STATE OF FLORIDA : : AGENCY FOR HEALTH CARE ADMINISTRATIO STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, . % y 70 Petitioner, O T vs. Case Nos. (Fines) 2007006188 _ (Conditional) 2007006189 GUARDIAN CARE, INC. d/b/a GUARDIAN CARE NURSING & 2, REHABILITATION CENTER, > et 3o f° - Respondent. Fes S i / ZaS «2 got se oo ADMINISTRATIVE COMPLAINT Be =, ~ COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Guardian Care, Inc. d/b/a Guardian Care Nursing & Rehabilitation Center (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of seven thousand five hundred dollars ($7,500.00) pursuant to Subsection 400.23(8)(c), Florida Statutes (2006), and to assign conditional licensure status beginning on March 19, 2007, and ending on May 2, 2007, pursuant to Subsection 400.23(7)(b), Florida Statutes (2006), based upon three class II deficiencies. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2006). EXHIBIT i) \" 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408, Part II, and 400, Part II, Florida Statutes (2006). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the licensing and regulatory authority that oversees skilled nursing facilities in Florida and enforces the applicable federal and state statutes, regulations and rules, governing such facilities. Chs. 408, Part II, and 400, Part Il, Fla. Stat. (2006); Ch. 59A-4, Fla. Admin. Code. The Agency may deny, suspend, or revoke a license issued to a skilled nursing facility, and impose administrative fines pursuant to Sections 400.121, 400.23, 408.813 and 408.815, Florida Statutes (2006); assign conditional licensure status pursuant to Subsection 400.23(7), Florida Statutes (2006); and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2006). . 5. The Respondent was issued a license by the Agency (License No. 1186096) to operate a 120-bed skilled nursing facility located at 2500 West Church Street, Orlando, Florida 32805, and was at all times material times required to comply with the applicable federal and state regulations, statutes and rules. I (TAG N 700) The Respondest Sait To Ensure That Its Residents Were Free From Abuse And Neglect In Violation Of F.S. 400.022(1)(m) And F.S. 415.102(1) 6. The Agency re-alleges and incorporates paragraphs 1 through 5. 7. Under Florida law, all licenses of skilled nursing 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 right to be free from mental and physical abuse.” 400.022(1)(0), Fla. Stat. (2006). 8. Under Florida law, “abuse” means “any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult’s physical, mental, or emotional health. Abuse includes acts and omissions.” § 415.102(1), Fla. Stat. (2006). 9. Under Florida law, “neglect” means “the failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, which a prudent person would consider essential for the well-being of a vulnerable adult. The term ‘neglect” also means the failure of a caregiver or vulnerable adult to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. ‘Neglect’ is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death.” § 415.102(15), Fla. Stat. (2006). 10. Under Florida law, “caregiver” means “a person who has been entrusted with or has assumed the responsibility for frequent and regular care of or services to a vulnerable adult ona temporary or permanent basis and who has a commitment, agreement, or understanding with that person or that person's guardian that a caregiver role exists. ‘Caregiver’ includes, but is not limited to, relatives, household members, guardians, neighbors, and employees and volun- teers of facilities as defined in subsection (8).” § 415.102(4), Fla. Stat. (2006). 11. Under Florida law, “facility” means “any location providing day or residential care or treatment for vulnerable adults. The term ‘facility’ may include, but is not limited to, any hospital, state institution, nursing home, assisted living facility, adult family-care home, adult day care center, residential facility licensed under chapter 393, adult day training center, or mental health treatment center.” § 415.102(8), Fla. Stat. (2006). 12. Under Florida law, “vulnerable adult” means “a person 18 years of age or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to a mental, emotional, long-term physical, or developmental disability or dysfunctioning, or brain damage, or the infirmities of aging.” § 415.102(26), Fla. Stat. (2006). 13. On or about March 19, 2007, the Agency conducted a complaint survey of the | Respondent and its Facility (CCR #2007002708). 14. Based upon record review, observation and interview, the Respondent failed to prevent verbal abuse of a resident by a staff member for 1 of 3 sampled residents (Resident #3) which resulted in the mental anguish of a known hospice resident with cancer. 15. Resident #3 was a resident of the Respondent’s Facility and was a vulnerable adult as defined by statute. 16. During an interview with Resident #3 on March 19, 2007, at approximately 1:45 p-m., the Resident stated that the former administrator had “cussed -at” him or her as he or she was smoking outside with another resident and visitor in a designated smoking area at the front of the Facility. 17. The Resident stated that the cussing incident happened “about a week and a-half ago” at approximately 9:00 a.m. in the presence of one of the Facility’s security guards, who was supervising the smoking session at the time. 18. The Resident stated that when the former administrator saw the visitor give the other resident a cigarette, the former administrator became “agitated” and “went off” verbally on them. 19. | When the former administrator asked the visitor if he or she had given the other resident a cigarette, the visitor replied, "Yes, why?"and then stated that he or she thought the new smoking rules allowed it, as long as the security guard provided supervision. 20. Resident #3 stated that the former administrator then adamantly interjected that all of the residents needed to comply with his laws regarding smoking! 21. Resident #3 stated that the former administrator then looked at him or her, and in ’ an aggressive tone of voice asked, “What's wrong with you?" 22. Resident #3 then replied back to the administrator: “Why are you looking at me?” 23. Resident #3 stated that at this moment the former administrator said to him or her: “because you're part of the... problem,” and then walked away. 24. Resident #3 stated that the former administrator's outburst made him or her feel “shocked” and “‘scared” because “I didn't know what he was gonna do next." 25. Resident #3 stated: "it made me shut my mouth." 26. Resident #3 stated that he or she hung out in his or her room after it happened. 27. _ Resident #3 stated: “I thought he might kick me out [of the facility] and I... have no place to go.” The Resident further stated: “I just knew to stay away from him.” 28. Resident #3 was oriented to person, place, and time when interviewed. 29. A review of Resident #3's medical record revealed diagnoses which included cancer and anxiety. The Resident received hospice services. 30. According to the most recent Minimum Data Set dated February 13, 2007, the Resident did not have any long or short term memory problems and was oriented to person, place, and time. 31. The Resident's medical record did not have any documentation relating to the verbal abuse allegation occurrence. 32. During a telephone interview with the day shift security guard on March 19, 2007, at approximately 5:30 p.m., it was confirmed that on March 8, 2007, at approximately 8:45 a.m., he witnessed the incident. 33. He described the administrator's behavior and demeanor as "agitated" and "red faced". He confirmed that the former administrator had looked at Resident #3 and with an angry voice had asked the Resident, "What's wrong with you?" 34. Resident #3 then asked, "Why are you looking at me?" 35. | The security guard then stated that the former administrator said: "because you are part of the . . . problem" and then "angrily walked away mumbling" to himself. 36. The security guard stated that the incident affected Resident #3. 37. He stated that Resident #3 was typically an outgoing person, but after the incident, the Resident became quiet, “went into a shell,” and stayed out of sight. 38. He stated that he was concemed about Resident #3 and had checked on him or her throughout the day to make sure he or she was alright. 39. A review of Resident #3’s medical record revealed a written care plan indicated that the Resident needed to be encouraged to attend activities for socialization and needed help to foster new relationships in the nursing home environment. 40. One of the approaches was as follows: “Make resident feel welcome and provide opportunity to express feelings.” 41. During the telephone interview with the security guard, he further stated that he was stunned and very concerned by the former administrator's language and behavior. 42. He stated that he "thought it [was] verbal abuse and that's why I reported it" to the Facility's assistant administrator at approximately 11:00 am. that same morning, after the administrative staff got out of the daily moming meeting. 43. The security guard also reported it to the executive assistant at approximately 1:00 _ p.m. that day. 44. A review of the Facility logs did not reveal any documentation that the allegation of verbal abuse had been identified, reported to the CAU, and/or investigated by the Facility. 45. The Facility log review included the “Grievance/Complaint Log” for March 2007, the” Suspected Abuse/Neglect Log” for March 2007 and the “Accident/Incident Log” for March 2007. 46. During an interview with the Facility’s interim administrator/risk manager/abuse coordinator on March 19, 2007, at approximately 5:00 p.m., it was confirmed that the security guard had reported the allegation of verbal abuse to her on the moming of March 8, 2007. 47. The interim administrator stated that at the time of the allegation, she was the assistant administrator and that the former administrator had been the risk manager and abuse coordinator. 48. She indicated that the social worker shared the abuse coordinator responsibilities with the former administrator at the time. 49. She indicated that the Facility did not notify the social worker of the verbal abuse allegation. 50. The interim administrator stated the Facility's regional management office had been notified of the verbal abuse allegation by the facility's human resource director and the executive assistant. 51. She stated that the regional nurse consultant and the regional human resources director became involved. The regional nurse consultant conducted the investigation and indicated that the former administrator had not been suspended during the investigation. 52. A review of the Facility's investigation revealed an interview with Resident #3. The investigation documentation stated as follows: “[Resident #3] talked about how shocked/ surprised [he or she] was to hear that language, how people use it to put power in their words. . . -but don’t realize how others take it.” 53. The investigation's conclusion, dated March 16, 2007, revealed that according to the regional nurse's findings, the former administrator’s behavior “was very inappropriate.” 54. The former administrator was asked to resign or be terminated. 55. The former administrator submitted his resignation dated March 15, 2007. 56. During a telephone interview with the Facility's management company Chief Executive Officer on March 19, 2007, at approximately 6:15 p.m., it was revealed that based upon its investigation, the Facility concluded -that the incident did not rise to the severity of verbal abuse. 57. During an interview with the regional human resources director and the interim administrator on March 19, 2007, at approximately 4:30 p.m., both persons stated that they would consider the incident to be verbal abuse. 58. A review of the “Protection” component of the abuse prohibition policy included the following: Upon identification of suspected abuse and/or neglect, provide for the immediate safety of the resident/patient. Means of providing protection including, but are not limited to: .. . 3) Employee Suspension from Duty -- In the case of a direct caregiver, or other facility employee, being suspected of allegedly abusing, neglecting, or mistreating a resident/patient, the Administrator (in his/her absence the Director of Nursing, Assistant Director of Nursing, Charge Nurse, or designee, in that order) must relieve the individual of his/her duties without pay until the investigation is complete. 59. During an interview with the Facility’s regional human resources director and interim administrator/risk manager/abuse coordinator on March 19, 2007, at approximately 5:00 p.m., it was confirmed that the former administrator had not been suspended according to the Facility’s abuse prohibition policy and procedures to protect the resident pending the in-house investigation, which was conducted by the regional nurse consultant. 60. A review of the "Reporting" component of the abuse prohibition policy included that the appropriate state and federal authorities would be notified as follows: the Abuse Registry Hotline would be notified within 24 hours, the Immediate Federal Report would be sent within 24 hours, and the 1 Day Adverse Incident Report wound be reported within 24 hours of the occurrences. 61. Follow-up reporting protocols included the 5 Day Federal Report would be sent within 5 days, the 15 Day Adverse Incident Report would be sent within 15 days and a report to the appropriate licensure board would be sent when determined necessary. 62. During an interview with the Facility’s interim administrator/risk manager/abuse ’ coordinator on March 19, 2007, at approximately 5:00 p.m., it was confirmed that the Facility did not follow the reporting component of its abuse prohibition policies and procedures. 63. She also confirmed that the Central Abuse Hotline was not called. 64. She also confirmed that the Immediate and Five Day Reports were not submitted to the Complaint Administrative Unit and the 1 and 15 Day Reports were not submitted to the Facility Data Analysis Unit at the Agency. 65. When asked why the Facility had not reported the allegation of verbal abuse to the appropriate state and federal authorities, the interim administrator did not offer an explanation. 66. The Respondent’s actions and/or inactions constituted an isolated state class II deficiency as provided for by Florida law. . 67. Actlass II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan " of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2006). 68. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. ... A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8){b), Fla. Stat. (2006). 69. The Respondent was given a mandatory correction date of April 10, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of two thousand five hundred dollars ($2,500.00). The Respondent Failed To Immediately Report An Incident Of Resident Abuse To the Central Abuse Hotline In Violation of F.S. 415.1034(1)(a) 70. The Agency re-alleges and incorporates by referenced paragraphs | through 5. 71. Under Florida law, any person, including, but not limited to, any: .. . nursing home staff: assisted living facility staff; adult day care center staff; adult family-care home staff; social worker; or other professional adult care, residential, or institutional staff; who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or 10 exploited shall immediately report such knowledge or suspicion to the central abuse hotline. § 415.1034(1)(a), Fla. Stat. (2006). To the extent possible, a report made pursuant to paragraph (a) must contain, but need not be limited to, the following information: 1. Name, age, race, sex, physical description, and location of each victim alleged to have been abused, neglected, or exploited. 2. Names, addresses, and telephone numbers of the victim's family members. 3. Name, address, and telephone number of each alleged perpetrator. 4. Name, address, and tele- phone number of the caregiver of the victim, if different from the alleged perpetrator. 5. Name, address, and telephone number of the person reporting the alleged abuse, neglect, or exploitation. 6. Description of the physical or psychological injuries sustained. 7. Actions taken by the reporter, if any, such as notification of the criminal justice agency. 8. Any other information available to the reporting person which may establish the cause of abuse, neglect, or exploitation that occurred or is occurring. § 415.1034(1)(b), Fla. Stat. (2006). 72. On or about March 19, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR #2007002708). 73. Based upon record review and interview, the Respondent failed to report an occurrence of resident verbal abuse to the Central Abuse Hotline for 1 of 3 sampled residents (Resident #3). 74. The Agency re-alleges and incorporates by reference the allegations in Count I 75. A review of the Facility's March 2007 "Suspected Abuse/Neglect Log" revealed that the verbal abuse by the Facility’s former administrator of Resident #3 on March 8, 2007, had not been documented onto the log. 76. The log further revealed there were no calls made to Central Abuse Hotline during the month of March 2007. 77. The Facility did not report the abuse of Resident #3 by its former administrator to the Central Abuse Hotline. 78. During an interview with the Facility’s social worker/abuse coordinator on March 19, 2007, at approximately 4:30 p.m., she stated that the role of the abuse coordinator was shared between the administrator and herself. ) 79. The social worker further stated that she was responsible for calling the Central Abuse Hotline per state protocol and that the administrator was responsible for sending out the Immediate and 5-Day Reports to the Complaint Administrative Unit. 80. The social worker further stated that she had not been informed of the occurrence until minutes before this interview and therefore had not called the Central Abuse Hotline. 81. During an interview with the Facility interim administrator/abuse coordinator/risk manager on March 19, 2007, at approximately 5:00 p.m., it was confirmed that she was informed by the Facility security guard of the verbal abuse of Resident #3 by the former administrator on March 8, 2007. , 82. The interim administrator also confirmed that the regional nurse consultant had conducted the investigation about the verbal abuse and that the social worker/abuse coordinator was not notified about the incident. 83.. When asked, the interim administrator did not offer an explanation as to why the social worker nor the Central Abuse Hotline were notified about the incident. 84. | The Respondent’s actions and/or inactions constituted an isolated state class 1 deficiency as provided for by Florida law. 85. Acclass II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and 12 psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2006). 86. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. ... A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2006). , 87. | The Respondent was given a mandatory correction date of April 10, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of two thousand five hundred dollars ($2,500.00). The Respondent Failed To Notify The Agency About The Incident Of Resident Abuse Within One Business Day : In Violation Of F.S. 400.147(7) 88. The Agency re-alleges and incorporates by reference paragraphs 1 through 5. 89. Under Florida law, every skilled nursing facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: The development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. § 400.147(1)(d), Fla. Stat. (2006). . 90. Under Florida law, for purposes of reporting to the Agency under Section 400.147, the term “adverse incident” includes “abuse, neglect, or exploitation as defined in Section 415.102, Florida Statutes (2006). § 400.147(5)(b), Fla. Stat. (2006). 91. Under Florida law, a skilled nursing facility shall initiate an investigation and shall notify the Agency within 1 business day after the risk manager or his or her designee has received a report pursuant to Section 400.147(1)(d), Florida Statutes. The notification must be made in writing and be provided electronically, by facsimile device or overnight mail delivery. The notification must include information regarding the identity of the affected resident, the type of adverse incident, the initiation of an investigation by the facility, and whether the events causing or resulting in the adverse incident represent a potential risk to any other resident. The notification is confidential as provided by law and is not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the agency or the appropriate regulatory board. The Agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken in response to the incident. The Agency shall review each incident and determine whether it potentially involved conduct by the health care professional who is subject to disciplinary action, in which case the provisions of Section 456.073, Florida Statutes, shall apply. § 400.147(7), Fla. Stat. (2006). 92. Onor akout March 19, 2007, the Agency conducted a complaint survey of the Respondent and its Facility (CCR #2007002708). 93, Based on record review and interview, the Respondent failed to notify the Facility Data Administrative Unit (FDAU) of the Agency about an incident of resident verbal abuse by its staff for 1 of 3 sampled residents (Resident #3). 94. The Agency re-alleges and incorporates by reference the allegations in Count 1. 95. A review of the March 2007 facility log on March 19, 2007, revealed that it did 14 not contain any documentation of the occurrence of verbal abuse toward Resident #3 by the former administrator on March 8, 2007. 96. The Facility’s March 2007 log did not reveal any abuse occurrence reports sent to the FDAU of the Agency during March 2007. 97. The Facility did not report the adverse incident of verbal abuse of Resident #3 by its former administrator to the Agency. 98. During an interview with the Facility interim administrator/abuse coordinator/risk manager on March 19, 2007, at approximately 5:00 p.m., it was confirmed that she was informed by the Facility security guard of the verbal abuse of Resident #3 by the former administrator on Match 8, 2007. 99. She further indicated that after the Facility’s investigation, which was conducted by the regional nurse consultant, the former administrator resigned on March 15, 2007. 100. The Facility interim administrator also confirmed that a 1 Day Report had not been sent to the FDAU of the Agency regarding the adverse incident of verbal abuse.. 101. When asked, the interim administrator did not offer an explanation as to why the facility did not notify the FDAU of the verbal abuse allegation. 102. The Respondent’s actions and/or inactions constituted an isolated state class I deficiency as provided for by Florida law. 103. Acclass Ii deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. § 400.23(8)(b), Fla. Stat. (2006). 104. A class Il deficiency is subject to a civil penalty of $2,500 for an isolated 15 deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. .. . A fine shall be levied notwithstanding the correction of the deficiency. § 400.23(8)(b), Fla. Stat. (2006). 105. The Respondent was given a mandatory correction date of April 10, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to impose an administrative fine against the Respondent in the amount of two thousand five hundred dollars ($2,500.00). COUNTIV Conditional License 106. The Agency re-alleges and incorporates by reference paragraphs 1 through 5 and Counts I through II. 107. A conditional 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, was not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the Facility has no class I, class Il, or class III deficiericies at the time of the follow-up survey, a standard licensure status may be assigned. § 400.23(7)(b), Fla. Stat. (2006). 108. Due to the presence of one or more state class II deficiencies, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes, or the rules adopted by the Agency. 109. As aresult of these deficiencies, the Respondent was subject it the assignment of a conditional licensure status. 110. The Agency issued the Respondent a conditional license with an action effective date of March 19, 2007. A copy Exhibit A. 111. At the time of the follow-up survey, the Respondent had no class I, class t, or class Ill deficiencies. . 112. The Agency issued the Respondent a standard license with an action effective date of May 2, 2007. Exhibit B. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to assign conditional licensure status to the Respondent, a skilled nursing facility, commencing on March 19, 2007, and ending on May 2, 2007. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the total amount of seven thousand five hundred dollars ($7,500.00). 3. Assign conditional licensure status to the Respondent for he perio? beginning on March 19, 2007, and ending on May 2, 2007. 4. Assess costs related to the investigation and prosgé 5. Enter ary other relief that this Court deems# C20 4 Respectfully submitted this 29th day of Ju Thomas M. Hoeler, Seni Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel Sebring Building, Suite 330D 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 17 NOTICE bo, Wh, ye) The Respondent i is notified that it/he/she has the right to request an administre Poe ing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent w: i ‘ ie, an attorney, it/he/she has the right to be represented by an attorney in this matter. Speafic options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the. Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration ‘and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 922-5873. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and the Election of Rights form were served to: Vereen Reynolds, Administrator, Guardian Care Nursing & Rehab. Ctr., 2500 W. Church Street, Orlando, Florida 32805, by U.S. Certified Mail, Return Receipt No. 7005 1160 0002 2254 8979; and Michael P. AnnicHiarico, Registered Agent, fyi 4 ld f Guardian Care Nursing & Rehabilitation Center, 2500 West Chayc Stre Orlando, Florida f 32805, by U.S. Certified Mail, Return Receipt No. 7005 116 09 02/225 /8986, on this 29th day of June, 2007. Thomas M. Hoeler, Senior Attorney Florida Bar No. 709311 Agency for Health Care Administration Office of the General Counsel 525 Mirror Lake Drive North, Suite 330D St. Petersburg, Florida 33701 Telephone: (727) 552-1439 Facsimile: (727) 552-1440 Copies furnished to: Vereen Reynolds Administrator ; Guardian Care Nursing & Rehabilitation Ctr. 2500 West Church Street Orlando, Florida 32805 (Certified U.S. Mail) Thomas M. Hoeler, Senior Attorney Agency for Health Care Administration Office of the General Counsel 525 Mirror Lake Drive North, Suite 330D St. Petersburg, FL 33701 (Interoffice Mail) Michael P. Annichiarico Registered Agent Guardian Care, Inc. 2500 West Church Street Orlando, FL 32805 (U.S. Certified Mail Joel Libby Field Office Manager Hurston South Tower 400 W. Robinson, Suite $309 Orlando, FL 32801 S. Mail

Docket for Case No: 07-003470