STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY F OR "HEALTH CARB ADMINISTRATION, Petitioner, "vs. Case Nos. 2010011620 2010011623 KISSIMMEE HEALTH CARE ASSOCIATES, LLC, ‘d/b/a KEYSTONE REHABILITATION AND HEALTH 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 Kissimmee Health Care Associates, LLC, d/b/a Keystone Rehabilitation and Health 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 September 13, 2010 and ending September 16, 2010, impose an administrative fine in the amount of two thousand five hundred dollars ($2,500.00) based upon Respondent being cited for one Isolated State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). 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 facilities pursuant to the Omnibus-Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Filed February 9, 2011 4:17 PM Division of Administrative Hearings irra J... Chapters 400, Part Il, and 408, Part Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4, Respondent operates a 120-bed nursing home, located at 1120 West Donegan Avenue, , Kissimmee, FI 34741 and is licensed as a skilled nursing facility license number 130471039. 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 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 tules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2010). . 8. That based upon observation, interview, and the review of records, Respondent failed to provide necessary care and services to ensure adequate and appropriate health care consistent with the resident plans of care relative to. pain prevention during wound care, prevention of pressure ulcer development, the failure to ensure that each resident's drug regimen was free from unnecessary drugs relative to justification for use of an antipsychotic, failure to follow facility ptotocol for gastrostomy tube ‘placement before giving medications via G-Tube, and dirty oxygen concentrator filters in rooms, the same being contrary to law. 2 9. That Petitioner’s representative reviewed Respondent’s records related to resident number ninety-six (96) and noted as follows: a, b. The resident sustained a hematoma to the left lateral leg, origin unknown; The resident did not have a fall or incident per facility investigation; The resident was sent to the hospital on Septemebr 5, 2010; The physician did a surgical procedure ~ incision, and drainage on the hematoma - and placed the resident on antibiotic therapy to prevent infection; On September 8, 2010, a physician's order directed to cleanse left lower extremity (LLE) with NS, apply hydrogel ointment, and cover with dry sterile dressing (DSD), change daily and as needed. 10. That Petitioner’s representative interviewed Respondent’s director of nursing (DON) on September 14, 2010 regarding resident number ninety-six and the nurse indicated that the. “resident had history of peripheral arterial disease (PAD), is-on Plavix, a blood thinner, and has an eruption of the blood vessel. 11, That Petitioner’s representative observed resident number ninety-six (96) on Septemebr 15, 2010 at 8:30 a. m. and noted as follows: a, The resident was in the resident’s room and was alert, oriented, pleasant, and verbally responsive to communication; The resident requires an interpreter because the resident speaks a different language, but understands minimal English; The resident was found sitting on a recliner chair and had the left leg elevated on an inverted trash can with a pillow underneath to support the leg; There was a dressing on the left lateral side of the leg that was. saturated with bright red blood; The date and time on the dressing was 9/14/10 at 1:40 p.m. 3 4 - f. A staff member was summoned to interpret for the resident and when the staff person arrived the resident pointed to the leg and asked for it to be changed, however the staff member did not notify the nurse at that time that the dressing fated net was saturated with blood and was draining through the pillow that supported the left leg.. , 12. That Petitioner’s representative interviewed resident number ninety-six (96) on ‘September 15, 2010 at approximately 8:45 am. who indicated a lack of memory as to: what happened to the resident's leg, but. stated that the resident must have "banged it on something” and indicated that it hurts when the dressing change is done. 13. That Petitioner’s representative again observed resident number ninety-six (96) on September 15, 2010 begining at 9:25 a.m. and noted as follows: a, The resident was in the resident’s room and the dressing was still not changed; b. The bloody discharge was draining onto the pillowcase; c. A nurse came into the room and called the wound care nurse to change the dressing; ‘ d. The wound-care nurse-arrived at 9:30 a.m. and started the dressing change ! : "procedure; . e. Aninterpreter was present to ensure the resident could be understood to verbalize “needs; . f. The following procedure was observed: L ‘The nurse gathered her equipment: normal saline (NS) vials; 4x4 gauze, hydrogel ointment; Kerlix; and disposable biohazard red bag; Ti, When the nutse attempted to remove the bloody dressing, the resident complained of pain and and was biting the finger and some tissue paper in the resident’s hand; ni. Vi. Vit. VIL. oy Xl. XI. “it was painful; The resident had a grimace on the face, was groaning in pain,-and stated, “mucho dolor" which translates to "a lot of pain." ‘The wound care nurse stopped and called the other nurse to get a physician's order for a pain medication; The resident was last medicated for pain on September.15, 2010 at 5:00 a.m. with Percocet 5/325 milligrams (mg), 1 tablet; . At 9:45 aum., a one-time order for pain medication was ordered and the pain medication was was given at that time; . . The nurse then continued with the dressing change without waiting for the thedication to take effect; She proceeded to remove the soiled bloody dressing that was stuck on the wound and the resident was groaning, biting at the finger, and verbalizing that The nurse did not stop the procedure despite the resident's signs and verbalizations of pain; The nurse poured NS onto the wound for removal of the gauze that was stuck, and still had a difficult time removing the dressing, but she did not stop the procedure; The nurse cleansed the wound with NS, hydrogel ointment was applied, the : wound was covered with a thick 4x4 gauze dressing, and wrapped with Kerlix; The wound bed was red, with some bleeding noted, wound edges were beveled, with large amount of bloody/ serosanguinous discharge. There was no odor noted. 14. That the wound size of resident number ninety-six (96) as measured by the wound care advance nurse practitioner (ARNP) on Septemebr 15, 2010 at 1:30 p.m. was length 6.6 follows: centimeters (cm.) x width 7.4 cm. and depth of 0.2 cm. ‘15, That Petitioner’s representative reviewed Respondent’s records, including medication - records and plans of care, for resident number ninety-six (96) during the survey and noted as a, The medication administration record (MAR) revealed the resident did not receive pain medications on a regular basis prior to daily dressing changes; . The resident received pain medications on the following dates after the dressing change order was written on Septemebr 8, 2010: September 8, 12, 13, and 14, ” , 2010; ° c. The resident received pain medication on Septemebr 15, 2101 at 5:00 am. ~d. The September medication administration record reflected an order was received on. March 19, 2010 for pain assessment every shift-5 am., 1 p.m., 9 p.m. with Instructions: Assess resident for pain every shift. . The resident had physicians ' orders of March 22, 2010 for Percocet 5.325 mg o one tablet as needed (prn) every 6 houts for pain-moderate, severe; The documentation for the pain assessment conducted at 5:00 a.m. on September 15, 2010 revealed the resident had evidence of pain and received Percocet one tablet at 5:00 a.m. for moderate pain in left leg; . Documentation at 5:27 a.m. indicated the pain medication was somewhat effective; . At 9:30 am the nurse began to change the.dressing without assessing pain and resident complained of "mucho dolor" or a lot of pain; ry ’ The next pain assessment was documented on September 15, 2010 at 1:00 p.m. and the resident still had moderate pain in the tower extremity and back; j. The effectiveness was documented within eight (8) minutes of administration, although the medication did not have enough time to take effect; k. The minimum data set (MDS) last quarterly assessment dated July 9, 2010 i : assessed the resident as able to ambulate with a walker and requires supervision - with most of the activities of daily living; . 1. The last "Discomfort and Pain data collection" assessment was conducted on July 13, 2010 and indicated the resident had no pain; | m, When the resident returned from the hospital on September 5, 2010 status post ‘ (s/p) incision and drainage of the hematoma on the left mi the staff failed to conduct a pain assessment; 13, 2010 and at that timé it was documented "no pain this period." 0. The care plan was not revised to reflect the current condition s/p incision and drainage to the hematoma on the left lateral leg; : p. An intervention was listed to evaluate pain intensity prior to providing interventions, but no such evaluation was implemented during the above- | described observed dressing change; . q. Another: intervention was to evaluate pain intensity 30-60 minutes after administering a treatment; r.- The nutse did not wait 30-60 minutes to evaluate the effect of the pain medication before continuing with a painful dressing change as above described. 16. That the above reflects Respondent’s failure to provide adequate and appropriate health care and protective and support services, including social services; mental health services, if 7 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, inter alia: a Failed to evaluate and update resident care plan’s to reflect the known necessity to manage resident pain; a7. _ Failed to timely assess resident pain in accord with physician directives; Failed to adequately and appropriately assess pain intervention; Failed to ensure the efficacy of pain medication prior to continued painful treatment. That Petitioner’s representative observed and interacted witli resident number one hundred twenty-five (125) on September 15, 2010 at 8:30 a.m. and the following was noted: a. The resident was in the resident’ s r the foot rest with oversized heel booties; The resident indicated the resident was uncomfortable in the chair and has pain in the legs; . The resident was alert and able to verbalize needs; _ The resident speaks a different language, but can let needs be known with minimal English. 18. That Petitioner’s representative reviewed. Respondent’s. records related to resdient number one hundred twenty-five (125) and noted as follows: a. The resident was readmitted to the facility from the hospital on December 10, 2009 with the following diagnoses: infected right heel ulcer with cellulitis, history of hip fracture, and osteoporosis; b. The resident was referred to a wound cate team and was treated for the heel pressure ulcer; c. The right heel pressure ulcer was resolved on August 25, 2010; d. On Septemebr 13, ‘2010, the pressure ulcer on the right heel had reopened and was staged at a "2." “19. That Petitioner’s representative observed Respondent’s wound care and dressing change for resident number one hundred twenty-five (125) by the advanced registered nurse practitioner (ARNP) for the wound physician on September 15, 2010 at 11:30 a.m. and noted as follows: a. The wound edges were clean with a moderate amount of serous, creamy, greenish ; discharge; no odor noted; wound bed-pinkish; : b.. The wound was measured by the ARNP and was length 3.2 centimeters (cin) x “width 1.5 cm. x depth less that 0.1 cm. "SAiter the dessing change was completed, Petitioner's representative asked the wound nurse to check the buttocks area as during the last two (2) days of survey, Septemebr 13 and 14, 2010, the resident verbalized discomfort from sitting in the ‘wheelchair for long periods of. time from 8:00 am. until after lunch or approximately 2:00 p.m.; d, Noted on the coccyx/ buttock area of the resident on September 15, 2010 at 11:45 a.m, were two (2) small open areas; e, The ARNP assessed the areas as a stage 2 pressure ulcers measuring: 1) length 0.5 cm. x width 0.3 cm. x depth less than 0.1 cm. and 2) length 0.3 cm. x width 0.3 om. x depth less than 0.1 om. . 20. That on September 13, 2010 at 11:45 a.m. during an initial visit with resident number one hundred twenty-five (125), Petitioner’s representative noted a sign was posted on the wall . behind the head of the bed indicating the family requested to leave the resident up in the wheelchair until 2:30 p.m. 21, That Petitioner’s representative could locate no documentation which would indicate that staff had been repositioning resident number one hundred twenty-five (125) on a regular basis while up in the wheelchair. 22. That Petitioner’s representative interviewed resident number one hundred twenty-five , (125) on Septemebr 14, 2010 at 9:30 a.m. and the following ‘was noted: , a. The resident indicated that the resident was experiencing pain in the legs and was: uncomfortable with the position in the wheelchair; b. A certified nursing assistant (C.N.A.) was called to reposition the resident by the surveyor at.that time; . . c The resident Stated that the resident keeps sliding down the wheelchair and was ‘very uncomfortable; d, Observation revealed the brakes of the wheelchair were not functioning; e. The hand brakes for the wheelchair did not reach the. wheel, therefore it would not ’ lock; . f. Without the wheels locked it was difficult for the C.N.A. ot the resident to reposition in the wheelchair. 23. That Petitioner’s representative noted that the last minimum data set assessment for resident number one hundred twenty-five (125), dated June 10, 2010, indicated as follows: a, The resident had a stage 4 ulcer on the right heel; b. The resident was assessed as moderately impaired in-cognition and was dependent upon staff with all activities of daily living; '¢, The resident triggered for pressure ulcers related to bed mobility and bowel/bladder incontinence. 10 24, That Petitioner’s representative noted care plans for pressure ulcer prevention dated June 16 to Septemebr 15, 2010 for resident number one hundred twenty-five (125) provided to: “inspect daily for signs and symptoms of skin breakdown; encourage and change position frequently; assist in position change daily. 25. That Petitionre’s representative interviewed Respondent’s cettified nursing assistant assigned to resident number one hundred twenty-five (125) during the survey who indicated that she observed the two (2) small areas in the coccyx that morning during the bed bath and informed the nurse. . 26. - That Petitionre’s representative interviewed Respondent’s nurse assigned to resident number one hundred twenty-five (125) during the survey who indicated as follows: a, She denied that she was informed of the new open ateas on the coccyx and was not aware.of them; . an neers ~~ Br The muse indicated residents receive a complete body check on shower days, 27. That Petitioner’s representative reviewed Respondent’s shower schedule with the certified nursing assistant which reflected that resident number one hundred twenty-five (125) | was scheduled for showers every Monday and Thursday'on the 3-11 shift. ; 28. That Petitioner’s representative reviewed the resident shower list for Monday, Septemebr - 13, 2010 which reflected that resident number one hundted twenty-five (125) refused to be showered. and thus there was no complete body check conducted that day. 29, That’ petitioner’s representative interviewed Respondent's unit manager during the survey who indicated that certified nursing assistants ate to conduct skin checks every shift and ’ report any.signs of breakdown to the nurse. 30. That the above reflects Respondent’s failure 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 11 with the resident cate plan, with established and recognized practice standards within the community where Respondent, inter alia: a, Failed to comply with care plan provisions requiring daily checks of skin for signs and symptoms of skin breakdown; Failed to comply with care plan provisions requiring the encouragement of and _ repositioning the resident frequently to minimize risk of skin breakdown. "31. . That Petitioner’s representative reviewed Respondent’s recordes related to resident number ninety-six (96) during the survey and noted as follows: a. expression; The last quarterly minimum data set (MDS) assessment, dated July 9, 2010, - assessed the resident on cognition as "1:1" ~- modified independence and usually understands; The resident was assessed as having sad, pained expression; worried facial The resident was not assessed for any behaviors; . The resident was referred to a psychiatrist for depression and anxiety and is followed up by the psychotherapist; The resident was seferred to a neurologist’ on July 13, 2010 for problems of dementia with confusion; Neurologist progress notes documented: Nas per nursing home staff, patient is suffering from dementia and is on ‘Bffexor patch, Complained. of increase confusion and mild disorientation. No other complaints." The neurologist ordered for a trial of Risperdal 1 mg 1 tablet every bedtime. and follow up in 6 weeks for this antipsychotic medication; . On August 26, 2010, the neurologist saw the resident again and documented in the report of consultation “Patient presented from nursing home and claims [] is 12 ane doing the same. Denies any new complaints. Mild episodes of confusion. Plan is to continue present treatments.” i, The resident continued to received the Risperdal with no diagnosis and documentation to justify it's use; j. Absent from the records was any indicia of monitoring of behaviors or any documentation in the nurses! notes that indicated the resident exhibited psychotic features; k. Psychiatrist progress notes dated August 23, 2010 documented that the , neurologist started the resident on Risperdal - "Patient appears more confused. Not agitated or depressed or anxious. Risperdal to be managed by neurologist." _ ‘32. That Petitioner’s representative interviewed Respondent’s director of nursing regarding resdient number ninety~six (96) on Septemeber 14, 2010 who validated that the neurologist had ordered ihe antipsychotic medication and will gt more information about the diagnosis. SSS 33. That on Septemebr 14, 2010, the physician's ‘orders sheet revealed orders to add "dementia with psychosis" to the resident's diagnoses with no explanation to justify it's use. 34. That Petitioner’s representative observed resident number ninety-six (96) on Septemeber ‘14, 2010 at 1:15 p.m. and noted the resident was alert and able to make'needs known, was sitting on the chair bedside the bed, and was calm, pleasant, with no behaviors observed, and was verbally responsive to communication, 35. _. That Petitioner’s representative noted in Respondents records related to resdient number _ ninety-six (96) the following: . a The resident was originally admitted to the facility with diagnoses of hypertension, dementia, hyperlipidemia, congestive heart failure, and renal insufficiency; “community where Respondent, inter alias” “b. Current psychoactive medications are: Exelon transdermal patch 4.6 mg/24 hours. 1 patch daily for depression; Risperdal | mg. 1 tab. every bedtime (no diagnosis); Ativan 0.5 mg. 1 tab every 8 hours as needed for anxiety behavior. Tranxene 3.75. mg. 1 tab. every 8 hours for depression; Zolpidem Tartrate 5 mg. | tab. every: bedtime as needed for insomnia. . 36. That Petitioenr’s representative reviewed Reespondent’s policy and procedure of behavior management and noted that staff is to document frequency of behavioral symptoms and effectiveness of interventions on the behavior symptom monitoring record. 37, That the above reflects Respondent’s failure 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 a. Failed evaluate the appropriate use, of Risperdal, b. Failed to monitor resident behaviors for frequency of behavioral symptoms; c. Failed to evaluate medication interventions for behavioral issues, , ° 38. That: Petitioner’s representative reviewed Respondent’s records related to resident _ number sixty-nine (69) during the survey and noted as follows: 39." That Petitioner’s representative reviewed Respondent’s records related to resident number sixty-nine (69) during the survey and noted as follows: . a. The resident was admitted to the facility on December 25, 2009 with a physician's order for Xanax 0.25 milligram (mg) 1 tablet three times daily (tid) for anxiety; b.. Absent from the record was any indication of Respondent’s monitoring of behavioral symptoms and effectiveness of interventions in the Behavior Symptom 14 ) Monitoring Record as required by facility policy for psychoactive medication management; . c.. The clinical record: and the 2010 pharmacy consultant reports did not reflect any attempts at dose reduction. 40. That Petitioner’s tepresentative interviewed Respondent’s River Rock Unit Manager regarding resident number sixty-nine (69) on Septemeber 14, 2010 who indicated as follows: ‘a. The computerized medication administration program has a behavior flow sheet for documenting planned interventions used to address behaviors, but the program does not allow facility staff to document behaviors and implementation of interventions other than medications to address behaviors; b. The facility has, no other method of documenting the effectiveness of non- pharmacologic interventions to address behaviors; prior to administration of the medications; d. There is no tool for tracking behaviors or the effectiveness of these interventions. o ali, That Petitioner’ s Tepresentative observed resident number sixty-nine (69) on Septemebr 15, 2010 at 12:15 PM and noted he resident in bed with no evidence of anxious behaviors, , 42, That Petitioner’s representative interviewed Respondent’s Director of Nursing regarding resdient number sixty-nine (69) on Septemeber 15, 2010 who indicated that no gradual dose ‘reduction (GDR) of the psycotropic medication had been attempted on resdient number sixty- nine (69) and agreed a gradual dose reduction should have been attempted. - 43, That the above reflects Respondent’s failure to provide adequate and appropriate health cate and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent “e. Non-pharmacological interventions to address behaviors should be attempted | . with the resident care plan, with established and recognized practice standards within the community where Respondent, inter alia: a. Failed evaluate the appropriate use of psychoactive medications; b. Failed to monitor resident behaviors for frequency of ‘behavioral symptoms; c. Failed to evaluate medication interventions for behavioral issues. 44, ‘That Petitioner’s representative reviewed Respondent’s records regarding resident number. sixty-two (62) during the survey and noted as follows: ' a. The resident was admitted to the facility on October 21, 2000 with a physician's . orders for Seroquel 25 mg 1 tablet twice il (bid) for psychosis and on June:21, 2010 for Ativan 0.5 mg bid; | . . be Absent from the records was any indication of monitoring of behavioral symptoms and effectiveness of interventions in the Behavior Symptom management, 45, That Petitioner’s representative interviewed Respondent’s River Rock Unit Manager regarding resident number sixty-two (62) on Septemeber 14, 2010 who indicated as follows: a. The computerized medication administration program has a behavior flow sheet for documenting planned interventions used to address behaviors, but the program does not allow facility staff to document behaviors and implementation of interventions other than medications to address behaviors; | b. The facility has no other method of documenting the effectiveness of non- phatmacological interventions to address behaviors; c. There was no tool for monitoring behaviors. 46, That the above reflects Respondent’s failure to provide adequate and appropriate health care and protective and support services, including social services; mental health services, if 16 Monitoring Record as required by facility policy for psychoactive medication ee 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, inter alia: . ‘ a. Failed evaluate the appropriate use of psychoactive medications; b. Failed to monitor resident behaviors for frequency of behavioral symptoms; c. Failed to evaluate medication interventions for behavioral issues. 47, That Petitioner’s representative observed medication administration by Respondent’s staff on September 14, 2010 at approximately 9:30 a.m. and noted a follows: a. The nurse was observed not to check for gastrostomy-tube (g-tube) placement for resident number one hundred sixty (160) before administering medication; b. Before medications were administered the: nurse was asked if she should check for placement of the g-tube and she answered "yes." 48, That Petitioner’s representative reviewed the medication administration record and noted that nurses were to check for g-tube placement before administering flushes or medications. 49, That Petitioner’s representative interviewed Respondent’s staff nurse and unit manager of the 100-hall regarding the necessity of checking for g-tube placement and the same was confirmed. . 50. That the above reflects Respondent’s failure to provide adequate and appropriate health cate 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, inter alia, failed appropriately check for g-tube placement prior to the administration of medications. 17 51. That Petitioner's representative noted during a tour of the Respondent facility on - September 13, 2010 at about 9:15 a.m. that rooms numbered one hundred thirteen (113) and one hundred twenty-one (121) had oxygen concentrator filters occluded with dust. 52. That Respondent’s staff and unit nurse accompanying Petitioner’s representative during this tour confirmed the above observation. . . 53, That the Agency determined that these failures relate to the operation and maintenance of a facility or to the personal care of residents that directly threaten the physical or emotional health, safety, ot security of facility residents cited this deficient practice.as an Isolated State Class IE deficiency. 54. The Agency provided Respondent with the mandatory coirection date for this deficient practice of October 16, 2010. - WHEREFORE, the Agency seeks to impose an administrative fine in the amount of two thousand five hundred dollars ($2,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§-400.23(8)(b) and 400.102, Florida Statutes (2010). . COUNT II 55. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count 1 of this Complaint as if fully set forth herein, 56. Based upon Respondent’s one cited State Class I deficiency, it was not in substantial compliance at the time of the sievey with critetia 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)(a), 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 Statutes (2010) commencing September 13, 2010 and ending September 16, 2010. 18 Respectfully submitted this / q day of January, 2011. . Walsh II, Esquire . No. 566365 ‘A éncy for Health Care Admin. 525 Mitror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) DISPLAY OF LICENSE Pursuant to § 400. 23(7)(), Fla. Stat. (2005), Respondent shall post the most current license i ina 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 tight to retain, and be represented by an attomey i or admi i 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) 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. AFINAL ORDER BY THE AGENCY. 19 U.S. Certified Mail, Return Receipt No: Agent for Kissi CERTIFICATE OF SERVICE J HEREBY CERTIFY that a true and correct copy of the foregoing has been served by 7008 0500 0001 9560 7226 to Jose Alecia, Administrator, Kissimmee Health Care Associates, LLC, 1120 West Donegan Avenue, Kissimmee, Fl 34741, and by Regular U.S. Mail to Corporation Service Company, Registered ee Health Care Associates LLC, 1201 Hays Street, Tallahassee, Florida as J. Walsh II, Esquire Agency for Health Care Admin. 525 Mirror Lake Drive, 330G - St. Petersburg, FL 33701 ~Agency for Health Care “Kamin Thomas J. Walsh, I Senior Attorne: - 525 Mirror Lake Drive, #330G St. Petersburg, FL 33701 (Interoffice Mail) 32301, on this f - day of January, 2011. 4 | # Fla. Bar. No. 566365 92'7.552.1947 (office) | ; Copies furnished to: | 7 foo Jose Alecia, Administrator, ‘Corporation Service Company, i... Kissimmee Health Care Registered Agent __ ! ‘Associates, LLC, Kissimmee Health Care i ; 1120 West Donegan Avenue, Associates LLC, : Kissimmee, Fl 34741, 1201 Hays Street, Tallahassee, : (US Certified Mail) Florida : (US Mail) Theresa DeCanio ; Field Office Manager i AHCA Health Quality | Assurance H Area Office 7 (Interoffice Mail) 20 "SENDER: COMPLETE THIS SECTION COMPLETE THIS SEC TION ON DELIVERY | B, Hapélved by (Printed! Name). - Ms || Alcelis Crespo. emote kk Ahh Lilian : s delivery addrass different foniiten 1? Ld Yea ; ; .ItYES, enter delivery address-balaw: +; EP&o. Jose Alecia, Administrator, ‘ Kissimmee Health Care Associates, LLC, * :1120 West Donegan Avenue, Kissimmee, a : il 34741, 3. Senice Type — :, + El Cértifed Mall = Cl Express Mell, : Ste ee ee ee, El Regtstered C1 Return Receipt for Merchandi Bi theured Mell (2) 6.0.0," 4 Reafricted Delivery? (eta Fo) “Fone 0500 00 Ibo 722e { PS Form 381 4, February 2004 "— Domastio Return Receipt ae 102595-02-Matt

Docket for Case No: 11-000674