STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION. _ Ay a STATE OF FLORIDA, “> AGENCY FORHEALTHCARE () |- S Cor ADMINISTRATION, Petitioner, vs. Case Nos. 2007010202(FINE) 2007010204(CL) LPSNE, INC. d/b/a THE NURSING CENTER AT LA POSADA, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, LPSNF, INC. d/b/a THE NURSING CENTER AT LA POSADA (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida . Statutes (2007), and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) pursuant to Section 400.23(8)(c), Florida Statutes (2007), and to assign conditional licensure status beginning on July 11, 2007, and ending on September 18, 2007, pursuant to Section 400.23(7)(b), Florida Statutes (2007), based upon one Class II deficiency. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 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 (2007). 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 skilled nursing facilities. Chapter 408, Part II, and Chapter 400, Part II, Florida Statutes (2007); Chapter 59A-4, Florida Administrative Code (2007). 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 (2007); assign conditional licensure status pursuant to Section 400.23(7), Florida Statutes (2007); and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2007). 5. The Respondent was issued a license by the Agency (License No. 130471034) to operate a 40-bed skilled nursing facility located at 3600 Masterpiece Way, Palm Beach Gardens, Florida 33410, and was at all times material times required to comply with the applicable federal and state regulations, statutes and rules. COUNT I The Respondent Failed to Ensure The Right To Adequate And Appropriate Health Care In Violation of Section 400.022(1) Florida Statutes (2007) 6. The Agency re-alleges and incorporates by reference paragraphs | through 5. 7. Pursuant to Florida law, 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. 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. 8. On or about July 9, 2007, the Agency conducted an Annual Survey of the Respondent and its Facility. 9. Based on observation, record review and interview the facility failed to ensure that for two (2) of ten (10) sampled residents, Resident number one (1) and Resident number two (2), the facility failed to provide Resident number one (1) the necessary treatment to promote healing and prevent new sores from developing and for Resident number two (2) admitted without a pressure sore failed to prevent the development of a pressure sore. 10. A review of the Clinical Record for Resident number two (2) reveals that the resident was admitted to the facility on May 1, 2007 with diagnoses including cellulitis, status post hip fracture. A review of the Braden Skin Assessment dated May 1, 2007 reveals the resident scored a twelve, which confirms the resident was at high risk for skin breakdown. The Minimum Data Set dated May 1, 2007 reveals that Resident number one (1) was admitted to the - facility with one Stage 2 pressure sore to the right heel. The Initial Skin Alteration Report dated May 1, 2007 reveals that the wound on the right heel measured 5.5em long x 6cm wide. The type of alteration was listed as a Type I Pressure Ulcer and a description of the skin revealed, "Intact skin, color purple and mushy.” 11. A review of the Comprehensive Care Plan for Skin Breakdown dated May 2, 2007 for Resident number two (2) reveals the identification of a Stage I Pressure Ulcer to the right heel. Interventions included : - Assess risk factors - Keep clean and dry as much as possible - Skin checks as ordered and with showers. - Encourage physical activity, mobility and Range of Motion to maximum potential. - Turn and reposition frequently on air mattress. - Monitor labs per Physician. - Granulex right heel every shift. 12. The Ongoing Skin Alteration Report dated May 3, 2007 reveals that the right hee] ulcer was determined to be a Stage II and was 4cm long x 4cm wide and described as being "reddened". 13. The May 10, 2007 Ongoing Skin Alteration Report reveals that the right heel wound was 2.5cm long x 2.5em wide, Necrotic (black) and a Stage IV. 14. On May 10, 2007, an additional intervention was added to Resident number two’s (2) Care Plan for Skin Integrity as follows: Ensure twice a day milkshake and at bedtime. 15. The Physician's Progress Note dated May 11, 2007 did not reveal the identification of /or concern regarding the right heel ulcer. 16. A Physician's Order dated May 15, 2007 reveals that staff were to, clean the left heel with Normal Saline and apply Granulex Spray every day and as needed and cover with a dry dressing. This order was transcribed to the Comprehensive Care plan as well as the notation, "Stage I Pressure Ulcer to the left heel: preventable." 17. The Physician's Progress Note dated May 16, 2007 for Resident number two (2) reveals, "ulcer in the left foot with erythema in the left lower leg." The note reveals the plan to get a podiatry consult for the left ankle ulcer. There was no identification of the right heel ulcer in the May 16, 2007 note. A Physician's Orders dated May 16, 2007 reveal, "Podiatry Consult for left heel ulcer.” 18. A Physician's order dated May 17, 2007 reveals, "Consult Dr. Magilen Wound Care Team for evaluation, treatment ulcer right heel." Until consult, heels to be floated at all times in bed." The order to float heels when in bed was never transcribed to the Comprehensive Care Plan for Resident number two (2). 19. | The Comprehensive Care Plan for Resident number two (2) revealed a new entry dated May 17, 2007, "Left heel Stage 2 Pressure Ulcer.” 20. The Physician's Progress Note dated May 21, 2007 reveals, "Heel ulcers present with scabs. Continue wound care management. 21. The Ongoing Skin Alteration Report dated May 24, 2007 reveals the right heel Stage IV Pressure Ulcer was 2cm long x 2.3 cm wide. The description of the alteration was listed as: “intact skin." The wound was not identified as being necrotic. 22. The Physician's Progress Note dated May 27, 2007 reveals, “heel ulcer is not resolving. I suspect peripheral arterial disease as a cause of non-healing heel ulcer. I told him/her that he/she might need to follow with his/her doctor and get a testing done for Peripheral Arterial Disease.” 23. The Physician's Progress Note dated May 30, 2007 and June 1, 2007 reveals, "He/she has a heel ulcer in the right side, which is slowly improving. Continue Accu zyme dressing." The June 8, 2007 Physician's Progress note reveals, "The ulcer in the right heel is not healing and erythema surrounding is noted. Heel cellulitis with ulcer. We will start Bactrim for one week. Continue dressings daily. Add heel protectors to prevent for the pressure." The identification of heel protectors was never added to the Comprehensive Care Plan for Resident number two (2). 24. The Ongoing Skin Alteration Report dated June 6, 2007 reveals the Stage IV Arterial Ulcer to the right heel was 2cm long x 2.4 cm wide and intact skin. The description of the wound was identified as "intact." The wound was not described as being necrotic. 25. The June 14, 2007 Ongoing Skin Alteration Report identified the Stage IV Right heel ulcer as being 2.3 cm long x 2.3 cm wide and necrotic. . 26. The Physician's Progress Note dated June 15, 2007 reveals,"Heel ulcer is not healing. Will refer to Wound Care doctor." A review of the record of Resident number two (2) revealed a subsequent Physician's order dated June 15, 2007 as follows: "Wound Care Consult : Diagnosis Ulcer heel.” 27. The June 19, 2007 Ongoing Skin Alteration Report identified the Stage IV right heel ulcer as being 2. cm long x 2.3 cm wide x 1.0 cm deep. There was no identification of the color of the wound and the surrounding skin was described as being discolored. 28. The June 21, 2007 Ongoing Skin Alteration Report identified the Stage IV right heel ulcer as. being 2.3 cm in length x 2.3 cm in width and no depth. The wound was described as necrotic and having no surrounding skin alteration. 29. The June 26, 2007 Ongoing Skin Alteration Report reveals the Stage IV Arterial Right heel ulcer to be 2.3 cm in length x 2.3 cm in depth, reddened and necrotic. The surrounding skin was described as indurated. 30. The July 5, 2007 Ongoing Skin Alteration Report reveals the Stage IV Arterial Right heel ulcer was 2.0 cm in length x 2.3 cm in width and described as necrotic. 31. The Surveyor conducted an observation of Resident number two (2) during the initial tour on July 9, 2007 at 10:20 a.m. The resident was asleep, seated in a wheelchair with bilateral foam boots on both feet. The resident's feet were touching the foot pads of the wheelchair and were not "floated." 32. The Surveyor interviewed the Unit Manager of the East Wing on July 9, 2007 at 2:01 p.m. to determine if a Wound Care Consult had been conducted on Resident number two (2) for his/her right heel ulcer. The Unit Manager confirmed that a Wound Care Consult had not been conducted and offered to contact the Physician to obtain one at that time. 33. The Surveyor conducted an additional observation of Resident number two (2) on July 10, 2007 at approximately 8:00 a.m. The resident was seated in a wheelchair with socks on both feet and the feet positioned on the footrests of the wheelchair. 34. An observation of Resident number two (2) was conducted with the Assistant Director of Nursing/Risk Manager at 10:01 am. The Assistant Director of Nursing/Risk Manager removed the socks from the resident's feet. The Surveyor observed a large hard black/necrotic circle on the heel of the right foot. The left foot had a black/necrotic round area approximately the size of a nickel on the top of the left great toe. A Band-Aid covered the toe next to the smallest toe on the left foot. The foot was pink and inflamed extending to approximately the middle of the lower leg. The Assistant Director of Nursing/Risk Manager was asked why the Podiatry Consultation ordered on May 15, 2007 and the Wound Consultation ordered on May 15, 2007 and June 15, 2007 were not conducted. The Assistant Director of Nursing/Risk Manager stated, "the doctor changed his mind.” The Surveyor asked the Assistant Director of Nursing to identify documentation in the Clinical Record which confirmed that the Physician discontinued the orders for the Podiatry and Wound Care Consultations. 35. An interview was conducted with the Assistant Director of Nursing/Risk Manager on July 10, 2007 at approximately 2:45 p.m., who confirmed that the ordered Podiatry Consultation dated May 17, 2007,and the Wound Care Consultations ordered on May 17, 2007 and June 15, 2007 were not conducted. The Assistant Director of Nursing/Risk Manager stated, "We missed it. We wrote one again last night.” 36. The Assistant Director of Nursing/Risk Manager confirmed that there were no physician orders to discontinue the orders for the Podiatry and Wound Care Consultations. 37, A review of the clinical record for Resident number one (1) revealed that the resident was re-admitted to the facility on December 26, 2006 with diagnoses that included Esophageal Stricture, Hypertension, Non-Insulin Dependent Diabetes Mellitus, Congestive Heart Failure, Gout, Gastric Ulcer, and Hypothyroidism. A Readmission Nursing Data Collection form dated December 26, 2006 documented that the resident had an excoriation on the buttocks. The resident did not have any open areas on admission. The December 26, 2006 Braden Scale risk assessment identified the resident as a Mild risk (score of 15). There was no further documentation that the assessments were updated to correspond to the resident's condition as identified on the Minimum Data Set listed below. The resident's risk factors declined thus changing the resident's risk for the development of pressure ulcer to high risk. On the December 26, 2006 assessment, the resident moisture risk factor was coded as occasionally moist. The resident is totally incontinent of bowel and bladder. The resident's mobility risk factor was coded as slightly limited - makes frequent though slight changes in body or extremity position independently. The resident is total assist for mobility. The resident's nutritional risk was coded as probably inadequate. The resident has an esophageal stricture and is only able to consume nectar thick liquids. A review of the Activity of Daily Flow sheets revealed that the resident consumed less than 25% at meals and often spit out liquids. The resident's friction and shear factor was coded as a potential problem - moves freely or requires minimum assistance. The resident is total assistance for bed mobility and transfers. 38. An initial Minimum Data Set dated January 3, 2007 documented that Resident number one (1) was total assistance of two staff for bed mobility, transfer, bathing and toilet use. The resident was total assistance of one staff for ambulation via wheelchair, dressing and personal hygiene.’ He/she was extensive assistance of one staff for eating and was totally incontinent of bowel and bladder. He/she had chewing and swallowing problems and was on nectar thick liquids. The resident did not have any skin ulcers identified. Skin treatments identified were pressure relieving device for the bed, turn and position program and ointments for preventative protective skin. The quarterly April 3, 2007 Minimum Data Set documented the same as above. 39. A December 26, 2006 care plan identified a problem of at risk for skin breakdown related to Resident number one (1) being admitted with some excoriation to bilateral buttocks and bilateral groin area, incontinent of Bowel and Bladder. The following interventions were documented: - Assess risk factors - Keep clean and dry as much as possible - Skin checks as ordered and with showers - Encourage physical activity, mobility and range of motion to maximum potential - Turn and position frequently - Monitor labs per physician - Report signs and symptoms of skin breakdown to physician - Treatment per physician order Lantiseptic cream to coccyx every shift and as needed - Observe skin condition by staff every shift and report any changes 40. A January 9, 2007 Nurse Practitioner Progress note documented that Resident number one (1) had an esophageal obstruction, appetite remains poor despite change in diet, anorexia secondary to progressing Dementia and esophageal obstruction expect weight loss, skin breakdown, etc. The facility still did not update the resident's risk factors or implement any interventions to prevent breakdown. 41. A Nursing Progress note dated May 27, 2007 documented that the Certified Nursing Assistant brought to the writers attention a two (2) cm open area to the right buttocks. 42, An initial skin alteration report dated May 28, 2007 documented a .5 long x cm wide Stage II area to the right buttocks. 43. A review of the physician orders documented that on May 27, 2007 the physician prescribed to clean right buttock with Normal Saline and apply Xenaderm three times daily. On May 31, 2007 the Xenaderm was reordered to add the dressing change to continue three times daily and as needed until resolved, cover with dressing. Turn and position as part of daily routine. Referral to Hospice for nutrition recommendations. Also on May 31, 2007 the physician prescribed for Resident number one (1) to receive a gel cushion to wheelchair. The gel 10 cushion was prescribed after the resident was identified with the Stage II pressure ulcer of the buttock. 44. The care plan was updated on May 28, 2007 after Resident number one (1) was identified as having a open area on the coccyx - Stage 2 to the right buttocks. Interventions identified were: Treatment as ordered - Normal Saline and Xenaderm three times daily - Reposition frequently - Gel cushion in wheelchair - Pressure reducing mattress or specialty bed - Daily skin observation during bathing - Weekly body audit and wound assessment - Ensure adequate hydration/nutrition - Report sign/symptoms of infection or significant change to physician 45, Aninterview was conducted on July 10, 2007 at 11:05 a.m. with the Risk Manager /Acting Director of Nurses. The Risk Manager confirmed that risk assessment (Braden Scale) was completed on admission and the facility does not formally reassess the resident's risk when the resident's condition changes. It was discussed with the Risk Manager that the admission Braden Scale identified Resident number one (1) as a mild risk. The December 26, 2006 Braden Scale was reviewed and identified the changes in the resident's risk factors. Though Resident number one’s (1) risk changed, the facility continued to implement routine preventions as listed on the December 26, 2006 care plan. The facility utilized a pressure reducing mattress and turning and positioning. However, the Risk Manager confirmed that the facility does not have any bedridden residents and further confirmed that this resident was out of i the bed in his/her wheelchair most of the day for meals and activities. However, no pressure relieving device for the wheelchair was implemented until after the development of the Stage II pressure ulcer. The Risk Manager further confirmed that the gel cushion was not implemented until after a "problem was identified". Further questioning of the Risk Manager concerning what pressure relieving interventions were implemented for this resident while the resident was out of the bed in the wheelchair. "We assume that the resident is checked every two hours and is repositioned at that time". Additionally the resident is not a “small emaciated person” and getting him/her up every two (2) hours should be sufficient.” 46. Areview of the labs on Resident number one (1) revealed on January 28, 2007 a comprehensive metabolic panel revealed a low Total protein level of 5.4 (normal range 6.0 - 8.3) and an Albumin level of 3.2 (normal 3.5-5.7). There was no documentation that a pre-albumin level was done. The resident is on Hospice. The Risk Manager confirmed in the above interview that Hospice residents, labs aren't done. 47. During the initial tour of the East Wing on July 9, 2007 at 9:05 a.m. Resident number one (1) was out of the room. On July 9, 2007 at 11:50 a.m. the resident was observed sitting in his/her wheelchair in the dining room for activities. The resident was observed on July 9, 2007 at 12:45 p.m. in the wheelchair in the dining room being fed lunch. On July 10, 2007 at 9:30 a.m. the resident was out of the bed in the wheelchair in the dining room for activities. 48. The July 5, 2007 ongoing skin alteration report continue to document Resident number one’s (1) right buttocks has a .2cm long x .3 cm wide Stage II pressure ulcer. 49. An observation of the wound care and skin was conducted on July 10, 2007 at 11:45 a.m. with the Licensed Practical Nurse and Certified Nursing Assistant. Resident number one (1) was observed to have a reddened area on the right buttock with a small open area on the 12 right buttock. The Licensed Practical Nurse completed the wound care and an observation of the resident skin was completed. The resident was wearing socks. The resident did not have in place any pressure relieving devices for the resident's feet. The Surveyor identified several reddened areas on the resident's feet. The resident’s right heel had multiple red pimple size areas surrounding the right heel, a reddened area approximately 1/2 inch in diameter on the outer aspect of the right great toe. The resident's left great toe crossed over to the 2nd toe. The 2nd toe had a reddened area where the great toe touched the 2nd toe. 50. Resident number one (1) was also noted to have edema in his/her feet. An interview was conducted with the Licensed Practical Nurse at this time. The Licensed Practical Nurse confirmed the resident's need for heel protectors and floating the heels for this resident. 51. An interview was conducted with the Licensed Practical Nurse on July 11, 2007 at 10:45 a.m. to confirm that the prevention was implemented. The Licensed Practical Nurse was also questioned concerning Resident number one’s (1) routine. Resident number one (1) is gotten out of bed by the 11-7 shift before breakfast at 7:30 a.m. The resident remains in his/her wheelchair for activities until after lunch at 12:30 p.m. The resident is then put back to bed and usually remains in bed until dinner. The nurse then stated that today July 11, 2007 she just had the Certified Nursing Assistant put the resident back to bed because “the resident gets up so early plus he/she has that opened area." The nurse further confirmed that she had the Certified Nursing Assistant turn the resident from side to side. The nurse stated she would update the care plan to reflect these changes to assist with pressure relief. 52. Based upon the above-described events, the Respondent’s actions or inactions constitute a Class II deficiency in that it has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by 3 an accurate and comprehensive resident assessment, plan of care, and provision of services. 53. A Class Il 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. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shali be levied notwithstanding the correction of the deficiency. 54. In this instance, the Agency is seeking a fine in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00), as an isolated state Class II deficiency. 55. The Respondent was given a mandatory correction date of August 11, 2007. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00). COUNT Assignment of Conditional Licensure Status Pursuant to Section 400.023(7)(b) Florida Statutes 56. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 57. The Agency re-alleges and incorporates by reference the allegations in Count I. 58. The Agency is authorized to assign conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2007). 59. Due to the presence of a Class I deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part Il, Florida Statutes (2007), or the rules adopted by the Agency. 14 60. A conditional licensure status means that a Facility, due to the presence of one or more Class I or Class II deficiencies, or Class Ill deficiencies not corrected within the time established by the Agency, is 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 II, or Class Ill deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. 61. | The Agency assigned the Respondent conditional licensure status with an action effective date of July 11, 2007. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 62. The Agency assigned the Respondent standard licensure status with an action . effective date of September 18, 2007. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the Respondent conditional licensure status for the period between the assignment of the conditional license and the standard license pursuant to Section 400.23(7), Florida Statutes (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 against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00.). 15 3. Assign conditional licensure status to the Respondent for the period beginning on July 11, 2007, and ending on September 18, 2007. 4. Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. OOD day of __ POY cen&4007. Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 Respectfully submitted this NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING 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 BY THE AGENCY. 16 CERTIFICATE OF SERVICE KERNS Se I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and the Election of Rights form were served to: Deborah L. Wesch, Administrator, LPSNF, Inc. d/b/a The Nursing Center at La Posada, 3600 Masterpiece Way, Palm Beach Gardens, Florida 33410, by U.S. Certified Mail, Return Receipt No. 7004 2150 0004 5871 0996; and F & L Corporation, Registered Agent for LPSNF, Inc. d/b/a/ The Nursing Center at La Posada, One Independent Drive, Suite 1300, Jacksonville, Florida 32202, by U.S. Certified Mail, Retum Receipt No. 7006 2150 0004 5871 0989, on this ae day of Povey tr~ , 2007. ‘fa low Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 338-3203 17 Copies furnished to: Deborah L. Wesch, Administrator LPSNF, Inc. d/b/a The Nursing Center at La Posada 3600 Masterpiece Way Palm Beach Gardens, Florida 33410 Andrea M. Lang, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (U.S. Certified Mail) (Interoffice Mail) F & L Corporation, Registered Agent for Diane Reiland LPSNF, Inc. Field Office Manager d/b/a The Nursing Center at La Posada One Independent Drive, Suite 1300 Jacksonville, Florida 32202 (U.S. Certified Mail) Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (U.S. Mail) 18 EXHIBIT A Original Certificate For Conditional License For LPSNF, INC. d/b/a The Nursing Center at La Posada Certificate No. 14711 License No. SNF130471034

Docket for Case No: 07-005662