OO arate. “tege-STATE OF ELORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, ~ oe Petitioner, _ V0 unite et neve Case Nos, 2010006647 _ ie se" 9910006648 * SOVEREIGN HEALTHCARE OF ATLANTIC SHORES, LLC d/b/a oe : me oon __ ATLANTIC SHORES NURSING AND REHAB CENTER, “ Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency” or “Petitioner”), by and through the undersigned counsel, and files this Administrative Complaint against SOVEREIGN HEALTHCARE OF ATLANTIC SHORES, LLC d/b/a ATLANTIC SHORES NURSING AND REHAB CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing 05/06/10 and ending 06/05/ 10, and impose an administrative fine in the amount of two thousand dollars ($2,000.00), based upon Respondent being cited for two (2) uncorrected and isolated State Class II deficiencies. “ Filed November 30, 2010 10:19 AM Division of Administrative Hearings JURISDICTION-AND VENUE |--=« ae t The Agony as fran pursuant $9120.60 and 00:06; Forde Statutes 200} 2. Venue lies pursuant to Florida Administrative Code R.28-106.207. seca PARTIES 3. The Agency 1 is the: Tegulatory authority responsible for licensure of nursi g homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Oninibus Reconciliation Act of 1987, Title IV, Subtitle € (as, amended), Chapters 400, Part H, and 408, Part II, Florida “Statutes, and Chapter 59A-4, Florida Administiative Code. - 4, Respondent operates a 120-bed nursing home, located at 4251 Stack Bivd., Melbourne, FL 32901, and is licensed as a skilled nursing facility license number 16420951. 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 (Tag N101) 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, “[eJach medical record shall contain sufficient information to clearly identify the resident, his diagnosis and treatment, and results. Medical records shall be complete, accurate, accessible and: systematically organized.” Fla. Admin. Code R. 59A- 4.118(2). 8. That pursuant to Florida law, “[e]very licensed facility shall comply with all applicable standards and rules of the agency and shall: (j) Keep full records of resident admissions and discharges; medical and. general health status, including medical records, personal ‘and social Page 2 of 14 | shistory, and identity and address of next-of-kin or other persons who may have responsibility,fo) the-affairs—of the-residents;and individual -resident_care plansineluding,_but-not limited_to, prescribed services, service | frequency and duration, and -service-goals. The records shall-be-open to inspection by the agency.” See § 400.141(1)G), Fla. Stat. (2010). 9. -.That a Relicensure Survey’ was conducted from Margh 22-26, 2010 at Respondent's “~ ae fants facility. 10. That based on record réview and interview, Respondent failed or refused to-maintain resident medical records in an accurate, complete and orgariiZéd manner for four (4) of twenty- Resident No. 242, hereafter “R117”, “R149”, “R168” and “R242”). 11. That the findings include the following: a, Review of R168’s clinical record on 03/22/10 revealed a physician’s order teas sheet (hereafter “ROS”) for 3/10 belonging to another resident and roommate ) in R168’s medical record. The POS had been signed by the physician, An interview with the Unit Manager (hereafter “UM”) of the south wing at 11:30 a.m. confirmed the POS was filed in the wrong chart. ‘dD. During a review of R242’s medical record a Mini Mental Exam (hereafter “MME”) was found. The MME was not signed by the person who administered the test and there was a hole punched to indicate the day of the month the resident was tested. Review of the Social Service Director’s notes confirmed the MME was done but her note was not dated, nor did she indicate who administered the exam and/or when the MME was done. i. An attempt to review of the physicians notes, dated 03/15/10, for R242, was done at that time. On 03/22/10 at approximately 4:00 p.m., the North — Page 3 of 14 ceva, secure? me ee ore Wing UM...vag..able. to. interpret, the physician’s notes regarding her eRe RL tae assessment.of the resident or her plan of care for the resident. it, A progress note was found in R242’s medical record-under-the-purple-tab for physician consults was written 03/2_/10 (date illegible). At that time, the UM confirmed she could not interpret what date the a note was een ” written and she confirmed there was no resident name on the | Hrogress note. ers: iti. On 03/24/10 at approximately 1:55 p.m, an interview was conducted with “ Respondent’s Medical Director. He reviewed the provider’s notes and agreed they were not legible. He could not interpret the notes or confirm what the providers plan of care wes the R242. c. Review of the medical record for R149 was performed, The Face Sheet was reviewed for pertinent information, Missing was the Admission time, date and admission from, Advance Directives, Level of Care, Estimated Length of Stay, Admitting Diagnosis, and Other Diagnosis Allergies. i. Interview with the North wing UM was conducted 03/26/10 at approximately 5:00 p.m. She confirmed if the resident went to the hospital the Face Sheet would be copied and sent with R149. She agreed that the missing information could be found in the residents medical record and should have been updated on the Face Sheet. d. A medication pass observation was conducted with R117 on 03/25/10 at approximately 8:55 a.m. The POS. could not be found in the resident’s medical record to reconcile the medications R117 received. Page 4 of 14 « 12..,..,.dAn-dnterview was conducted with the-South wing UM 9n.03/25/10 at approximately 9:10... am. She review RH?'s-medicat record, checked the physicians box-and-confirmed the March——_—— POS was not in the medical record” She eventually found R117's POS in the medical record of ome his/her roommate. 13. The Agency provided Respondent with the mandatory correction date for this deficient ; practice of 04/26/10. ~ | _ - 14. That on or about 05/06/10, the Agency completed a Revisit to Annual Health Survey of Respondent’s Facility. ° . 15. That based on 6bservation, interview and record review, the Facility failed or refused to ensure that physicians orders were properly transcribed for one (1) (Resident No. 71, hereafter “R71”) sampled resident who did not have a medication transcribed from the April’s Medication Administration Record (hereafter “MAR”) to the May’s MAR, which could lead to the resident soe, “ not receiving prescribed medications. te ane 16. That record review for R71 revealed a physician’s order was written 04/27/10 for Vitamin D3, 400 units, one (1) tablet orally daily. 17. That a review of the MAR for 4/10 revealed the medication was given from 4/28-30/10; review of the MAR for 5/10 showed the medication was not documented on the MAR and was not given. 18. That during an interview at on 05/06/10 at 10:00 a.m. with the Director of Nursing and the UM, they each stated they did not know why the medication was not given. A telephone call to the consultant pharmacist revealed the medication was in stock and should have been given as ordered. Page 5 of 14 39:,,..That in the case-at bar, the aboy, ect, inter alia, that Respondent: ....... cats vow is Bn ON atilaciae itn vt a Filed medical records in the wrong chart; 6. Had unsigned and incomplete medical records; “ret c. Had missing and/or misplaced POS; d. Had undocumented MARs; and ener’ e e. Improperly administered medications. * 20. That in the case at bar, the-above reflect, inter-alia, that Respondent failed and/or refused to maintaii complete, accurate and organized medical records for Respondent's residents, the ” failure of which is’contrary to law. 21. That these failures, collectively and individually, constitute no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical. physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan” of care, and provision of services of the Respondent’s residents. 22. That the Agency determined these failures relate to the operation and maintenance of the Facility or to the personal care of residents which is a deficiency the Agency considers will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited this deficient practice as an isolated and uncorrected State Class III deficiency. «A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 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 licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, a civil penalty may not be imposed.” See § 400.23(8)(c). Page.6 of 14 \Svaie oc. WHEREEORE, the Agency seeks to impose-an-administrative fine.in the amount of one = ———“thousand-dollars ($4,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to-§§400:23(8)(-c) and 400-102; Florida Statutes (2010): | COUNT Ii (Tag 'N201) sna 23. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set . | forth herein. _ / ~ 24. That pursuant to Florida law, “t]he tight 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 establishédand recognized practice standards within the community, and with rules as adopted by the agency.” See § 400.022(1)(1), Fla. Stat. (2010). - 25. That a Relicensure Survey was conducted from March 22-26, 2010 at Respondent’s “ facility. om 26, That based on observation, the Respondent failed or refused to ensure that proper catheter - care was performed on one (1) of two (2) residents reviewed for catheter use investigation which could lead to a decline in the care and physical well being of the resident (specifically Resident No. 22, hereafter “R22”). 27. ° That findings include the following: a. On 03/24/2010 from 10:10 a.m. - 10:30 a.m., the following occurred: catheter care for R22 was performed by the licensed practical nurse (hereafter “LPN”) caring for the resident. She brought the entire treatment cart into the resident’s room. She washed her hands appropriately but when she came out into the room where the cart was at she took her keys out of her pocket and unlocked the cart. She gathered the supplies and put them on top of the cart, Page 7 of 14 TE aaa b. —hback to the cart and put gloves on. She got the body wash and squeezed seme into-the-water.—As she was squeezing the bottle, she dropped the bottle-into the water. She picked it out of the water and continued to squeeze the body wash into. it. ‘She.then opened up several packets of 4x4 gauze pads and put them into the water. She took tape, additional packets of 4x4s and the basin of water to: the resident’s bedside.. The treatment cart remained in’ the resident’s room. She placed the basin-on the ovetbed table. She asked the resident to sit on the side of the bed. With the resident in a sitting. position, she took one of the soaked 4x4 and washed [resident’s body part] in a circular downward motion. She took another wet 4x4 and did the same motion. She then took a dry 4x4 and dried the area off. She took off her gloves and then, assisted the resident with pulling up his/her pants. sam / i, She took the treatment cart back out of the room and put it back into the medication.room. She did not clean the cart before taking it into the resident's room or after taking it out of the room and putting it back in the medication room. ii. The name of the body wash she used was “Medline Shampoo and Body Wash”. The body wash directions were : “Either apply to damp cloth or add small. amount. to basin of warm water. Cleanse patient’s face. Continue down the body. Rinse thoroughly. Pat dry.” She did not rinse -- the area where she used the body wash. Review of the chart of R26 revealed the resident had diagnoses of diabetes, seizure and atrial fibrillation. . Review. of physician’s. orders dated 03/10/10 Page 8 of 14 cera: Zeyealed the resident was to have a-splint-on the right hand.at night and to-- aE have-it removed -during the day. 1 iii. iv. Observation of the resident revealed” the Tesident- wearing the tight-heexd——H— re splint while sitting in an activity at 10:30 a.m. on 03/22/10, At 9:10 a.m.’ on 03/24/10, the resident was observed lying in bed without the right hand splint on at that time. The resident was observed again on 03/24/10 at _ - 11:45 a.m: eating lunch with thé tight hand splint affixed to the right hand. . An interview took place with the resident’s 7-3 certified nursing assistant (hereafter “CNA”) at 1:20 p.m. on 03/24/10, The CNA was asked when she put the splint on the resident. ‘The CNA stated she “put in on when s/he gets up in the morning. That was when therapy used to do it.” Review of the CNA flowsheet at 1:30 PM with the CNA revealed, “right hand splint on at bedtime, off in AM.” : An interview took place at 1:35 p.m. on 03/24/10 with the occupational therapist (hereafter “OT”) who planned the use of the right hand splint for R26. The OT stated at this time: “you want the hand to be able to get air and be observed to check on the skin integrity during the day.” An interview with a nursing staff person took place at 1:40 p.m. on 03/24/10. The nursing staff person stated she was unaware of the right hand splint order. She stated the order had not been flagged properly so that nursing and support staff would have known to apply the splint at bedtime instead of in the morning. 28. The Agency provided Respondent with the mandatory correction date for this deficient practice of 04/26/10. Page 9 of 14 8 sesame 2D is ‘itt igen coe shat on or about 05/06/10, the: “Agency completed a al Revisit to Annual Health Survey, of Respondents Faeility: 30, That based on observation, interview and record review, the Facility-failed-or-refused-to— t—— ensure that proper suprapubic (hereafter “SP”) catheter care was performed by a licensed” professional for one (1) (Resident ? No, 23, hereafter “R23”) of three (3) sampled residents. for ~— oe eae wes catheter care, which could lead to a urinary infection. 31. That on 05/05/2010 at 1:45"p.m. R23 had SP catheter care completed by the LPN The UM. was iii attendance. 32. That the LPN gathered the supplies and placed them in the room. She had one (1) basin and she put warm water in it. She prepared the resident and exposed the SP site. With a wet wash cloth she poured some body wash onto the cloth. She cleaned the outer area of the skin away from the insertion site, She put the wash cloth into the water and dunked it. She squeezed the ya EOE . orate excess water out. With the same wash cloth she cleaned around the catheter insertion site. Yessir 33. With a clean wash cloth she put it into the dirty water and squeezed the excess water out. She cleaned the catheter tubing from the insertion site outward. She patted the skin dry and also __ the catheter. 34. After leaving the room, an interview with the UM and the LPN took place regarding the observed use of dirty water to clean the catheter site and the catheter and not rinsing the resident or the tubing. The UM confirmed the above findings as what she observed as well. 35. Per the directions on the body wash: a. Medline Shampoo & Body Wash b. Reorder: MSC 095060 c. Kiwi Mango’ d. 8 FL oz. e Body Wash Directions: Either apply to damp cloth or.add small amount to basin of warm water. Cleanse patient's face. Continue down the body. Rinse thoroughly. Pat dry. Page 10 of 14 poy pstaiesvctaheagionn 36. .“~Perthe facility’s policy: SHE RE2-0007-7 Suprapubic Catheter Care: Treatment and Therapies soo a Chapter: Genitourinary Purpose: Proper care of the catheter site reduces skin irritation and/or infection. A nurse performs this procedure. Procedure: ... 8, Cleanse skin around the catheter and the entire visible length of the catheter with soap and water, manipulating catheter as little as possible. 9. Rinse well and dry. ag oe rh 9 37." That in the case at bar, the above reflect, infer alia, that the Respondent provided improper and unsanitary cathetet’ care to a resident and failed to follow physician’s-orders regarding a splint, the failure of which is contrary to law. 38... That these failures, collectively and individually, constitute no. more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or se ate conan psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services of the Respondents residents. 39. That the Agency determined these failures relate to the operation and maintenance of the Facility or to the personal care of residents which is a deficiency the Agency considers will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited this deficient practice as an isolated and uncorrected State Class ITI deficiency” 2 “A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 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 I! deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A citation for a class I!] deficiency must “specify the time within which the deficiency is required to be corrected. If a class I! deficiency is corrected within the time specified; a civil penalty may not be imposed.” See § 400.23(8)(c). Page 11] of 14 ee °F ae raaeen denne sand 2 eae ce of Florida, ‘pursuant to $§ 400.23(8)(c) and 400-102, Florida Statutes: (2010). COUNT JIL (Conditional Licensure) 40. The Agency re-alleges. and incorporates paragraphs one (1) through five (5) and Count I Co Sar! and Count II of this Complaint as Sif fully set forth herein. 41. ~ Based upon Respondent’s two (2) cited State Class III deficiencies, it was not in... substantial conmplfance 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 (2010). 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 we Statutes (2010) commencing 05/06/10 and ending 06/05/ 10. [REMAINDER OF PAGE LEFT BLANK INTENTIONALLY] Page 12 of 14. ; 1 eger--Respectfully.submitted this _[° ay of November,.2010, .. - easiness rece STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1942 Facsimile: (727) 552-1440 E-mail: Thomas.Asbury@ahca.myflorida.com By: Thomas F. Asbury, Esq. Fla. Bar No. 567523 DISPLAY OF LICENSE Pursuant to § 400.23(7)(d), Fla. Stat. (2010), Respondent shall post the most current license in a prominent place and a list of the deficiencies of the facility shall be posted in a prominent place that is in clear and vitdbstructed public view at or near the place where residents are being admitted to that facility. Licensees receiving a conditional licensure status for a facility shall prepare, within ten (10) working days after receiving notice of-deficiencies, a plan for correction of all deficiencies and shall submit the plan to the agency for approval. 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 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 to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. 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. Page 13 of 14 sense cneeviib~ CERTIFICATE OE.SERVICE THEREBY CERTIFY that a-true and -correet copy of the foregoing has been furnished by———— U.S. Certified Mail, Return Receipt No. 7008 0500 0001 9560 8780 on this {o & day of oo ‘| 4251 Stack Blvd. November, 2010 to Sovereign Healthcare of Auantic Shores, LEC d/b/a Atlantic Shores Nursing and Rehab Center, ATTN: Dennis J. Digloria, Administrator, 4251 Stack Blvd., Melbourne, FL 32901. f Thomas F. Asbury, Esq. Copies furnished to: National Corporate Research, LTD:, Inc., Registered Agent 515 EB. Park Ave. - Tallahassee, FL 32301 (U.SMail) - Sovereign Healthcaré 6f Atlantic Shores, LLC d/b/a Atlantic Shores Nursing and Rehab Center oa ATTN: Dennis J. Digloria, Administrator Melbourne, FL 32901 (U.S. Certified Mail) Theresa DeCanio Thomas F. Asbury, Esq. AHCA Field Office Manager Senior Attorney Orlatido, Florida Agency for Health Care Admin. ; (Interoffice) 525 Mirror Lake Dr, 330 a ; St. Petersburg, Florida 33701 . : (Interoffice) Page 14 of 14 ceo gp RIO, CHARLIE CRIST ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY September 14, 2010 a a ox ATLANTI@ SHORES-NURSING AND REHAB CENTER 4251 STACK BLVD MELBOURNE, FL 32901 eam wte seeks Sete - Dear Administrator: The attached license with Certificate #16430 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 Fae cogent Issued for a status change to Conditional Sincerely, Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management ee feLORIDA — —— 2727 Mahan Orive, MS#33 i COMPARE DARE Visit AHCA online at Tallahassee, Florida 32308 Health Care in the Sunshine ahca.myflorida,;com wwieFloridaGorapareCare;goy r p}o1006 UILez0] 0107Z/0e/60 “ALVG NOLLVaidxa 7/90/S0 *ALVG SJALLOSIaa Lag! di0 th e. Z Of Ze AONVHO SALVLS Scaa 021 “TVLOL 106ZE Td “ANUNOPTAN GATE AOVIS 182 WALNAD @VHTY UNV ONISUNN SHYOHS OLLNV IV q / -Buimorjoy ou; eyerado 0] pezuoyne SI SQsuaol] St ; pue ‘somselg ePUOLY “Il wed ‘OOy JaudeyD Wy peztoUrMe “HoHEASTUTEIPY O20 TIPS Td fouasy “epiioy gy Jo ates om 4q pardope suouepBar pue sin au) ypim pat[doo sey OTT ‘SHYOHS OLINVILV JO FAVOBLIVAH NDISUAACS Ftp CATOD OF St SAL qINOH DNISWON AONVUNSSV ALIT¥N0 HLTH JO NOISIAIG NOLLVULLSINIAIGY &UVO HLTVSH YOd AONADV - BPLOLA JO 2783S i TSHOCPOIANS °# ASNAOIT OeroT # ALVOWILARO ag ea tpn CHARLIE CRIST ELIZABETH DUDEK GOVERNOR INTERIM SECRETARY September 14,2010 : Lenssen ATLAN#IC SHORES NURSING AND REHAB CENTER oo snanem 4251 STACK BLVD MELBOURNE, FL 32901 Dear Administrator: . The attached license with Certificate #16431 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 _.Jallahassee, Florida 32308 Issued for a status change to Standard Sincerely, Cade Oia Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management ‘MFLORIDA - - 2727 Mahan Drive, MS#33 AP OMPATE CARE Visit AHCA online at Tallahassee, Florida 32306 Hoalth Garo In the Sunshine ahca.myflorida.com fF * . . . "wirdicFlorldeGomparéCare.gov O10C/0C/60 -ALVG NOLLVaidxa eee onemstunupy ares Weep Joy Aouad y ‘Aigiosoeg We] a (Lae) ee] 0107/90/90 ‘ALVC SALLOS ATT “~ 7 FONVHO SNLVLS A) Sad 0Zt “TVLOL T06ZE 1a “SANUNOSTAN CATA MOVES Str : WALNAO VHA UNV DNISUNN SAYOHS OLLNVILV : -Sumoypoy sup atetado 0} pozLoyIne st gosusdl] ot pur ‘sameng epLord ‘Ti wed “Oop saxdeyo UI peztorpne “uoHeTsTuTIpY 125 wea} 104 AousSy “epuopy Jo aveig amp Aq paydope oneyaor pur som ay ym potjduios sey OTT ‘SHYOHS OLLNVTLV JO. FAVOHLIVAN NOLRIAAOS 223 WHOS 07 St SILL dIWOH DNISHON AONVENSSV AALTVND HITVdH JO NOISIAIG NOLLVLLSININGV FVO HLTVdH dod AONFOV PLO] JO 2921S Tevet -# JLVOMILYO =a Sear ene a 3 TSG0CPOTENS “# ASNAOIT SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, an. . Also complete {tem 4 If Restricted Delivery Is desired, @ Print yourrame-and address on the rayerse so that we can return the card to you, m_Attach-this.card.to.the.back of the maliptece,. or-orthe frontif space permits, D. Is dallvary address different trom item.17_ (1 Yes {t YES, enter delivery address below: ~ 1 No 1. Article Addressed to: Atlantic Shores Nursing and Rehab Center ATTN: Dennis J. Digloria, Administrator 4251 Stack Blvd. Melbourne, FL 32901 sec, 2. Article Number 7008 050 (Transfer from servive taxroy . PS Form 3811, February 2004 Domestle Return Recelpt 102595-02.M-11 0 0002 4560 8760 aye . wes phen - we rag wT haat piesa see : sac hau STRUM Saree tude osishiginatenss eS bay oo ei remen - eas sins

Docket for Case No: 10-010438