STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ' STATE OF FLORIDA, ”- AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, _ vB. Case Nos. 2011003789 (Fine) uo 2011003792 (CL) PINEHURST HEALTH CARE ASSOCIATES, LLC d/b/a SEAVIEW NURSING AND REHABILITATION 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 PINEHURST - "HEALTH CARE ASSOCIATES, LLC d/t/a SEAVIEW NURSING AND REHABILITATION CENTER (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes - -(2010), and alleges: i ' NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of TWO ‘THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) pursuant to Section 400.23(8)(b), Florida Statutes (2010), based upon one (1) Class Il deficiency and to assign conditional licensure status beginning on March 3, 2011, and ending on April 1, 2011, pursuant to Section 400.23(7)(b), Florida Statutes (2010). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. Filed July 5, 2011 4:44 PM Division of Administrative Hearings BC _—E— eee JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2010). . 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2010). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4, The Agency is the regulatory authority responsible for the licensure of skilled nursing facilities and the enforcement of all applicable federal and state statutes, regulations and rules governing skilled nursing facilities pursuant to Chapter 400, Part Il, Florida Statutes (2010) and o Chapter 59A-4, Florida Administrative Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121 and 400.23, Florida : Statutes (2010); assign a conditional license pursuant to Section 400.23(7), Florida Statutes (2010); .and assess costs related to the investigation and prosecution of this case pursuant to Section . 400.121, Florida Statutes (2010). 5. - Respondent operates an 83-bed nursing home, located at 2401 N.E. Second Street, Pompano Beachi, Florida 33062, and is licensed as a skilled nursing facility, license number 1441096. Respondent was at all times material hereto, a licensed skilled nursing facility under the licensing authority of the Agency, and was required to comply with all applicable state rules, regulations and statutes. COUNT] The Respondent Failed To Ensure The Right To Receive Adequate And Appropriate Health Care and Protective and Support Services in Violation of Section 400.022(1)(), Florida Statutes (2010) 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, all licensees of nursing home facilities shall adopt and make public - astatement 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: 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. Section 400.022(1(I), Florida Statutes (2010). 8 On or about February 28, 2011 through March 3, 2011 the Agency conducted a Licensure , Survey of the Respondent's facility. . 9. _ Basedon observation, interview and record review, the facility failed to ensure a resident's right to receive adequate and appropriate health care and services consistent with the resident care — plan as evidenced by not providing seizure medications for Resident number ninety nine (99) resulting in hospitalization and by not providing restorative services, podiatry care and not addressing concerns caused by a room change and fear of transfer by mechanical means resulting ~ in a-functional decline for Resident number eighty two (82), ) 10. During a review of the facility's grievance procedure, it was noted that the facility received a grievance from Resident number ninety nine (99) on September 7, 2010 regarding not receiving his/her prescribed medications on September 4, 2010, which resulted in Resident number ninety nine (99) having a seizure on September 5, 2010. 11. Resident number ninety nine (99) reported that he/she had been out of the facility on a pass on September 4, 2010, returned to the facility at 9:30 p.m., requested his/her routine 9:00 p.m. medications and never received them. Resident number ninety nine (99) reported that, while out of the facility on a pass the following day (September 5, 2010), he/she had a seizure and was taken to a hospital for evaluation. 12, Nursing documentation in Resident number ninety nine’s (99) clinical record confirmed ‘that the resident's sister called the facility on September 5, 2010 at 8:30 p.m. to report that the - : ; resident had a seizure and was taken to the hospital. Resident number ninety nine (99) returned to , the facility on September 6, 2010 at 12:30 a.m. with hospital discharge instructions that indicated the resident had a “recurrent seizure". A _ On September 7, 2010, the facility documented that it was: confirmed that Resident number ninety nine (29) did not receive his/her 9:00 p.m. medications on September 4, 2010. The facility : documented that Resident number ninety nine (99) retumed to the facility on September 4, 2010 at : 10:20: p.m. and nursing did not administer the resident's 9:00 p.m. medications because the time © ° - was outside of the standard 1 ‘hour window before and-after the préscribed time. 14, The facility documented that Resident number ninety nine (99) was informed that he/she would ‘have to.be in the facility between 8:00 p.m. and 10:00 p.m. to receive his/her prescribed . 9:00 pam, medications, No evidence was found to indicate that the nurse made any attempts to vontact the physician, if there were concerns regarding administering Resident number ninety nine” 's (99) medications twenty (20) minutes after the prescribed window. 15. . A review of Resident number ninety nine’s (99) prescribed medications revealed that the following medications scheduted to be administered at 9:00 p.m. were not administered on September 4, 2010: e Clonazepam 0.5 mg, ordered to be administered every twelve (12) hours for anxiety; « Kaletra 50-200 mg ii tablets, ordered to be administered every twelve (12) hours for HIV/AIDS; : ¢ Lamotrigine 200 mg, ordered to be administered every twelve (12) hours for seizure disorder; ° Ttizivir one (1) tablet, ordered to be administered twice daily for HIV, and * Venlafaxine ER 75 mg, ordered to be administered once a day for depression. ' “16. A review of the consumer medication facts for dosing revealed the following statement for . all of the above medications: "If you miss a dose, take it as soon as you remember; if it is almost — ti time for your next dose, skip the missed dose andr resume your usual medication schedule," ; as . Resident number ninety nine’s (99) next t dosages for all of these medications, except - Venlafaxine, were for 9:00 a.m. the following morning, ten (10) hours and forty (40) minutes after - Resident number ninety’ nine (99) returned to the facility on September 4, 2010 at 10:20 p.m. . The Venlafaxine was not echeduled again until the following night at 9:00 p.m., twenty two > - 22) hours and forty (40) minutes after Resident number ninety nine (99). returned to the facility. This’ was, s confirmed during an interview with the Director of Nursing on March 2, 2011 at 3: 15 op Pan, | | | 19. Resident number eighty two (82) was admitted to the facility on March 31, 2010, with a” diajpiosis to include renal failure, Cardiovascular Accident, optic atrophy and convulsions. A , review of the minimum data set dated December 15, 2010 did not identify a cognitive status, and ; identified depressed behaviors and total assistance for activities of daily living. 20, - Diiring an interview on March 1, 2011 at 2:38 p.in. with Resident number eighty two (82) and his/her family member, the family member stated, "Therapy was stopped because of no progress and now Resident number eighty two (82) is lying in the bed 24/7. This is not good". 21, Resident number eighty two (82) also expressed that staff has been rough with him/her during care, Resident number eighty two’s (82) family member stated he/she had participated in the care plan meeting in December 2010, and asked about therapy and stated, "We were told they | | | . would check into it but nothing happened ...I also notified staff that the boot Resident number -_ éighty two (82) wears’on his/her leg is broken .., it is supposed to keep his/her foot/leg straight, it : now curves to the side... nothing has been done", Resident number eighty two (82) stated his/her - : foot really hurts. 7 22. At observation of the foot and leg at the time of the interview revealed the boot was on the ; left foot tothe aide, . 2. During an interview on March 2, 2011 at 12:45 p.m., the Minimum Data Set Coordinator . sated he became aware of the therapy request and the broken orthotic boot at the care plan . r meeting ‘in December 2010 and was reminded of it again yesterday by Resident number eighty tf two's (82) family member. The Minimum Data Set Coordinator went on to say he reminded the . therapist to follow-up. ~ There was no evidence of documentation the facility followed-up with the request about ; therapy ot the broken: boot since December 2010. . 25. A further review of the record revealed a physical therapy plan of treatment dated August ; 5, 2010 “documentiag, "Patient discharged from physical therapy ‘services due to plateau: in "functional progress...At the time of discharge Resident number eighty two (82) is able to perform 7 turns in bed to the left side with moderate assistance and to the right side with maximum assistance... Resident nurnber eighty two (82) is able to transition from supine to sit with moderate assistance and from sitting at end of bed to the wheel chair with slide board and moderate assistance times two (2). Patient exhibits fair static sitting balance and poor static standing balance...Patient may benefit from restorative nursing program to address range of motion, bilateral lower extremities...physical therapy will reassess Resident number eighty two (82) as needed.” 26. There is no evidence physical therapy had reassessed Resident number eighty two (82) ; ‘since he/she was discharged. 27. During an interview on March 2, 2011 at 2:00 p.m., the Rehabilitation Director stated she did not know anything about the boot and contacted the physical therapist via phone. 98. = The telephone interview with the physical therapist revealed that he was made aware of the’ ‘broken boot “about a month ago" and gave no reason why there was no follow-up. The Rehabilitation Director stated, “He probably just got busy and forgot...he was told by a nurse and - nothing was ever written down". 29.- The Rehabilitation Director was asked if Resident number eighty two (82) w was receiving restorative nursing as documented on the therapy discharge note. “30, _. The: restorative Certified Nursing Assistant stated Resident number eighty two (82) has never been on the restorative caseload. No-reason was given why Resident number eighty two (82) . bad not received restorative nursing. . BL ‘The physical therapist was' contacted again via phone regarding the recommendation for , “restorative nursing and he stated usually they complete a form and train the Certified Nursing ; “Assistant to work with the resident, He stated he never filled out the form. The Rehabilitation Director stated, "[ do not have time to go behind everyone and alot of times things are passed on in - the hali and not written down, so it gets forgotten". - . 32. An observation and interview on March 2, 2011 at 4:26 p.m. with the Director of Nursing and Resident number eighty two (82) revealed the resident wearing an orthotic boot on the left leg. The resident's skin was cracked and the toenails overextended on both feet. Resident number eighty two (82) was asked if anyone had come in to look at his/her feet or cut his/her toenails, Resident number eighty two (82) stated, "No, her mom tries to do it but her feet hurt”. 33. A review of Resident, number eighty two's (82) record revealed no documentation the resident was ever seen by a podiatrist or had his/her toe nails cut since admission on March 31, 2010. 34. A review of Resident number eighty two’s (82) vision care plan with onset date of April 13, 2010 revealed the resident had impaired vision as evidenced by not being able to see. Resident - number eighty two (82) stated that it happened after the Cardiovascular Accident. Resident number eighty two (82) is at tisk for injury due to his/her impaired vision. Interventions: included: "Announce self when approaching resident and keep call light in easy reach and prompily : * answered”. . 35. A review of the Care Plan Conference Summary and Attendance Sheet was dated September 30, 2010. The conference notes documented the following: There was a discussion of ‘Resident number eighty two (82) being in bed. Resident number eighty two (82) i is afraid ‘that the ~ staff does not use the Hoyer lift properly. Staff does not know how to use the Hoyer lift Staff will get staff that Resident number eighty two (82) likes. : 36. During an interview with Resident number eighty two (82) on February 28, 2011 at 2: 23 “p.m. regarding his/her room change on January 13, 2011, Resident number eighty two (82) stated, “They gave me fifteen (15) minutes and moved me to a new room. I told them J did not want to move because the rooin was in front and I could hear things. Now I'm in the back .of the hall and . don't hear anything." 37. A psychiatrist note dated January 31, 2011 documented Resident number cighty two’ s (82) room. change: resident "reports this new roommate is worse". 38, _An interview was conducted with Resident number eighty two (82) on March 2, 2011 at 2:20 p.m. Resident number eighty two (82) stated that he/she did not want to move from his/her room, because Resident number eighty two (82) is blind and cannot tell the difference between night and day. Resident number eighty two (82) liked the sounds of people walking by. Resident number eighty two (82) stated that about a month previously he/she was teld he/she would be transferred to another room, because there was another resident who was having frequent falls and needed the room to be closer to the staff. . 39. Resident number eighty two @) stated his/her current roommate does not sleep at night and keeps him/her up when the roommate makes sounds and claps his/her hands. Resident number - eighty two (82) further stated he/she is afraid in this new room, since it is on a quiet hallway far : 7 away from any activity. Staff walks into Resident number eighty two’s (82) room all the time. “without announcing themselves and many times when Resident number eighty two (82) asks who - itis, they do not respond, It makes Resident number eighty two (82) scared, so sometimes Resident _ number eighty two (82) will use the call light to call for the nurse, but many times the staff will.not ; “answer right away. 40. - During an interview on March 3, 2011 at 4:15 p.m. with the Director of Nursing regarding Resident nunber eighty two’s (82) refuisal to get out of bed, the Director of Nursing stated she was aware that Resident number eighty two (82) is afraid to get out of bed “he/she does not like the Hoyer lit and is afraid of transfers". . . 4, - The Director of Nursing stated it was awhile ago that she knew Resident number eighty two (82) was aftaid of transfers and stated it was discussed and should have been care planned, . 42. ; ‘A review of the récord did not reveal evidence the facility has addressed Resident number . eighty t two’s (82) fears or attempted any new approaches to transfer out of bed. 43, _ During an interview on March 2, 2011 at 4:26 p.m. with Resident number eighty two (82) and the Director of Nursing regarding getting out of bed, Resident number eighty two (82) stated ’ every time they get me up they bump my foot and it happens all the time. Resident number eighty two (82) also stated the wheelchair they put him/her in is very uncomfortable. The Director of Nursing reminded Resident number eighty two (82) of a time when a geriatric chair was used and asked if that was better. Resident number eighty two (82) stated it was more comfortable but they took it away and he/she did not know why. "44, — During an interview with the Director of Nursing on March 3, 2011 at 9:00 a.m. regarding any additional information for Resident number eighty two (82), the Director of Nursing stated she spoke with staff and they knew Resident number eighty two (82) was aftaid of heights and the Hoyer lift. No additional information was provided. ; 45. ; A review of the social worker notes dated December 14, 2010, a quarterly assessment, : : documented that Resident number eighty two (82) scored a fifteen (15) on the Brief Interview o on "Mental Status assessment (13-15 = cognitively intact); the “resident's mother reports she believes Resident number eighty two (82) won't get out of bed because Resident number eighty two (82) is : fearful because he/she can't see the people around. him/her.” a 46. ~ An interview was conducted. with the facility social worker on March 2, 2011 at 1:15 p.m. a The social worker stated that Resident number eighty two (82) likes to stay in his/her room; : Resident: number eighty two (82) is afraid of what he/she does not know. Resident number eighty * two (82): has lots of visitors daily and i is s total care. The social worker stated Resident number: i eighty two (82) needed to be moved because the facility had another resident that needed to have ‘that room due to frequent falls. ) ; ; . 47, The social worker further stated Resident number eighty two (82) reported he/she needed a roommate who could not get out of bed, would leave him/her alone and not rummage through his/her stuff . Resident number eighty two (82) told the social worker he/she did not want to move, but the social worker encouraged Resident number eighty two (82) to give it a try. 48 A review of the facility's policy and procedure regarding transfer within the facility | included: Procedure #3: note: If resident refuses to change rooms, provide further information and explanation as to why the change is required, clarify resident wishes and accommodate, as able. _ Document resident response; note further actions taken and outcome. Procedure #5: document notification of transfer, resident response and adjustment. 49. The Agency determined that this deficient practice compromised the resident's ability to : maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of : services. The Agency cited Respondent for a Class II deficiency as set forth in Section 400.23(8)(b), Florida Statutes (2010). 50." A Class Il deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5, 000 for & pattemed deficiency, and $7,500 for a widespread deficiency. The fine amount shall - be doubled for each deficiency if the facility was previously cited for one or more Class 1 or Class I deficiencies during the last licensure inspection or any inspection or F complain investigation since: the fast licensuie inspection. A fine shall be levied ‘notwithstanding the conection of the : deficiency. - 5h° Based upon the above findings, the Respondent's actions, inactions or conduct constituted an isolated Class II deficiency pursuant to Section 400.23(8)(b), Florida Statutes (2010). “WHEREFORE, the Agency intends to impose an administrative fire in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) against the Respondent pursuant to Sections 400.23(8X(b) and 400.102, Florida Statutes (2010). , COUNT _ Assignment Of Conditional Licensure Status ‘Status Pursuant To Section 400.23(7)(0), Florida ; Statutes (2010) 52. The Agency revalleges and incorporates by reference the allegations in Count I. 53. The Agency is authorized to assign a conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2010). 54, Due to the presence of one (1) Class Il deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part I, Florida See ane bee cere ee - 400.23(7)(b), Florida Statutes (2010). Statutes (2010), or the rules adopted by the Agency. 55. The Agency assigned the Respondent conditional licensure status with an action effective date of March 3, 2011. The original certificate for the conditional license is attached as Exhibit A andi is incorporated by reference. : 56. The Agency assigned the Respondent standard licensure status with an action effective 2 date of April 1, 2011. The original certificate for the standard license is attached as Exhibit B and is ' inicorporated by reference. , WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, espectfully requests the Court to enter ‘a final order granting the Respondent conditional licensure a status. for the period beginning March 3, 2011 and ending on April 1, 2011 pursuant to Section. CLAIM FOR RELIEF ‘WHEREFORE, the Petitioner, State of Flotida, Agency for Health Care Administration, , respectfully requests the Court to enter a final order granting the following relief against the o Respondent a as follows: 1. Make findings of fact and conclusions of law in favor of the Agency. 2: . Impose an administrative fine against the Respondent in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2, 500.00.). 3. Assign conditional licensure status to the Respondent for the period beginning on ‘March 3, 2011, and ending on April 1, 2011.” 4, Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this. Lat day of fratitde 2011. ary Paley adeeh Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel _ 2295 Victoria Avenue, Room 346C. Fort Myers, Florida 33901 (239) 335-1253 - _ NOTICE - RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN - ADMINISTRATIVE WEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES, THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE . ‘HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS \ MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN , io ‘TRE: ATTACHED ELECT: TON OF RIGHTS. : - ALL’ REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE *. ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE" ; ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 412-3639. THE RESPONDENT IS. FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE ] I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and _ a - Bleetion of Rights form were served to: Corporation Service Company, Registered Agent for . : ~ Pinehurst Health Care Associates, LLC d/bla Seaview Nursing and Rehabilitation Center, 1201 a Hays Street, Tallahassee, Florida 32301, by United States Certified Mail, Return Receipt No. 7009 on : 1680 0001 5449 4776 and to Lisa R. Izquierdo, Administrator, Pinehurst Health Care Associates, — ALL dib/a Seaview Nursing and Rehabilitation Center, 2401 N.E. Second Street, Pompano Beach, . Florida 33062, by United States Certified Mail, Return Receipt No. 7009 1680 0001 5449 4769 on this Aad day of Qugee, 2011. Res I Ligy acest General Counsel Florida Bar No. 0355712: Agency for Health Care Administration Office of the General Counsel _ 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 335-1253 ; : Copies furnished to: Mary Daley Jacobs, Assistant General Counsel [> - Agency for Health Care Administration a Office of the General Counsel : 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (interoffice Mail) Bernard Hudson, Health Services and. _| Facilities Consultant Supervisor | Bureau of Long Term Care Services Long Term Care Unit Agency for Health Care Administration ’ FP Gisa R. Izquierdo, Administrator | Pinehurst Health Care Associates, LLC _ d/b/a Seaview Nursing and Rehabilitation Center | _)2401-NLE. Second Street _ |; Pompano Beach, Florida 33062 | (U.S. Certified Mail) “1 -Corporation Service Company "| Registered Agent for mo . | Pinehurst Health Care Associates, LLC |: d/b/a Seaview Nursing and Rehabilitation Center - 11201 Hays Street ; “| Tallahassee, Florida 32301 - | (US. Certified Mail) | Tallahassee, Florida 32308 (Interoffice Mail) .| Arlene Mayo-Davis - 1 Field Office Manager : “Agency for Health Care Administration | 5150 Linton Boulevard, Suite 500 Deltay Beach, Florida 33484 } US. Mail) 2727 Mahan Drive, Building #3,Room 1213B) > STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ~ STATE OF FLORIDA, _ AGENCY FOR HEALTH CARE “ADMINISTRATION, _..., Petitioner, VS Case Nos. 2011003789 (Fine) : oS : 2011003792 (CL) : PINEHURST HEALTH CARE ASSOCIATES, LLC 7 dfbla SEAVIEW NURSING AND REHABILITATION CENTER, _.. Respondent. / ELECTION OF RIG) This Hléction 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, 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. . Pléase'use this form unless you, your attorney or your representative prefer to reply in accordance with Chapter 120, Florida Statutes (2010) and Rule 28, Florida Administrative Code. PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency fot Health Care Administration Attention; Agency Clerk - 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: 850-412-3630 Fax: 850-921-0158 PLEASE SELECT ONLY 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 hearing. J 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 penaity, fine or action. ‘ - OPTION TWO (2) I 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 I may submit testimony and written evidence to the Agency to show that the proposed administrative action is 400 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 J request a format hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing. OPTION. THREE (3) by itself is NOT sufficient to obtain a .. 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, It must be ‘received by the Agency Clerk at.the address above within 21 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 Adininistrative-Code, which requires that it-contain: : 1. Your name, address, telephone number, and the name, address, and telephone number of your representative or 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 statemént of alt 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, .. : ; co . License Type: ____ (Assisted Living Facility, Nursing Home, Medical Equipment, Other) ae : Licensee Name: License Number: Contact Person: Name Title Address: ae aoe Street and Number City State Zip Code Telephone No. -_ Fax No. E-Mail (optional) Thereby 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:___. Title: Print Name: | we eke Exhibit A Original Certificate of Conditional License Pinehurst Health Care Associates, LLC d/b/a Seaview Nursing and Rehabilitation Center Certificate No. 16715 License No. SNF1441096

Docket for Case No: 11-003332

Orders for Case No: 11-003332