ia 2 bel af ndorsement Requi Fig ovo! 34 ¢G 02/07/2005

Docket for Case No: 05-000876