STATE OF FLORIDA “lA AGENCY FOR HEALTH CARE ADMINISTRATIO STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, < Petitioner, OT -S7 a4 CARE CENTER OF ORMOND BEACH, INC., AHCA No: 2007012724 vs. ficopy Respondent. / oe ADMINISTRATIVE COMPLAINT ADMINISTRATION (hereinafter “Agency” or “Petitioner”), by and through its undersigned counsel, and files this Administrative Complaint against CARE CENTER OF ORMOND BEACH, INC. (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION SUE HE ACTION Section 429, 14(1)(e) 1, Florida Statutes (2007). JURISDICTION AND VENUE 1. The Agency has Jurisdiction pursuant to Sections 20.42, 120.60, 408, Part II, and 429, Part I, Florida Statutes (2007). 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable Statutes, rules, and regulations goveming assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes, Chapter 408, Part II, Florida Statues, and Chapter 58A-5, Florida Administrative Code. 4. Respondent operates an assisted living facility located at 1410 Hand Avenue, Ormond Beach, Florida 32174, and has been issued by the Agency a standard assisted living facility license (License # 10589). 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was Tequired to comply with all applicable rules and statutes, COUNTI 6. The Agency re-alleges and incorporates Paragraphs One ( 1) through Five (5) as if fully set forth herein. 7. Pursuant to Rule 58A-5.019(4)(a) and (b), Florida Administrative Code, notwithstanding the minimum staffing ratio specified in paragraph (a) (minimum staffing for 6- 15 residents, 212 hours per week), all facilities shall have enough qualified staff to provide resident supervision, and provide or arrange for resident Services in accordance with resident scheduled and unscheduled service needs, resident contracts, and resident care standards. 8. On or about November 02, 2007, the Agency conducted a survey of the Respondent’s facility (hereinafter “Facility”), 9, Based on observations, resident records review, facility records review and an interview with the administrator, the facility failed to provide enough qualified staff to provide resident supervision, and arrange for residents scheduled and unscheduled service needs for 15 residents residing in the secured memory care unit. The findings include: 10. A review of resident records revealed 15 residents are housed in a locked memory care unit. 11. During observations of residents on November 1, 2007 at 10:00 A.M., 11:15 AM., 2:00 P.M. and 3:30 P.M., it was observed that only one staff member was assigned to care for 15 residents. | 12. The resident records reveal that all residents in this unit suffer from some form of dementia and require supervision. 13. The physical configuration of the unit does not allow for the ability of one staff member to supervise the activities of all residents. 14. Observations noted that residents not being assisted by the staff member were exhibiting exit seeking behaviors, and calls for assistance to people outside the unit. 15. In an interview with. the administrator on or about November 1, 2007 at 11:30 A.M,., it was confirmed that the normal scheduling for this unit was one caregiver for each shift, seven days a week. 16. This was also confirmed using the work schedules for October and November, 2007 17. This schedule does not provide enough staff to meet the basic needs of fifteen residents with minimal needs, including but not limited to assistance with the activity of daily living such as toileting. 18. During observations of the unit from inside the main entrance to the unit, it was revealed that the lack of supervision and assistance to the residents was a direct cause of carpeting being removed from the entrance due to multiple toileting events at the front doors of the unit. 19, This was a direct result of the lack of caregivers to meet the basic toileting needs of the residents. . | 20. | The Agency determined that this deficient practice was related to the operation and maintenance of the Facility or to the personal care of facility Residents, and directly threatens the physical or emotional health, safety, or security of Facility Residents. 21. The Agency cited the Respondent for a Class II violation in accordance with Section 429.19(2) (b), Florida Statutes. * 22. The Respondent’s failure to make a reasonable effort to ensure that enough qualified staff to provide supervision are available violates Rule 58A-5.019(4)(b), Florida Administrative Code, as set forth in this count and constitutes grounds for the imposition of an administrative fine in the amount of ONE THOUSAND AND NO/100 DOLLARS ($1,000.00), pursuant to Section 429.19(2)(b), Florida Statutes. COUNTII 23, The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) as if fully set forth herein. 24. — Pursuant to Rule 58A-5.0185(7)(f), Florida Administrative Code, the facility must make every reasonable effort to ensure that prescriptions for residents, who receive assistance with self-administration of medication or medication administration, are filled or refilled in a timely manner. 25, On or about November 02, 2007, the Agency conducted a survey of the Respondent’s facility. 26. Based on resident record reviews and interviews with the administrator, owner and nursing director, the facility failed to ensure that medications were-filled or refilled in a timely manner for 19 of 31 residents residing at the facility. No interventions or communication regarding this situation was documented by staff, administration, or ownership, who were all aware of the problem. The findings include: 27. A review of residents' Medication Observation Records revealed the following residents did not have their medications as prescribed according to their September, October and November 2007 Medication Observation Records. Staff initials were circled and a notation was made that the medication was not available. 28. 29, Resident #29 a. Risperdal 0.125 mg 1 every morning. This was not received from October 26 through the end of the month. b. Risperdal 0.5 mg 1 at bedtime. This was not received from October 25" through the end of the month. c. Exelon 1.5 mg 1 twice daily. This was not received from October 25" through the end of the month. d. Lovastatin 40 mg 1 at bedtime. This was not received from October 27" through the end of the month. Resident #27 a. Erythromycin ointment, apply every night in both eyes. This was not received from October 17 through the end of the month. b. Aciphex 20 mg | tablet by mouth twice daily. Both doses were not received on October 26" and 29th. One dose was not received on the October 27” and 28" and 30 c. Artifical tears .1 drop in each eye at 9am, 12pm, Spm and 9pm. This was not received from October 21 through the end of the month. d. Cozaar 100 mg 1 tab daily, Not received from October 26th through the end of the month. e. Metoclopram 5 mg 1 tab 4 times a day after meals and at bedtime. This was - not received from October 27" through the end of the month. 30. 31. 32. 33. Resident #26 a. Namenda 10 mg | tab twice daily. This was not received from October 26" through the-end of the month. b. Effexor XR 75 mg 3 capsules daily. This was not received from October 26" through the end of the month. c. Zyprexa 7.5mg | tablet at bedtime. This was not received from October 26" through the end of the month. ; d. Aricept 10 mg 1 tab daily. This was not received from October 26" through the end of the month. e. Medi-tabs PM 25-500 mg ! tab at bedtime. This was not received from October 5 through the end of the month. Resident #25 a. Thiamine HCL 100 mg 1 in the moming. This was not received from October 6" through the 224 b. Klor-con 10 tab ER in the a.m. This was not received from October 14 through the end of the month. c. Sertraline 25 mg 1 in the morning. This was not received from October 10" through the end of the month. Resident #19 a. Detrol LA 4mg 1 daily. This was not received from October 26% through the end of the month. b. Plavix 75 mg 1 daily. This was not received from October 26 through the end of the month. ¢. Metformin 500mg once daily. This was not received from October 26" through the end of the month. d. Amlodipine 5 mg once daily. This was not received from October 26" through the end of the month. e. Lovastatin 40 mg at bedtime. This was not received from October 26" through the end of the month. Resident #17 34. 35. 36. 37. 38. a. Namenda 10 mg twice daily. This was not received from October 23rd through October 30". Resident #15 a. Digoxin | tab daily. This was not received on October 16", 22"¢, 23", 26"" and 29", Resident #13 a. Naproxen 375 mg twice aday. This was not received from October 11 through the 16". Resident #10 a. Amlodipine 10 mg 1 daily. This was not received from October 12" through October 30", b. Famotidine 20 mg | tablet with lunch. This was not received from October 26" through the end of month. c. Lexapro 10 mg, 1 qd, This was not received October 26" through end of month. d. Buspar 5 mg twice a day. This was not received from October 12" through October 15", then only had one dose daily from October 19-22™, Resident # 9 a. Metamucil 1 packet twice a day. This was not received from October 15" through the end of the month. (On the 19" the resident was out of the building.) b. Flomax 0.4 mg daily. This was not received on October 1-5") 8-12", 17-18", and the 23 through the end of the month. c. Benztropine Mesylate 1 three times a day. All three doses were not received from October 11th through the 16™. One dose was not received on October 7”, 8", and 9”. d. Seroquel 300 mg one daily. This was not received on October 1, 7%, gh of and 10”. Resident # 7 39. a. Aricept 10 mg, | tablet at bedtime. This was not given from October 25" through the end of the month and November I. b. Thyroid 30 mg 1 tablet in the moming. This was not given from October 26" through the end of the month and November 1. c. Levothyroxine 100 meg tab 1 tab in the moming. This was not given from October 26" through the end of the month and November 1. d. Mirtazapine 15 mg, 1 tablet at 9 pm. This was not given from October 224 through the end of the month and November 1. e. Omeprazole 20 Mg cap, take two capsules at 6 a.m. This was not given from October 26 through the end of the month and November 1. f. Nu-iron 150 mg | daily. This was not given from October 23 through the end of the month and November 1. g. Ceftin 500 mg 1 tab twice a day was ordered on 10-19-07 for a new urinary tract infection, but was not started until 10-23-07. Resident #6 a. Metoprolol 50 Ing % tab twice a day. This was not given starting the evening dose on October 26" through the end of the month and November 1" and 24, b. Nystatin 10000 pow 1 dose topically twice daily. This was not given starting the evening dose on October 18 through the end of the month and November |* and 2”°, c. Omeprazole 20 mg 1 cap daily before meal. This was not given starting October 26 through the end of the month and November 1" and 24. d. Aricept 10 mg 1 tab by mouth daily. This was not given starting October 26 through the end of the month and November 1* and 274 e. Amlodipine 2.5 mg | tab daily. This was not given starting October 26 through the end of the month and November 1°* and 2™* f. Calcium 500/D 1 tab three times daily. This was not given starting October 26 through the end of the month and November 1* and 2"! . 8. Carb/Levo 25-100 (Sinemet) 1 tab three times a day. This was not given Starting October 19 through the end of the month and November 1" and 27! . h. Sertraline 25 mg 1 tab twice a day. This was not given starting October 26 through the end of the month and November 1° and 2” . i. Alprazolam 0.25mg 1 tab twice a day. The evening doses of October 27, 29", and 30" were not given as well as both doses of November 1* and one dose November 2". j. Metoclopram 10 mg ] tab twice a day. This was not given starting October 26 through the end of the month and November 1" and 2” . 40. Resident #5 a. Marinol 2.5 mg 1 cap twice a day. This was not given on September 1-18", October 27-31% and November 1 and 24, b. Folic acid 1 mg one daily. This was not given on September 1-10". c. Atenolol 25mg one daily. This was not given on September 1-10", 25", 26" and October 29"-31". d. Enalapril 5mg one daily. This was not given on September and, gh git ash and 26" and October 27-31*, e. Carb/Levo 25-100 one three times a day. This was not given on September 1- 10", one dose on the 24" and 26th, two doses on the 25", one dose from October 12-20", one dose on the 23” and 24" of October, two doses on the 25" of October and all doses on the 26" through the end of the month. f. Lortab 5/500 one four times a day. This was not given for 2 doses on September 1, 17", 18", October 27", and all four doses on October 29", 30" and 31°, November 1 and one dose on November 2. 41. Resident #28 was out of medications from November 1 to November 2, 2007 and did not receive the following: a. Namenda 10mg. one tab by mouth 2 times daily b. Triam/HCTZ 375/25 one cap daily c. Thera M one tab by mouth daily. This is a vitamin. d. Omeprazole 20mg one tab by mouth daily at bedtime e. Zyrtec 10mg. one tab by mouth daily at bedtime 42. f. Zyprexa Smg. one by mouth at bedtime 8. Lorazepam 0.25 one tab by mouth every 8 hours as needed for anxiety/agitation Resident #11 was out of medications from October 21, 2007 through November 2, 2007 and did not receive the following: 43. a. Meprazzole 20mg one cap by mouth daily b. Furosemide 20mg one tab by mouth daily c, Lexapro 10mg one tab by mouth every night at bedtime d. Risperdal 0.5mg one tab by mouth daily at bedtime e. Viokase 16 one tab by mouth three times a day f. Lorazepam 0.5mg one tab by mouth every 6 hours as needed for agitation g. Lactulose 15m] by mouth as needed for constipation h. Theratab one by mouth daily. This is a vitamin. i. Namenda 10mg one tab by mouth 2 times a day j. Triam/HCTZ 375/25 one cap by mouth once in A.M. k. Potassium Chloride 20meq one tab daily 1, Hydrocodone/Apap 7.5/500 one tab by mouth every four hours as needed for pain m. Timolol Solution one drop right eye daily n. Keflex 500mg. one cap by mouth daily. This is an antibiotic. Resident #23 was out of medications from October 26, 2007 through November 2, 2007 and did not receive the following: a. Celebrex 200mg one cap by mouth daily b. Plavix 75mg one tab by mouth daily c. Salt Tab one by mouth daily 10 d. Lunesta 3mg one by mouth at bedtime e. Ferrous Sulfate 325mg one tab by mouth 3 times a day f. Clonidine 0.1 mg one tab by mouth 2 times a day as needed if blood pressure is greater or equal to 160 g. Enalapril 20mg one tab by mouth 2 times a day h. Vytorin 10-40mg one tab by mouth at bedtime 1. Benicar HCT 40-125 one tab by mouth daily in A.M. j. Hydrochlorot 12.5mg one cap by mouth daily in A.M. k. Norvasc 10mg one tab by mouth daily 1, Omeprazole 20mg one by mouth daily 44, __ Resident #8 was out of medications from October 26, 2007 through November 2, 2007 and did not receive the following: a.Diprolene Lotion 0.05 Apply to scalp 2 times per day b, Furosemide 20 mg one tab by mouth daily c. Omeprazole 20 mg one cap by mouth daily before breakfast d. Potassium Chloride 10 meq one tab by mouth daily with food e. Nifedipine 30mg ER one tab by mouth daily f. Cupex Apply to scalp once a day g. Derma Smooth/Fish oil apply to scalp daily as needed h. Synthroid 25 mcg one tab by mouth daily i. Colchicine 0.6 m one tab by mouth daily 45. Resident #16 was out of medications from November 1 through November 2, 2007 and did not receive the following: 11 a. Synthroid 100mg one by mouth daily b. Ensure/Boost Nutritional Supplement 2 times daily 46. Resident #3 was out of medications from November 1 through November 2, 2007, and did not receive the following: a. Vitamin B-12 one by mouth in the morning. 47.. In interviews with the administrator, nursing director and the owner of the facility on November 1, 2007 at 11:30 A.M., it was confirmed that these residents have not received medications for the time periods specified. There was no documentation of any effort to fulfill these medications though the staff was aware that they needed to be filled, 48. The deficient practice described in this count constituted, in part, the basis for an Emergency Order of Immediate Moratorium on Admissions, which the Agency imposed upon the Respondent on or about November 5, 2007, pursuant to Sections 408.814(1) and 120.60(6), Florida Statutes (2007). 49, Based upon the above, the Agency determined that the Respondent facility failed to ensure that prescriptions for residents, who receive assistance with self administration of medication or medication administration, are filled and refilled in a timely manner, in violation of 58A-5.0185(7)(f), Florida Administrative Code. 50. The Agency determined that this deficient practice was related to the operation and maintenance of the facility and to the personal care of facility residents, and presents an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. 51. The Agency cited the Respondent for a Class I violation in accordance with Section 429.19(2)(a), Florida Statutes and intends to impose upon the Respondent an 12 administrative fine in the amount of FIVE THOUSAND NO/100 DOLLARS ($5,000.00). COUNT IIT 52. The Agency re-alleges and incorporates Paragraphs One (1) through Five (5) and twenty-seven (27) through forty-six (46) as if fully set forth herein. 53. Pursuant to Rule 58A-5.0182, Florida Administrative Code, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 54. On or about November 02, 2007, the Agency conducted a survey of Respondent’s facility. Based on resident records review and interviews with the administrator, owner and nursing director the facility failed to provide care and services regarding physician ordered medications and treatments appropriate to the needs for 19 of 31 residents. The findings include: 55. An interview with the owner and administrator on November 1, 2007 at 11:30 AM., revealed that Residents #5 and #6 listed below did not receive medications, resulting in a decline in condition. 56. Record review (Medication Observation Record) of Resident #5 revealed the following medications were not given for extended periods of time, resulting in pain and decline in condition: _a. Marinol 2.5 mg 1 cap twice a day (used for nausea/vomiting). This was not given on September 1-18", October 27-31% and November 1° and 2". b. Folic acid 1 mg one daily (used for anemia related to folate deficiency). This was not given on September 1°-10". c. Atenolol 25mg one daily (used for hypertension). This was not given on September 1-10", 25", 26" October 29-315". 13 57. d. Enalapril 5mg one daily (used for hypertension). This was not given on September 2%, 8, 9", 25" and 26" and October 27-31*. e. Carb/Levo 25-100 one three times a day (anti-Parkinson 's Agent). This was not t given on September 1-10" 2 ONE dose on the 24"*"4 26th, two doses on the 25", one dose from October 12- 20", one dose on the 23° and 24" of October, two doses on the 25" of October and all doses on the 26" through the end of the month. f, Lortab 5/500 one four times a day (used for pain) This was not given for 2 doses on September 1, 17", 18", October 27", and all four doses on October 29", 30" and 31, November 1 and one dose on November 2. The resident on 11-2-07 at 10:30 a.m. was observed lying in her/his bed; bilateral fingers were bent from arthritis. The resident stated that his/her back hurt and she/he could barely get out of bed with help. The resident stated she/he was having falls and the staff took her/his walker away. He/she uses a wheelchair which was observed sitting beside the bed. 58. The facility failed to meet the needs of Resident #6 by not assisting with medication administration as ordered which could have contributed to a fall and elevated blood pressure. This resident resided in the locked unit (Dementia Unit) and the facility did not maintain or help administer his/her medications as prescribed. a. Metoprolol 50 mg % tab twice a day (used for blood pressure). This was not given starting the evening dose on October 26" through the end of the month and November 1“ and 24, b. Nystatin 10000 pow 1 dose topically twice daily (used for fungal infections). This was not given starting the evening dose on October 18 through the end of the month and November 1° and 2™4. c. Omeprazole 20-mg | cap daily before meal (used for stomach related upset). This was not given starting October 26 through the end of the month and November 1 and 2"4, d. Aricept 10 mg 1 tab by mouth daily (used for mild/moderate dementia of the Alzheimer 's type). This was not given starting October 26 through the end of the month and November Ist and 2nd. 14 e. Amlodipine 2.5 mg | tab daily (used for hypertension). This was not given starting October 26 through the end of the month and November 1" and 2° f. Calerum 500/D 1 tab three times daily (used for osteoporosis). This was not given starting October 26 through the end of the month and November 1* and 2nd, g. Carb/Levo 25-100 (Sinemet) 1 tab three times a day (used as an anti-Parkinson ''s agent). This was not given starting October 19 through the end of the month and November 1° and 2nd. h. Sertraline 25 mg 1 tab twice a day (antidepressant). This was not given starting October 26 through the end of the month and November 1" and 2™. i. Alprazolam 0.25mg 1 tab twice a day (anti-anxiety). The evening doses of October 27, 29", and 30" were not given as well as both doses of November 1* and one dose November 2”°. 59. The facility staff was asked to record Resident #6's vital signs due to missing multiple doses of blood pressure medications. On 11-2-07 at 9:00 a.m., the resident's blood , Pressure was 182/118, pulse 138, respirations 24. Staff responded that the resident was exercising at the time. 60. The resident's vitals were taken once again in the lying position at 9:30 a.m. which revealed blood pressure 183/92, pulse 102, and respirations 24. 61. The resident was seen by a neurologist on 10-19-07 and the neurologist made a recommendation to start Namenda 5 mg, 1 tab twice a day for 2 weeks and then 10 mg twice a day. This was provided in the clinical record. 62. The director of nursing (“DON”) stated she was not aware if the resident's attending physician was made aware of this recommendation and the resident:was not receiving this medication. 15 63. The DON also stated that the resident had a fall and produced an incident report. The incident report was not dated, but had a time of 3:45 a.m. which revealed the resident was found on the floor by the bed. 64. The staff member who witnessed this and wrote the report did not sign it. 65. The physician or responsible party was not notified of the incident. 66. The DON did sign the incident report on October 29, 2007, an undisclosed time after the incident occurred. There was no entry in the clinical record to give any further details of the incident. 67, Due to the resident's dementia, she/he was unable to recall any incident. 68. As referenced in Count II, the owner and administrator on November 2, 2007, at 12:00 P.M., further noted the 19 residents’ physicians were not notified of medications not being received by the residents and no documentation of communication with the residents or the responsible parties was available to verify they were aware of the failure of residents to receive their physician prescribed medications. These residents are all at risk for complications of existing medical conditions, based on the facility’s failure to provide health care providers' orders. 69. These medications were not withheld as a result of physician orders, resident absence from the facility, resident refusal, or any other circumstances beyond the Respondent’s control. 70. There is no indication that any health care provider was given the opportunity to weigh the effects of their patient’s failure to receive prescribed medications and the immediate or long term effects, the lack of pharmaceuticals may have on the patient’s health and well-being. 16 71. Respondent was aware that residents were without their prescribed medications, but nonetheless has not taken any action to ensure that medications were timely received. 72. Respondent’s deficient practices in this instance present the potential for great danger to resident health and safety. 73. _ Each of the prescribed medications is pivotal in the management of resident health issues and resident care. | 74. Based upon the above, the Agency determined that the Respondent facility failed to ensure that the facility provides care and services appropriate to the needs of residents accepted for admission to the facility, in violation of 58A-5.0182, Florida Administrative Code. 75, The Agency determined that this deficient practice was related to the operation and maintenance of the facility and to the personal ‘care of facility residents, and presents an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefrom. . 76. | The Agency cited the Respondent for a Class I violation in accordance with Section 429.19(2)(a), Florida Statutes, and intends to impose upon the Respondent an administrative fine in the amount of FIVE THOUSAND NO/100 DOLLARS ($5,000.00). COUNT IV 77. The Agency re-alleges and incorporates paragraphs one (1) through seventy-six (76) as if fully set forth herein. 78. That pursuant to Florida law, the Petitioner Agency for Health Care Administration may revoke the license of an Assisted Living Facility for an intentional or negligent act materially affecting the health or safety of a client of the provider, for a violation of applicable rules or for a demonstrated pattern of deficient performance. Sections 408.815(1)( b)- 17 (d). 79. The Agency may also revoke the license of an Assisted Living Facility for the facility having been cited with one or more class I deficiencies. Section 429.14(1)e1, Fla. Stat. (2007). 80. The Respondent facility was cited with two (2) class I deficiencies. 81. The Agency intends to revoke the license of the Respondent as a result of the numerous cited deficiencies above recited as a result of its survey of November 2, 2007. CLAIM FOR RELIEF WHEREFORE, Petitioner, State of Florida, Agency for Health Care Administration, requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I through IV. 2. Assess against Respondent an administrative fine of ELEVEN THOUSAND NO/100 DOLLARS ($11,000.00) for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Grant such other relief as the court deems is just and proper. NOTICE OF RIGHTS Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. 18 RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE OR REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY Z. AB SALM SQUIRE Florida Bar I.D. No. 30942 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 (850) 922-5873 - Telephone (850) 921-0158 or 413-9313 - Facsimile OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Owner/Operator of Care Center of Ormond Beach, Inc., 1410 Hand Avenue, Ormond Beach, Florida 32174, Return Receipt No. 7000 0520 0024 8388 1655 by U.S. Certified Mail on this dow day of Nov trmboer _, 2007. ZA SALM ESQ. Copies To: Care Center of Ormond Beach, Inc. 1410 Hand Avenue Ormond Beach, Florida 32174 19°

Docket for Case No: 07-005729