STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2009010559 (Fines) 2009010560 (Cond.) BRIDGEVIEW CENTER, LLC ' d/b/a BRIDGEVIEW CENTER, 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 Bridgeview Center, LLC, d/b/a Bridgeview Center (hereinafter ““Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 upon Respondent, pursuant to Sections 400.022(1)(1) and 400.23(8), Florida Statutes (2009). The imposition of this fine is based on two Class II deficiencies. The Agency also intends to impose a Conditional rating effective September 4, 2009 ending September 23, 2009, pursuant to section 400.23(7), Florida Statutes (2009). 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. 1 Filed December 21, 2009 2:21 PM Division of Administrative Hearings. 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 facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 65-bed nursing home, located at 350 Ridgeview Avenue, Ormond Beach, Florida 32174, and is licensed as a skilled nursing facility license number 10590961. 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. COUNT I RESPONDENT’S FACILITY FAILED TO ENSURE THE SAFETY OF A RESIDENT WHICH RESULTED IN THE RESIDENT HAVING BILATERAL FRACTURED FEMURS §400.102(1), Florida Statutes (2009) ISOLATED CLASS II DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to section 400.102(1), Florida Statutes, Florida law states: In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 8. That on September 4, 2009, the Agency conducted an unannounced complaint survey at the Respondent’s facility. The findings include: 10. Based on a review of resident's clinical record, and interview with the resident, an interview with the Director of Nursing and hospital provided documentation, the facility failed to ensure the safety of one of three residents, Resident #1, from an injury of unknown origin which resulted in the resident having bilateral fractured femurs, which caused the resident to experience pain for a documented seven days. 11. Resident #1, who was admitted to the facility on 3/24/08, had updates to the Minimum Data Set (MDS) on 2/3/09 and 5/1/09 which revealed that the resident was cognitively impaired, was dependent on staff, had daily mild pain and had not fall/fracture in the last thirty days. 12. However, a significant change was completed on 7/22/09 revealing that the resident had fallen in the last 180 days, last fall on 4/10/09. The resident was noted at risk for falls, keep the resident's bed low and use a mechanical lift. 13. The use of the mechanical lift was noted on the 7/27/09 plan of care which also noted that the resident had an overall decline in their activities of daily living. 14. Resident #1 had resided in the facility from 3/24/08 through 7/31/09 when she was discharged to the hospital with bilateral fractured femurs. 15. Medical record review revealed Resident #1 was totally dependent on staff for all activities for daily living and required a mechanical (Hoyer) lift for transfers. 16. Resident #1 was confused and moderately impaired and was unable to express themselves. 17. A review of the resident's clinical record did not reveal an incident that caused the resident to sustain fractures. 18. Documentation revealed Resident #1 was in their usual state of health until 7/24/09 at 7 PM when nursing documentation revealed Resident #1 complained of an increase in pain and new orders were received for pain management. 19. | Documentation revealed Resident #1 continued to have pain up until 7/31/09 when the resident was seen by an orthopedic doctor outside the facility. 20. This appointment resulting in a direct transfer to a local hospital. 21. Interview with the Director of Nurses on 9/4/09 revealed the facility did an investigation which "found the facility was not at fault and the facility could not determine how the fractures occurred". 22. The Director of Nursing stated when first interviewed that Resident #1 stated to facility staff he/she had a fall, but according to the Director of Nursing, Resident #1 subsequently denied having a fall. 23. The Director of Nursing would not allow the investigation documentation to be viewed by the surveyors and there was no proof an investigation into the incident had taken place. 24. The Director of Nursing stated there had been no in-services to staff since 7/24/09 on transfers, Hoyer lifts or falls because there was no evidence an incident had occurred. 25. An x-ray report completed on 7/28/09 at the facility revealed the following condition at that time for Resident #1: a. "Right knee, there is a fracture involving right supracondylar femur with moderate displacement. Intact knee arthoplasty. There is associated joint effusion, osteoporosis is present. Impression-An acute right knee fracture as described, intact knee arthroplasty”. b. "Left knee, there is a fracture involving left supracondylar femur with moderate displacement. The joint shows no dislocation. There is associated joint effusion, osteoporosis is present. Impression acute left knee fracture as described above. Intact knee arthoplasty. 26. On 7/29/09, the family member requested an appointment for the resident with an orthopedist and requested notification of the appointment date and time so that she may attend with the resident. 27. There was a written order on 7/29/09 for an "Ortho consult ASAP with whoever can do it." 28. Resident #1 was transfer to an orthopedic appointment on 7/31/09 at 2 PM and later directly transferred to one local hospital's emergency room where the emergency department physician documented bilateral patella fractures/femurs which occurred 1 week ago. 29. The physician noted resident in nursing home questionable chair lift fractured bilateral legs. 30. Resident #1 was then transferred to another local hospital for further treatment. 31. The emergency department physician documentation revealed " Patient received from (hospital) with complaint of bilateral leg fractures. Patient was apparently involved in a mishap involving a Hoyer lift at the nursing home one and half week s ago. (The resident) was not x- rayed and placed into knee immobilizers. (Family member) states it was not until she insisted upon x-ray that they found (the resident) had bilateral patellar fractures and femur fracture. 32. The physician's physical included the finding of the right thigh has a palpable distal femur fracture with angulation deformity with tenderness in this area as well as bilateral knees diffusely ". 33. | Documentation by an internist assigned to care for Resident #1 at the local hospital revealed "Apparently (the resident) had an accident within the past 7-10 days. (The resident) is non-ambulatory and lives in a skilled nursing facility. (The resident) requires assistance to transfer and at some point the patient suffered some injury, most likely involving a transfer difficulty which resulted in a right femur fracture and also a fracture at the left distal femur where it intersects at the knee arthroplasty hardware. The patient had ongoing pain for the past week ". 34. An interview with the facility's Director of Nursing on 9/4/09 at 1 PM revealed that Resident #1 was not examined by a physician before 7/31/09 or sent to the local emergency department because the resident "was not in pain and seemed comfortable". 35. On review of the facility report to AHCA (Agency for Healthcare Administration) both the One Day Report and the 15 Day Report documentation revealed the "Date of Incident" to Resident #1 took place on 7/29/09. 36. A review of the Adverse Incident form (15 Day report received on 8/13/09) noted the incident date was 7/29/09. 37. Under circumstances the facility documented that the resident had ecchymotic areas (purple discoloration of the skin) to bilateral lower extremities in the lower thigh/knee region as well as the left fifth toe. However, there was no documentation in the clinical record which indicated the presence of these ecchymotic areas to both lower legs, only to the right leg per skin assessment conducted on 7/28/09 at 10 PM. 38. The facility also stated in the report that a "thorough investigation" had been conducted and they were unable to determine cause of the injury. 39. It further stated that the “care plan was followed. Incident therefore determined not adverse". 40. The resident was alert enough to tell the facility that he/she had increasing pain for 7 days, beginning 7/24/09. 41. The resident was evaluated in a physician's office on 7/31/09 and directly admitted to an acute care hospital at that time. 42. The admitting diagnosis was that the resident, who had resided in the facility since 2008, had sustained bilateral femur fractures within the last 7-10 days. 43. The facility did not provide documentation as to what happened to Resident #1 that caused the resident to have pain, to include direct care staff interviews between 7/23/09 at 7 pm until the first sign of pain was documented at 7/24/09 at 7 PM. 44, There was no evidence that the facility acknowledged this incident as an adverse incident which resulted in increasing pain and the resident being admitted to the hospital with leg fractures. 45, An interview with Resident #1 on 9/4/09 at 2 PM at another skilled nursing facility where the resident currently resides revealed upon questioning on what had caused his/her broken legs the resident stated that he/she fell at home when moving but the resident did not know how they fell. 40. Observation on 9/4/09 at 10:15 am on the 2 North unit in room 203B revealed a totally dependent resident who was in the process of being transferred by a Hoyer lift. 47. A surveyor was observing with a full view but outside of the resident's room. The unit manager got up from the desk and walked past the surveyor into the resident's room. The aide had already placed the Hoyer lift sling under the resident and attached it to the lift. The lift was ljocated on the side of the bed with the aide behind it. 48. The nurse manager was standing at the foot of the bed and the wheelchair was at the foot of the bed. 49. The aide was cranking up the lift when the resident started screaming "my legs, my legs" at which time the aide readjusted the resident's legs. 50. The resident was a bilateral below the knees amputee and was then tumed in the lift and rolled over to the wheelchair with the unit manager standing by. Sl. It was observed that the resident rooms that are semi-private do not have space for the lift and a wheelchair to be placed alongside the bed. 52. The Agency provided Respondent with the mandatory correction date for this deficient practice of October 4, 2009. 53. The above constitutes a violation of section 400.102(1), Florida Statutes, and constitutes an isolated class II deficiency pursuant to section 400.23(8)(b), Florida Statutes. 54. | WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 400.102, Florida Statutes (2009). COUNT IT RESPONDENT?’S FACILITY FAILED TO PROVIDE MEDICAL SERVICES TO PREVENT PAIN FOR A RESIDENT RESULTING IN DELAYED TREATMENT § 400.022(1) (1), Florida Statutes (2009) ISOLATED CLASS ff DEFICIENCY 55. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 56. That pursuant to section 400.022(1)(1,) Florida Statutes, Florida law states: All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (I) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. 57. That on September 4, 2009, the Agency conducted an unannounced complaint survey at the Respondent’s facility. The findings include: 58. Based on a review of resident's clinical records, an interview with the resident, an interview with the Director of Nursing and hospital provided documentation, the facility failed to provide medical services to prevent pain for one of three residents, resulting in delayed treatment, obtaining x-rays and a discharge to the hospital for further diagnosis and treatment. 59. The resident told the facility of being in pain and the facility's records documented that Resident #1 experienced pain for over a week without recognizing a cause. 60. Resident #1, who was admitted to the facility on 3/24/08, had updates to the Minimum Data Set (MDS) on 2/3/09 and 5/1/09 which revealed that the resident was cognitively impaired, was dependent on staff, had daily mild pain and had not fall/fracture in the last 30 days. 61. However, a significant change was completed on 7/22/09 revealing that the resident had fallen in the last 180 days, last fall on 4/10/09. 62. The resident was noted at risk for falls, keep the resident's bed low and use a mechanical lift. The use of the mechanical lift was noted on the 7/27/09 plan of care which also noted that the resident had an overall decline in their activities of daily living. 63. | Areview of all MDS'since admission revealed that Resident #1 had not experienced any pain. 64. A review of the nurse's notes in the clinical record for Resident #1 from 7/14/09 at 7 PM through 7/23/09 at 7 PM revealed no documentation of the resident experiencing any pain. 65. A review of the clinical record for Resident #1 revealed that the resident was administrated Lortab tablet one, twice a day for pain. 66. Nursing documentation revealed on 7/24/09 at 7 PM "customer complaining of increased pain upon movement (legs) scheduled Lortab given per orders. 67. - Acall was placed to the ARNP and a new order to increase pain mediation was received, new order per ARNP to increase Hydrocodene 5/325mg to one every 8 hours and Hydrocodene 5/325mg one every 4 hours as needed for pain. 68. There was no documentation of any type of assessment started to determine why the resident was having an increase in pain. 69. On 7/25/09 at 2 pm nursing documentation revealed “continue to medicate with Lortab 5/325mg one by mouth every 8 hours around the clock”. 70. Documentation on 7/26/09 revealed that the resident continued on Lortab every 8 hours around the clock per doctor's order for pain management. 71. 7/25/09 at 5:30 pm nursing documentation revealed Resident #1's family member voiced concern over the resident's bilateral lower leg pain and left hip area. A call was placed to an ARNP and an order received for Baclofen 5 mgm twice a day and to increase the Lortab to 7.5/325mg one every 8 hours around the clock. 72. Nursing documentation on 7/26/09 at 11:45 pm revealed Resident #1 had a bruise on the left foot fifth digit. The resident was noted "grimacing in pain" on movement of the bilateral legs. 73. Nursing documentation on 7/27/09 at 10:30 pm revealed the resident was medicated for left hip pain. Nursing documentation also revealed that the Resident's family member was at the facility during the evening and requested an x-ray due to Resident #1's increased leg pain. 74, Nursing documentation on 7/28/09 at 3:20 am and 1:30 PM revealed Resident #1 complaining of "right leg pain and having facial grimacing". The resident stated that “it hurts" and "ouch" when it is touched. 75. On 7/28/09 at 1:30 PM it was documented that Resident #1 had "grab" an aide's arm during care and stated "it hurts". The resident at that time indicated that the pain was in their lower body. Further documentation at 1:30 PM revealed an x-ray was ordered. 76. On 7/28/09 at 10 PM an assessment of the resident's skin was completed noting ecchymotic areas on the right leg. 77. Progress notes on 7/28/09 by the ARNP (time unknown) revealed Resident #1 with "general pain specifically in hips, femurs, knees and feet" and that the family member had requested an x-ray. 78. A Mobilex radiology report dated 7/28/09 at 10:46 PM revealed "Right knee there is a fracture involving right supracondylar femur with moderate displacement. Left knee there is a fracture involving left supracondylar femur with moderate displacement”. 79. The report was faxed to the ARNP on 7/29/09 at 6:35 am. 80. On 7/29/09 at 4 am it was documented that Resident #1 was having pain with a change in position. 81. On 7/29/09 at 3:15 PM documentation revealed splints applied to both knees to stabilize the knees. Documentation also revealed Resident #1 was not eating well and a diet change was made. 82. Nursing documentation on 7/29/09 at 3:19 PM revealed the Director of Nursing being notified of the x-ray report. 83. Documentation described Resident #l's appearance as being "pale and slightly waxy, with dark circles under her eyes; complaint of pain and facial grimaces”. 84, On 7/29/09, the family member requested an appointment for the resident with an orthopedist and requested notification of the appointment date and time so that she may attend with the resident. There was a wnitten order on 7/29/09 for an "Ortho consult ASAP with whoever can do it. " 85. On 7/30/09 at 2:30 PM the nursing documentation revealed Resident #1 having a yellowish discoloration to knees, with increase leg pain. 86. | Nursing documentation on 7/30/09 and 7/31/09 revealed Resident #1 "still complaining of pain". 87. On 7/31/09 at 2 PM nursing documentation revealed that Resident #1 was at the doctor's office. 88. Later documentation at 2:45 PM revealed that Resident #1 was in route to the local hospital for "fx (fracture) to femur". 89. | Documentation from the local hospital dated 7/31/09 revealed on the History and Physical "Apparently had an accident within the past 7-10 days; At some point the patient suffered some injury, most likely involving a transfer difficulty which resulted in a right femur fracture and also a left distal femur fracture where it intersects knee arthoplasty hardware. The patient had ongoing pain for the past week”. 90. An interview with the facility's Director of Nursing on 9/4/09 at 1 PM revealed that Resident #1 was not examined by a physician before 7/31/09 or sent to the local emergency department because the resident "was not in pain and seemed comfortable". 92. On review of the facility report to AHCA (Agency for Healthcare Administration) both the One Day Report and the 15 Day Report documentation revealed the "Date of Incident" to Resident #1 took place on 7/29/09. 93. A review of the Adverse Incident form (15 Day report received on 8/13/09) noted the incident date was 7/29/09. Under circumstances the facility documented that the resident had ecchymotic areas (purple discoloration of the skin) to bilateral lower extremities in the lower thigh/knee region as well as the left fifth toe. 94. | However, there was no documentation in the clinical record which indicated the presence of these ecchymotic areas to both lower legs, only to the right leg per skin assessment conducted on 7/28/09 at 10 PM. 95. The facility also stated in the report that a "thorough investigation” had been conducted and they were "unable to determine cause of the injury". It further stated that the “care plan was followed. Incident therefore determined not adverse". 96. The resident was alert enough to tell the facility that he/she had increasing pain for 7 days, beginning 7/24/09. 97. The resident was evaluated in a physician's office on 7/31/09 and directly admitted to an acute care hospital at that time. 98. The admitting diagnosis was that the resident, who had resided in the facility since 2008, had sustained bilateral femur fractures within the last 7-10 days. 99. The facility did not provide documentation as to what happened to Resident #1 that caused the resident to have pain, to include direct care staff interviews between 7/23/09 at 7 PM until the first sign of pain was documented at 7/24/09 at 7 PM. 100. There was no evidence that the facility acknowledged this incident as an adverse incident. The incident resulted in increasing pain and the resident being admitted to the hospital where it was determined that the resident had leg fractures. 101. Interview with Resident #1 on 9/4/09 at 2 PM at a skilled nursing facility where the resident currently resides revealed upon questioning on what had caused his/her broken legs the resident stated the he/she fell "at home" when moving but the resident did not know how they fell. 102. The Agency provided Respondent with the mandatory correction date for this deficient practice of October 4, 2009. 103. The above constitutes a violation of section 400.022(1)()), Florida Statutes, and constitutes an isolated class IL deficiency pursuant to section 400.23(8)(b), Florida Statutes. 104. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§, and 400.102, Florida Statutes (2009). COUNT Ill 105. The Agency re-alleges and incorporates paragraphs 1 and 2 of this Complaint as if fully set forth herein. 106. The Agency re-alleges and incorporates Count I and II of this Complaint as if fully set forth herein. 107. Based upon Respondent being cited with 2 State Class II deficiencies, it was not in 14 substantial compliance at the time of the survey with criteria established under Part II 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)(b), 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 Statutes (2009) commencing September 8, 2009. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Counts I, I and II. (B) Recommend administrative fines against Respondent in the amount of $5,000; (C) Impose a conditional license commencing September 4, 2009. (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this ii O day of December, 2009 . Carlton Enfinger, I] Fla, Bar. No. 793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Retum Receipt No. 7004 2890 0000 5526 4772 to: Facility Administrator Jason Kallen, Bridgeview Center, 350 S. Ridgeview Avenue, Ormond Beach, Florida 32174 and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 4765 to Registered Agent David J. Powers,P.A., 7777 Glades Road, Suite 300, Boca Raton, Florida 33434 on December £0. 2009: Copy furnished to: Rob Dickson, FOM 16 FLORIDA AGENCY FOR HEALTH CARE ADMINSTRATION CHARLIE CRIST THOMAS W. ARNOLD GOVERNOR SECRETARY December 3, 2009 Bridgeview Center 350 S. Ridgewood Avenue Ormond Beach, FL 32174 Re: License Issued for a Status Change to Conditional Dear Administrator: The attached license with Certificate #16087 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or 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 Sincerely, (Salsa. Gmlrouor Barbara Dombrowski Health Facilities Consultant Agency for Health Care Administration Division of Health Quality Assurance Enclosure cc: Medicaid Contract Management Certificate of Need SFLORIDA 2727 Mahan Drive, MS#33 BOOMPARE CARE Visit AHCA online at Tallahassee, Florida 32308 ” Health Care in the Sunshine http://ahca.myflorida.com F www.FloridaCompareCare.gov O10@/0€/r0 “ALVG NOILVUld Xa ASNAOIT 6002/0/60 ‘ALVC AAILOAAIA NOILOV ADNVHD SO.LV.LS Sdad 6tl *TVLOL pLIt@e Td ‘HOVAd GNOWYO HNANAAV GOOMADCH 'S 0S YELNAOD MATAPOCMa ‘SUIMOT[OJ 9y} ayeIado 0} pezioyne st sasusot] ay) se pure ‘saynjejg eplol.] ‘T] Hed ‘OO JoideyD ut peziuoyine ‘uonenstunupy eed yeapy Jo. Aoussy ‘eplio J Jo a1e1g ays Aq paydope suone|nsar pue soyny oy YIM palfduoo sey OTT “WALNAO MAIATOCIAA Jeu} wAFUOD 0} SI Sty], TWNOILLIGNOO HINOH ONISAUIIN FONVANSSV ALITWNO HLTVaH dO NOISIAIC NOILVaULSININGYV davO HLTVdH YOu AONYDV VPLIOL,] JO 33836 19606SOTINS :# ASNAOIT L8091 +# ALVOWILYAO Ro ~ FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST THOMAS W. ARNOLD GOVERNOR SECRETARY December 3, 2009 Bridgeview Center. 350 S. Ridgewood Avenue Ormond Beach, FL 32174 Re: License Issued for Status Change to Standard Dear Administrator: The attached license with Certificate #16091 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or 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 Sincerely, Borbare Umborel Barbara Dombrowski Health Facilities Consultant Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management Certificate of Need ORIDA - - MPARE CARE Visit AHCA online at Ith Care in the Sunshine http://ahca. myflorida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 £ www. loridaCompareCare.gov aouemssy Aylpend) wea] JO UOISIAICy ‘ O10Z/0E/P0 “ALVC NOLLVUIdXad ASNAOTI 6002/72/60 “ALVC JALLOAATA NOLLOV ADNVHD SALVLS S$ddd 61 “TVLOL pLIZ€ Td ‘HOVAE GNOWYO ANNAAV GCOOMADCI'S Ose YALNAO MATAPT OCI {SULMOTLOF ou} ayerado 0} pazLioy Ne si sasuadl| a] Se pur ‘sainqerg epuoly ‘TI we ‘OOP JaldeyD ul pezuouine ‘uoNeNsuIMUpy aed Wfeay 10,4 Aouedy “epLlol] JO a1z1g ay} Aq paidope suonesngar pue sop oy YIM patdutoo sey OTT “YALNAO MATAPOGIA 12y} wurpuos 0} St STU, MuvaNvLs HINOH ONISUAIN AFONVANSSV ALITWNO HL’ IVaH AO NOISIAIG NOILLVaULSININGY AavVO HL TVAH aod AONHOV UPLIO[ | JO 3387S 16091 -# ALVOISILYEO OFFI Posiage | 9 Certified Fes Return Raceipt Feo (Endorsement Required) Restricted Delivery Fee (Endorsement Rocuirog} Total Postage & Fees SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery Is desired. @ Print your name and address on the reverse so that we can return the card to you, § Aitach this card to the back of the mailpiece, or on the front If space permits. 1. Article Addressed to: » tereernes Mau Cl Express Malt O Registered _O Retum Recelpt for Merchandise Ci tnsured Mat (1 6.0.D.

Docket for Case No: 09-006955