Sep 10 2009 14:39 aa/le/2aed ld:ad 8589218158 PAGE 88/27 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, “VS. ‘ Case Nos. 2009007512 ; 2009007513 VISTA MANOR HEALTH CARE ASSOCIATES, LLC, d/b/a VISTA MANOR, Respondent. / ADMINISTRATIVE COMPLAINT . COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by | and through the undersigned counsel, and files this Administrative Complaint against Vista Manor Health Care Associates, LLC, d/b/a Vista Manor (hereinafter “Respondent”, pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE. OF THE ACTION This is an action to change Respondent's licensure status from Standard to Conditional commencing June 17, 2009 and ending June 30, 2009, and impose an administrative fine in the amount of one thousand dollars ($1,000.00), based upon Respondent being cited for one Isolated Uncorrected State Class Ill deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing Sep 10 2009 14:39 9/16/2889 1d:34 85892148158 PAGE 89/27 facilities pursuant to the Omnibus Reconciliation Act of 1987, Title TV, Subtitle C (as arnended), Chapters 400, Part 1, and 408, Part Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120-bed nursing bome, located at 1550 Jess Parrish Court, Titusville, PL 32796, and is licensed as a skilled nursing facility license number 1580096. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. . UNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, all licensees of nursing homes 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 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)(D, Fla. Stat. (2009). 8. That Florida law provides the following: “‘Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The Sep 10 2009 14:39 aa/le/2aed ld:ad 8589218158 PAGE 1@/27 professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(b), Fla. Stat. (2009). 9. That pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400.102(1)(a), Florida Statutes (2009). 10. That on or about May 4-8, 2009, the Agency completed a Relicensure Survey of Respondent’s facility. 11. That based upon observation, interview, and the review of records, Respondent the facility failed to provide 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 where Respondent failed to provide treatment and services for a resident who displayed difficulty in adjusting to long term care, failed to ensure a renal supplement was administered as ordered and a diagnosis and dosage was present for administering of eye drops for a resident, failed to follow a physician's order for the use of a clip belt restraint for a resident, and failed to provide a proper diagnosis for the use of an anti-psychotic medication for two (2) residents, said failures being contrary to law. 12. That Petitioner’s Representative reviewed Respondent’s records related to resident number forty (40) during the survey and noted as follows: a. The resident was admitted to the facility on September 24, 2008 from the hospital with diagnoses of abdominal pain 1/o (rule/out) diverticulitis, chronic obstructive pulmonary disease (COPD), osteoarthritis, and macular degeneration, b. Past medical history included bladder and breast cancer, ag/1la/ 28a 14:34 Sep 10 2009 14:40 8589218158 PAGE A physician's order of October 9, 2008 ordered a psychological consult for "elderly, legally blind, transitioning into long term care.” An initial assessment was conducted on October 17, 2008 and a tentative diagnosis was dementia without behavioral disturbances and anxiety; The next psychologist visit of November 11, 2008 indicated the resident emotionally, is still adjusting to the new life in the facility.” A April 6, 2009 progress note of the psychologist revealed that “the resident is not well {the resident] is in a great deal of pain, 30 much so, [the resident] is tearful and is experiencing feelings of hopelessness and despair.” A April 15, 2009 progress note of the psychologist revealed “initially the resident was making a favorable adjustment to living in the facility but more recently with the medical problems [the resident] is experiencing, [the resident] is talking about wanting to return home which is not realistic." A April 13, 2009 psychologist progress note reads that the resident "is not well, [the resident] is showing a great deal of weight loss, the resident is in constant pain and thought process were confused and continues to talk about going home." Documentation of the psychologist dated April 20, 2009 reflected the resident "is not eating and is very depressed." Documentation of April 27, 2009 revealed the resident's mood "is suspicious and paranoid and there are signs [the resident] is hallucinating; The resident’s physician's order sheet (POS) did not reveal medication for depression was prescribed; ) The resident was ordered on an anti-anxiety medication which was administered when there was an increase in anxiety behavior; 11/27 Sep 10 2009 14:40 aa/le/2aed ld:ad 8589218158 PAGE 12/27 i. Physician's notes did not address the depression the resident was expressing to the psychologist; "a. There were no recommendations or treatments provided to relieve the resident from feeling depressed other than the weekly sessions with the psychologist. 13, That Petitioner’s representative observed resident number ‘forty (40) on May 6, 2009 at 9:30 a. m. and found the resident in the wheeichair propelling self in the room, alert and responsive to communication, with the resident indicating that the resident wanted to go home and felt still capable of taking care of self and did not have an appetite to eat because the resident was depressed and lonely about not being allowed to go back home. 14. That Petitioner’s representative interviewed Respondent’s social worker regarding resident number forty (40) on May 7, 2009 who indicated that she was not aware the resident did not have an appetite, had experienced a significant weight loss, and had feelings of depression. 15. That Petitioner's representative reviewed the notes of Respondent's social worker and noted as follows: a. The notes did not reveal any follow-up on the psycho-social issues of the resident despite the weekly written progress notes of the psychologist describing the responses of the resident, b. The last note from the was dated March 27, 2009 for a quarterly review and documented, "the resident has no change in cognition, well being, mood or behaviors." c. The psychologist was seeing the resident on weekly sessions but did not recommend any medications or a psychiatrist consult for depressive behaviors. 16. That Petitioner's Representative reviewed Respondent’s records related to resident number one hundred twenty-seven (127) during the survey and noted as follows: aa/le/2aed ld:ad £ Sep 10 2009 14:40 8589218158 PAGE Physician orders for May 2009 prescribed Fosrenal 500 milligrams (mg.) before meals and at bed time with administration times of 6:30 a.m., 11:30 a.m., 4 p.m. and 10 p.m. The times were recorded on the medication administration record (MAR); Dietitian notes dated February 13, 2009 identified that Fostenal was not given at mealtimes and recommended a time change; The time change was present on the April 2009 medication administration record, however was not carried over to the May 2009 medication administration record; A physician's order of February 25, 2009 prescribed artificial tears to both eyes three times a day; No diagnosis requiring the prescribed eye drops was annotated; May 2009 physician’s orders contatined the same prescription. 17. That Petitioner’s representative interviewed Respondent's nurse treating resident number one hundred twenty-seven (127) during the survey who indicated as follows: a b. c. She was not aware that the time of administration of the resident’s Forsenal was not correct on the resident’s May 2009 medication administration record; She was not administering the prescribed Fosrenal before meals as ordered; The resident varied the times that the resident ate meals. 18. That Petitioner's representative interviewed Respondent’s Unit Manager on regarding the prescribed eye drops for resident number one hundred twenty-seven (127) duting the survey who indicated as follows: a. b. She confirmed that a dose and diagnosis for the eye drops were to be present, A clarification order was obtained from the physician on May 6, 2009 after this omission was identified. 13/27 Sep 10 2009 14:41 9/16/2889 1d:34 85892148158 PAGE 19, That Petitioner’s reopresentative reviewed the above referenced clarification order and noted that it prescribed natural tears, apply 1 drop to both eyes 3 times a day, however a diagnosis was still not present . 20. That Petitioner’s Representative reviewed Respondent’s records related to resident umber forty-six (46) during the survey and noted as follows: a, The resident had a diagnosis of Alzheimer's disease; b. The resident’s care plan dated April 27, 2009 for activities of daily living for the clip belt revealed the following statement about the clip belt: "Release clip belt for meals, exercise, supervised activity and toileting." c. The physician's order sheet for May 2009 contained the following directive regarding use of the clip belt: "Clip belt when up in wheelchair, release for group activities, exercise, toileting, and meals.” 21. That That Petitioner’s Representative observed resident number forty-six (46) during the survey and noted as follows: a. The resident was in the Starlight room on the Apollo 2 unit at 10:10 AM on May 7, 2009; b, The resident was sitting in the room with ten (10) other residents drinking coffee; c. The clip belt was observed attached to the resident in the locked position; d. A staff nurse was observed supervising the activity at this time; e. At 10:25 AM on May 7, 2009, the resident was again observed with the clip belt on in the locked position. . 22. The Petitioner’s representative questioned Respondent’s staff nurse about the resident having the clip belt on in the locked position at this time as the physician's order was to have the clip belt unlocked during supervised activities and at 10:27 AM on May 7, 2009, the staff nurse 14/27 9/16/2889 1d:34 Sep 10 2009 14:41 85892148158 PAGE unlocked the clip belt attached to the wheelchair of resident number forty-six (46). 33.° That Petitioner’s Representative reviewed Respondent’s records related to resident number one hundred sixty (160) during the survey and noted as follows: a The resident was admitted to the facility on January 13, 2009 with diagnoses of anxiety, cardiac disease, pneumonia and lymphedema; The resident was prescribed an anti-anxiety medication on April 29, 2009 to be given twice a day; . The resident's medication administration record reflected that the resident was ordered the anti-psychotic medication Risperidone 0.5 mg. to be given at bedtime for anxiety. Review of the facility's "2009 Nurses Drug Handbook” for the medication Respiradone did not indicate anxiety as a use for this drug. This finding was confirmed with the UM on 5/05/09 at approximately 11 a.m. 24. That Petitioner’s representative reviewed Respondent’s "2009 Nurses Drug Handbook” and noted that the medication Respiradone did not indicate anxiety as a use for this drug. 25. That Petitioner’s representative interviewed Respondent's unit manager on May 5, 2009 who confirmed that résident number one hundred sixty (160) was receiving Respizadone for anxiety and that Respondent’s policy did not indicate the use of the medication for the diagnosis. 26, That Petitioncr’s Representative reviewed Respondent’s records related to resident number ninety-five (95) during the survey and noted as follows: a. The resident was admitted on February 19, 2009 with renal failure and cardiac disease; Digoxin 0.125 mg. was ordered to be given after returning from dialysis treatments on Tuesday, Thursday and Saturday; 15/27 Sep 10 2009 14:41 Oo/18/2689 14:34 8589218158 PAGE 16/27 c. The resident's medication administration records did not show parameters for a pulse rate or taking an apical pulse; d. Respondent’s vital sign record sheet and the resident’s medication administration records for April and May 2009, reflected resident pulses recorded in the low 60's, one pulse of "56" on April 26, 2009 and another as "56" recorded on April 25, 2009; e. Absent from the records was any indication that the resident’s doctor was notified of the low heart rate. 27. That Petitioner’s representative reviewed Respondent's “2009 Nurses Drug Handbook" and noted that an apical pulse should be taken prior to administering Digoxin and that the doctor be notified of a low heart rate. 28. That the above reflects, collectively and individually, Respondent’s failure to ensure that adequate and appropriate health care and protective and support services, meluding 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 where, inter alia: a. Respondent failed to ensure that a diagnosis of depression was not addressed by the resident’s physician, b, Respondent failed to administer Fosrenal to a resident at times prescribed; c. Respondent failed to ensure that prescribed eye drops contained a diagnosis reflecting the medication’s necessity; d. Respondent failed to ensure that restraints were used in compliance with the residents care plan; Sep 10 2009 14:41 aa/le/2aed ld:ad 8589218158 PAGE 17/27 e. Respondent failed to ensure that prescribed medications addressed the resident's diagnosis in accord with Respondent’s nursing policy and procedure; and f. Respondent failed to take an apical pulse prior to administration of the Digoxin and failed to notify the resident’s physician of the noted low heart rates in accord with Respondent’s policy and procedure. 29. That Respondent had a duty to provide 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. 30. That these failures, collectively and individually, constitute intentional or negligent acts that materially affected the health or well being of the resident. 31, That the Apency determined Respondent had not provided the necessary care and services and had failed to assure each resident 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 and cited this deficient practice as an Isolated State Class III deficiency. 32. The Agency provided Respondent with the mandatory correction date for this deficient practice of June 8, 2009. 33. That on or about June 16-17, 2009, the Agency completed a revisit to the Relicensure Survey of Respondent’s facility. 34, That based upon observation, interview, and the review of records, Respondent the facility failed to provide adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational Sep 10 2009 14:42 9/16/2889 1d:34 85892148158 PAGE 18/27 activities: and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community where Respondent failed to Respondent failed to ensure medication for one (1) OF SIX (6) sampled residents was dispensed according to physician orders, the same being contrary to law. 35. That Florida Board of Nursing, Nurse Practice Act, states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1} the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the Jaws of this state to subscribe such medications and treatments. Section 464.003 (3)(a)(1)(2), Florida Statutes (2008). 36. That Petitioner’s representative reviewed Respondent's records regarding resident number thirty-eight (38) during the survey and noted as follows; a. The resident's medication administration vecord, "Pain Intervention Flowsheet" reflected on June i, 9009 at 3 a.m. that one Loratab was given for complaint of headache; b. No orders for Loratab to be given as needed (PRN) was located on either the June 2009 Physician Order Sheet (POS) or the medication administration record; c. The June 2009 medication administration record did contain an order for "Hydrocodone w/Guaifen SF SYR (for hhycotuss expectorant syrup) give | teaspoonful (5 milliliters) orally every 8 hours as needed for cough," which had been initialed by a nurse as having been administered on June 11, 2009. Sep 10 2009 14:42 Oo/18/2689 14:34 8589218158 PAGE 19/27 37. That Petitioner’s representative interviewed during the survey Respondent’s nurse consultant and Respondent’s nurse who had administered the Latateb to resident number thirty- eight (38) on June 11,2009 who indicated as follows: a. The nurse consultant confirmed that she could not find a as needed (PRN) order for the Loratab; b. The medication nurse confirmed she gave the Loratab to the resident and signed the medication administration record reflecting the administration of prescribed Hydrocodone w/Guaifen SF SYR in error. 38. That Petitioner’s representative interviewed during the survey Respondent’s executive director during the survey regarding resident number thirty-eight (38) who indicated as follows: a. The nurse thought this was an order for hydrocodone BIT/APAP (Loratab) instead it was for hydrocodone w/Guaifen SF SYR; b. She confirmed the nurse gave the wrong hydrocodone, charted in the wrong place, and did not thoroughly read and check physician orders. 39. That the above reflects, collectively and individually, Respondent's failure to ensure that 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 commiunity were provided to resident number thirty-eight (38) where a medication was provided in a non-emergent situation without prescription and the records of medication administration for the resident were completed tin error thereby not reflecting actual medication administered and in error reflecting the administration of a medication which had not been administered. Sep 10 2009 14:42 9/16/2889 1d:34 85892148158 PAGE 28/27 40, That Respondent had a duty to provide 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. 41. That these failures, collectively and individually, constitute intentional or negligent acts that materially affected the health or well being of the resident. 42... That the Agency determined Respondent had not provided the necessary care and services and had failed to assure each resident 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 and cited this deficient practice as an Isolated State Class [TI deficiency. 43, That the above constitutes an uncorrected isolated State Class II deficiency. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of $1,000.00 against Respondent, a skilled wursing facility in the State of Florida, pursuant to § 400.23(8)(c), Florida Statutes (2008). COUNT II 44, The Agency re-alleges and incorporates ‘paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. 45. Based upon Respondent’s uncorrected Class Ill deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part Il of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7){a), Florida Statutes (2009). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Sep 10 2009 14:42 aa/le/2aed ld:ad 8589218158 PAGE 21/27 Statutes (2009) commencing June 17, 2009 and ending June 3G, 2009. Respectfully submitted this 2-/_ day of August, 2009. Thomas wh Tl, Esquire Fla. Bar.No. 566365 Agency for Health Care Admin, $25 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY_OF LICENSE Pursuant to § 400.23(7)\(e), Fla. Stat. (2008), Respondent shalt post the most current 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. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attormmey in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agencp Clerk, Agency for Bealth Care Administration, 2727 Mahan Drive, Bidg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE U.S. Certified Mail, Return Receipt No; 7004 2890 0000 5526 5830 on August .7.-/, 2009 to: Reta Heob, Administrator, Vista Manor, 1550 Jess Parrish Court, Titusville, FL 32796, and by U.S. Mail to Corporation Service Company, Registered Agent, 12 Hays Street, Tallahassee, FL 32301-2525 : I HEREBY CERTIFY that a true and correct copy of the foregoing has been 00 by alsh H, Esquire Sep 10 2009 14:43 9/16/2889 1d:34 85892148158 Copies furnished to: Reta Heob, Administrator Corporation Service Company Vista Manor Registered Agent 1550 Jess Parrish Court 1201 Hays Street Titusville, FL 32796 Tallahassee, FL 32301-2525 (U.S. Certified Mail) (U.S, Mail) Diane D. King Thomas J. Walsh I, Esquire Field Office Manager Senior Attorney Hurston South Tower Agency for Health Care Admin. 400 W. Robinson, Suite 8309 525 Mirror Lake Dr, 330G Orlando, FL 32801 St. Petersburg, Florida 33701 (U.S. Mail) (interoffice) PAGE 22/27 9/16/2889 1d:34 85892148158 Sep 10 2009 14:43 PAGE FIONIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST HOLLY BENSON GOVERNOR ; SECRETARY July 21, 2009 VISTA MANOR 1550 JESS PARRISH COURT TITUSVILLE, FL 32796 Dear Administrator: The attached license with Certificate #15793 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is comect and consistent with your records, If errors of omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a status change to Conditional. Sincerely, . t Agency for Health Care Administration. Division of Health Quality Assurance Enclosure eel aid = cc: Medicaid Contract Management RECEN: Certificate of Need GEMESAL COVE JUL 2 4 2005 Aoaney tur Hes Cate Ac: 2727 Mahan Drive, MS#33 PLD RI Dee CARE Visit AHCA onling at Tallahassee, Florida 32308 Henith Care In the Sunshine hitp://ahoa myflorida,com wer. FloridaCompareGare.gov 23/27 Sep 10 2009 14:43 PAGE 24/27 14:34 8589218158 9/14/2889 SouEmssy ANEN? wor Jo woIsTAIG § STALE 600ZOE/H ALVG NOLLYaaxa SNA 6007/21/90 ‘Lyd HALLOGaALT NOLIOW FONWHO SALVLS SCHa O21 “T¥IOL 96LZE “Td “ATUASALLL LaNO3 HSRIAVd Sar oss YONVIN VISIA , . “BuULMo]pOy am gyerado. oH poznone Es SoSUZOT] aut S@ pur ‘somes epLOL T] ued ‘QOp sordeyy ur pezuomne ‘UORENsUIpY WED yes JO4 Aouady ‘epuopy jo ayEIg any Aq perdope suonejnar pure sap op yrim porjdwos sey 377 ‘SALVIDOSSY FAVS HLTVAH YONVAI VSIA retp wenp00 01 BUSTLE AINOH DNISUON AONVENSSY ALTIVND HLTVaH 4O NOISIAIG NOILVULSININGY FaVO HLTVaH Yo AONADV VPLIOL JO 938}5 Se008S TINS -# ASNT : LOLS] HA LVOLLL WAS aa/le/2aed ld:ad 8589218158 Sep 10 2009 14:44 PAGE 25/27 STATE OF FLORIDA ; AGENCY FOR HEALTH CARE ADMINISTRATION RE: VISA MANOR HEALTH CARE CASE NO: 2009007512 ASSOCIATES, LLC, d/b/a VISTA MANOR 2009007313 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (2)) days of the date you receive the attached Administrative, Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. "If your Election of Rights with your elected Option is not received by AHCA within twenty-one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a Final Order will be issued. Please use this form unless you, yout attorney or your representative prefer to reply in accordance with Chapter120, Florida Statutes (2008) and Rule 28, Florida Administrative Cade. PLEASE RETURN YOUR ELECTIC YN_OF RIGHTS TO THIS ADDRESS: Agency. for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: 850-922-5873 Fax: 850-921-0158 PLEASE SELECTONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) ____ I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a bearing. I understand that by giving up my right to a hearing, a Final Order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (@2)___si admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where 1 may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) ___ I dispute the allegations of fact and law contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. aa/le/2aed ld:ad 8589218158 Sep 10 2009 14:44 PAGE 26/27 PLEASE NOTE: Choosing OPTION THREE (3) by itself is NOT sufficient to obtain 2 formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Tt must be received by the Agency Clerk at the address above within 2] days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28~ 106.2015, Florida Administrative Code, which requires that it contain: 1, Your name, address, telephone number, and the name, address, and telephone number of your representative ox lawyer, if any. 2. The file number of the proposed action. 3. .A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes may be available in this matter if the Agency Agrees. , License Type: (Assisted Living Facility, ‘Nursing Home, Medical Equipment, Other) Licensee Name: : License Number: Contact Person: Name Title Address: : Street and Number City State Zip Code Telephone No. Fax No. E-Mail (optional) [hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the above licensee. Date: Signature: Tide: Print Name: Sep 10 2009 14:44 PAGE 27/27 9/16/2889 1d:34 85892148158 COMPLE FE THIS BE OCTION ON DET IVER Y Mee SENDER: COMPLETE 7, ® Gomplete itema 4, 2, ana 4. Also complete item 4 if Restricted Delivery is desired. 4 @ Print your name and actress on the averse 50 that we can return the card to you, - &@ Attach this card to the back of the rhalipiece, or on the front if space permits. 1. Aiticle Addressed to: SEO TION 221 BD. Is dalivary actress different from tens 19 Td IFES, enter delivery addrase below; 1] No Reta Heob, Administrator Vista Manor ; 1550 Jess Parrish Court Titusville, FL 32796 latumn Fecelpt for Merchenclisa O Insured Mal “D1 c.0.0. , , 4. Restricted Dalvery? iia Feo) ven ad 7004 28490 go00 Sseu sagn | t= 7a IZ ¢, PS Form 3811, Febmary 2004 Domautic Retum Flecaipt 10250-1546:

Docket for Case No: 09-004937