The Issue The issues to be resolved in this proceeding concern whether the Respondent is guilty of a violation known as a "Class II violation" or "deficiency" and, if so, whether a $2,500.00 fine and conditional licensure status should be imposed upon the Respondent facility.
Findings Of Fact The Agency for Health Care Administration (AHCA or Agency) is the regulatory agency charged with licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities and the appropriate provision of nursing and other elements of care in such facilities in Florida. The Respondent Haven of Our Lady of Peace, Inc., (Haven) owns and operates a skilled nursing facility, which is a 120 bed facility located in Pensacola, Florida. On July 20, 2004, a survey was conducted by AHCA of the Haven facility. One Agency representative was on the premises on July 20, 2004, to investigate a complaint received by the Agency. When the survey was made the facility was operating under a standard license (Number SNF11970951) issued by the Agency, with an effective date of July 1, 2004 through June 30, 2005. Haven was cited for a Class II deficiency and issued Notice of a Conditional License and a $2,500.00 fine as a result of the survey. It chose to contest this initial Agency action by availing itself of the right to a formal proceeding pursuant to Section 120.57(1), Florida Statutes. The basis of the charged Class II deficiency was an incident involving Resident 3, in which she fell from a seated position in a wheelchair, injuring her head. At the time of the incident an order had been written by the treating physician assigned to Resident 3, which read as follows: D/C lap buddy. D/C lateral supports. Velcro torso support while in w/c [wheelchair]. Release Q2 for toileting, exercise, repositioning. As a result of the survey, the Agency provided Haven with a "Statement of Deficiencies" stating upon what basis the purported Class II deficiency was believed to exist. Resident 3 experienced a fall when she turned over her wheelchair in July 2003 by leaning to far to the right. Haven, in response to this experience, tried several approaches to help Resident 3 when she was in the wheelchair. Lateral supports and "lap buddy" were the first two interventions. The lap buddy caused the resident aggravation and therefore was discontinued and the torso support device was implemented. The torso support was not a restraint, but rather was applied to assist Resident 3 in maintaining good position while in her wheelchair. While Resident 3 had fallen on several occasions, she had never fallen or leaned forward prior to the subject falling incident. If Resident 3 had previously leaned forward, then other devices, such as wedge cushions, would have been used rather than the torso support. The torso support is not a good device to use if a resident falls forward. The torso support was not intended to directly prevent falls. On July 17, 2004, Kathy Anderson, a Certified Nursing Assistant (CNA), was preparing Resident 3 for bed. Ms. Anderson took Resident 3 from the living room, at which Resident 3 had a torso support on, in her wheelchair to the bathroom in Resident 3's room. The torso support was taken off so that the resident could use the bathroom. Ms. Anderson, as she had done on many occasions while caring for Resident 3, then placed her in a good position in the wheelchair, without applying the torso support and pushed her several feet into the bedroom and placed the wheelchair perpendicular to her bed, with the wall at the right side of the wheelchair (to prevent the feared fall to the right based upon a past tendency of the resident to lean to the right). Ms. Anderson had leaned Resident 3 back in the wheelchair prior to moving her from the bathroom. During the many times Ms. Anderson had cared for Resident 3 she had never leaned forward in her wheelchair. Ms. Anderson determined, while in the bathroom, that the resident's diaper was wet and a dry diaper was needed. The diapers were located in a closet just outside the bathroom. Ms. Anderson, standing at the back of the wheelchair, when it was positioned as described above in the resident's room, was able to reach into the closet and obtain a diaper without losing sight of the resident. It was not necessary for Ms. Anderson to walk to the closet, as the distance was close enough for her to reach the diaper without other movement. As she had done in the past, Ms. Anderson had instructed the resident that she was getting a diaper. The resident was still sitting in the wheelchair when Ms. Anderson had the diaper in hand. The resident then suddenly leaned forward and fell from the wheelchair and struck her head on the bottom of the bed. Ms. Anderson tried to catch the resident when she saw her falling, but was unsuccessful. Ms. Anderson then called a nurse, Joyce Parks, and Resident 3 was placed in her bed. Dr. Holmes' order (and his testimony) provided that the supports should be released at least every two hours. The torso support is not worn when the resident is in bed. The torso support must be removed to change the resident's clothes. There was no reason for the torso support to be re- applied after the resident used the bathroom. Ms. Anderson provided appropriate supervision of Resident 3 and her actions did not violate Dr. Holmes's order. The fall that occurred on July 17, 2004, was unforeseeable as the resident had never leaned forward before, but had always leaned to the right after she had been sitting for a long time and grew tired. Further, the resident had been placed in the bed after using the bathroom by Ms. Anderson using the same procedure during the two months that Ms. Anderson had cared for the resident. Resident 3 was in the nursing home for about two years. Dr. Holmes advocated that the residents be restrained as little as possible. According to Dr. Holmes, Resident 3 was a "delightful lady" and the applying of a restraint would have negatively impacted her quality of life. The relevant regulation applicable to nursing facilities requires that anything that restricts a resident be classified as a restraint; therefore, Haven was required to list the torso support as a restraint. In actuality, the torso support was not and did not function as a restraint. A torso support is applied to position the resident more straight and in a better position in a wheelchair. A torso support allows a resident to sit more straight for a longer period of time, to be more comfortable and thereby enjoy a better quality of life. It was reasonable for Ms. Anderson to be standing behind the wheelchair when she wheeled Resident 3 out of the bathroom and into the bedroom. The resident's ability to reach her highest practicable mental, physical and psycho-social well- being was not compromised by the Haven staff in this instance. Resident 3 received adequate supervision and assistance devices on July 17, 2004, when this incident occurred.
Recommendation Based on the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is, therefore, RECOMMENDED that a final order be entered by the Agency for Health Care Administration, dismissing the Amended Administrative Complaint in its entirety; that no fine be assessed, and that the Respondent be granted a standard license for the period of time in question. DONE AND ENTERED this 24th day of June, 2005, in Tallahassee, Leon County, Florida. S P. MICHAEL RUFF Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 24th day of June, 2005. COPIES FURNISHED: Janis L. Rosenthal, Esquire Agency for Health Care Administration Fort Knox Building III, Mail Station No. 3 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Karen Goldsmith, Esquire Jonathon Grout, Esquire Goldsmith, Grout & Lewis, P.A. 2180 Park Avenue North, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration Fort Knox Building, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308
The Issue Whether the Petitioner's licensure status should be reduced from standard to conditional effective April 5, 2001.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: AHCA is the state agency responsible for licensing and regulating the operation of nursing home facilities, including ensuring that nursing homes are in compliance with criteria established by Florida statute. Chapter 400, Part II, Florida Statutes (2000).1 Beverly Fort Pierce, located in Fort Pierce, Florida, is a facility licensed to operate as a nursing home pursuant to the provisions of Chapter 400, Part II, Florida Statutes, and the rules found in Chapter 59A-4, Florida Administrative Code. AHCA conducted an annual relicensure survey of Beverly Fort Pierce from April 2 through April 5, 2001, ("April 5, 2001, survey") for the purpose of determining Beverly Fort Pierce's compliance with the state and federal criteria applicable to nursing homes. As is AHCA's usual practice, the alleged deficiencies found during the survey were reported on a form used by the federal Department of Health and Human Services, Health Care Financing Administration, HCFA-2567, which is commonly referred to as a "Form 2567." The deficiencies cited on the Form 2567 were identified in accordance with the criteria set forth in the State Operations Manual, which is published by the federal Health Care Financing Agency and provides guidance to state surveyors in interpreting and applying the federal regulations applicable to nursing homes receiving reimbursement from Medicaid and/or Medicare. The State Operations Manual, Guidance to Surveyors, includes "tag numbers" corresponding to provisions of the regulations found in Title 42, Chapter 483, Code of Federal Regulations. In the State Operations Manual, a "tag number" is associated with each provision of the federal regulations, and the intent of the regulation is set forth, together with guidelines, procedures, and probes which are to be used by the state surveyors in determining whether a particular regulation has been violated. The deficiencies cited on the Form 2567 completed as a result of the April 5, 2001, survey of Beverly Fort Pierce were each identified by the federal tag number, by a citation to the applicable provision of the Code of Federal Regulations, by a citation to the applicable Florida administrative rule, and by a Florida statutory classification as either a Class II or Class III deficiency. The Form 2567 included citations for three Class II deficiencies and for several Class III deficiencies. On May 18, 2001, AHCA returned to Beverly Fort Pierce and conducted the first "revisit survey" subsequent to the April 5, 2001, survey. The Form 2567 prepared for the May 18, 2001, revisit survey indicated that two deficiencies from the April 5, 2001, survey remained out of compliance. In its original five-count Administrative Complaint, dated December 3, 2001, AHCA identified as the bases for the reduction of Beverly Fort Pierce's licensure status to conditional two of the three Class II deficiencies and one of the several Class III deficiencies cited in the Form 2567 for the April 5, 2001, survey, as well as the two Class III deficiencies cited in the Form 2567 for the May 18, 2001, revisit survey. The Amended Administrative Complaint filed on the date of the hearing contained only three counts, and, at the hearing, AHCA voluntarily dismissed two of the three counts in the Amended Administrative Complaint. Accordingly, at the hearing, AHCA offered proof only with respect to the Class II deficiency identified in the Form 2567 for the April 5, 2001, survey based on the allegations that resident #13 developed pressure sores on her right heel, left heel, and right great toe while she was a resident at Beverly Fort Pierce.2 At the time of the April 5, 2001, survey, resident #13 was 92 years of age and had resided at Beverly Fort Pierce since November 21, 1995. Resident #13 was chosen by the survey team prior to the commencement of the survey as one of the residents to be observed during the team's visit to Beverly Fort Pierce. During the initial tour of the facility on April 2, 2001, the survey team leader, Judy Spiritu, visited resident #13's room and noticed that she was lying on her back in bed and was wearing heel protectors, although the one on the left leg was around her calf. Ms. Spiritu decided to observe resident #13 more closely during the survey, and she reviewed her clinical records and interviewed her caregivers. The Nurses Notes for resident #13 indicate that "pressure areas to bilateral heels" were noted by the care specialist at approximately 10:30 p.m. on March 1, 2001, and the resident's feet were elevated off of the bed. At 10:00 a.m. on March 2, 2001, resident #13's right heel and great toe were sprayed and wrapped and socks and heel protectors were applied. At 1:00 p.m. on March 2, 2001, blisters were noted on resident #13's right and left heels and right great toe; the blister on the right heel measured 3 centimeters by 3 centimeters, the blister on the top of the right great toe measured 0.5 centimeters by 0.5 centimeters, and the blister on her left heel measured 1 centimeter by 1 centimeter. The blisters were classified as Stage II ulcers, defined in Beverly Fort Pierce's records as "an ulceration in which partial thickness of skin is lost with involvement of the epidermal and/or dermal layers of skin."3 Resident #13 suffered from a number of serious medical problems, including seizure disorder, advanced Alzheimer's disease, carotid artery stenosis, a duodenal ulcer, hypertension, osteoporosis, arthritis, peripheral vascular disease, arterial sclerotic heart disease, and aortic heart disease. The Minimum Data Set dated February 15, 2001,4 indicated, among other things, that resident #13 was completely dependent on staff for turning and repositioning in bed, although she could move her legs, and that resident #13 was incontinent of bowel and bladder. Beverly Fort Pierce prepared a Problem Summary for resident #13 based upon the problems identified in the Minimum Data Set prepared February 15, 2001. Entries made in the Problem Summary for resident #13 on February 16 and 22, 2001, reflect that, over the previous 90 days, resident #13 had significant weight loss and decline in functioning with respect to activities of daily living and that she was totally dependent on staff for bed mobility.5 It was also noted in the Problem Summary entry for February 22, 2001, that resident #13 was at risk for the development of pressure ulcers because of incontinence, advanced Alzheimer's, and the decline in bed mobility. Beverly Fort Pierce had in place a Plan of Care for resident #13 for February 2001, and it was noted in the February 22, 2001, entry that resident #13 was at risk of developing pressure ulcers due to incontinence; it was further noted that, at the time, she had no pressure ulcers. A number of interventions were identified in the Plan of Care to deal with the risk that resident #13 would develop pressure ulcers, including use of a "pressure relieving mattress"; "protective/preventative skin care after each incontinent episode"; "monitor skin turgor for any area of concern"; "[i]ntervene as needed"; and "turn and reposition Q 2H [each two hours]." There is no mention in resident #13's Plan of Care that heel protectors should be used as an intervention until on or after March 2, 2001, when the Stage II ulcers on resident #13's heels and right great toe were first discovered. Although there is no indication in the Plan of Care of the date on which a pressure-relieving mattress was provided, Beverly Fort Pierce replaced all of its mattresses with pressure relieving-mattresses several years prior to the times material to this proceeding. Skin Assessment Forms completed for resident #13 for March and April 2001 documented that resident #13's skin was assessed weekly from March 5, 2001, through April 16, 2001, and the existence of blisters on the right and left heels and the right great toe were noted on the March 5, 2001, assessment.6 In addition, the Treatment Records for March and April 2001 carry a set of initials for each shift for most days through April 22, 2001, beside the entry of an order dated February 16, 1999, which required the following care: "Both siderails up when in bed due to alteration in safety awareness due to cognitive decline. Check q [each] 30 min[.] Release q2h [each two hours] for positioning and tolieting [sic]."7 It was not the policy of Beverly Fort Pierce to make a notation each time routine care such as turning and repositioning was provided, and the only explicit indication that resident #13 was turned and repositioned was an entry in the Nurses Notes for March 23, 2001.8 The first mention of the use of heel protectors was a notation in the Nurses Notes entered at 10:00 a.m. on March 2, 2001, and the use of heel protectors for resident #13 is often mentioned in the Nurses Notes after that date. A pressure ulcer is a sore that develops as a result of pressure to areas of the body referred to as pressure points, because the pressure diminishes the blood supply to the affected area and results in the death of the tissue; a pressure sore can develop in a matter of hours and may first appear as a Stage II blister because the damage to the tissue may initially occur beneath the surface of the skin. A stasis ulcer is an ulcer that develops on the lower extremities, most commonly in the "inner aspect of the lower third of the leg" and on the "lateral aspect of the leg."9 A stasis ulcer is related to chronic venous disease that inhibits the flow of blood from an area or to extensive arterial disease that inhibits the delivery of blood, oxygen, and nutrition to an area; a stasis ulcer develops over a period of time, not in one or two days, and is characterized by thickening, redness, and changes in the skin referred to as stasis dermatitis. Stasis ulcers develop as a result of a resident's clinical condition and are considered unavoidable. Based on the description in the Nurses Notes of resident #13's ulcers when they were first discovered and given the short time during which the ulcers developed, the ulcers on resident #13's heels and right great toe were pressure ulcers, not stasis ulcers,10 although the ulcers could have been caused in part by resident #13's vascular status.11 As noted in the entry on the Problem Summary of February 22, 2001, resident #13's medical condition had deteriorated during the previous 90 days, she had a number of serious medical problems, and she was very near the end of her life. A person with such morbidity factors is more likely to develop pressure ulcers despite being provided with appropriate routine preventive care and medical services than are persons with fewer or less serious medical problems. Although resident #13's clinical condition might have placed her at risk of developing pressure ulcers, the evidence presented by Beverly Fort Pierce establishes that the staff was aware that resident #13 was at risk of developing pressure ulcers and that certain preventive measures were included in her Plan of Care as a result of this risk, including providing her with a pressure-relieving mattress and turning and repositioning her in bed once every two hours. However, no requirement was included in the Plan of Care that heel protectors were to be used when resident #13 was in bed. Beverly Fort Pierce presented no evidence with respect to the preventive care that was actually provided to resident #13 prior to 10:30 p.m. on the night of March 1, 2001, when the pressure areas on resident #13's heels were noted. The evidence establishes that resident #13 was provided with a pressure-relieving mattress, but there is no evidence that she was turned and repositioned every two hours or that she was provided with heel protectors prior to 10:00 a.m. on March 2, 2001.12 Without proof of the preventive care that the staff provided resident #13, Beverly Fort Pierce has failed to establish that the pressure ulcers on resident #13's heels and right great toe were unavoidable.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order: Finding that Beverly Health and Rehabilitation Center, Fort Pierce, had a Class II deficiency at the time of the April 5, 2001, relicensure survey in that resident #13 developed pressure sores on her heels and right great toe that were not unavoidable; and Reducing the licensure status of Beverly Fort Pierce from standard to conditional, effective April 5, 2001, pursuant to Section 400.23(7)(b), Florida Statutes (2000). DONE AND ENTERED this 24th day of April, 2002, in Tallahassee, Leon County, Florida. PATRICIA HART MALONO Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 24th day of April, 2002.
Conclusions Having reviewed the Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency has jurisdiction over the above-named Respondent pursuant to Chapter 408, Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions. 2. The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The Election of Rights form advised of the right to an administrative hearing. 3. The parties have since entered into the attached Settlement Agreement. (Ex. 2) Based upon the foregoing, it is ORDERED: 1. The Settlement Agreement is adopted and incorporated by reference into this Final Order. The parties shall comply with the terms of the Settlement Agreement. 2. The Respondent shall pay the Agency $2,000.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. A check made payable to the “Agency for Health Care Administration” and containing the AHCA ten-digit case number should be sent to: Office of Finance and Accounting Revenue Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS 14 Tallahassee, Florida 32308 3. Conditional licensure status is imposed on the Respondent beginning on March 31, 2014, and ending on May 1, 2014. Filed April 8, 2015 10:33 AM Division of Administrative Hearings ORDERED at Tallahassee, Florida, on this (, day of. Apel , 2015. a retary Agency for Hea! e Administration
Other Judicial Opinions A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct_cgpy of this Final Order was served on the below-named persons by the method designated on this & ¢ LQ 7 , 2015. NN Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, Florida 32308-5403 Telephone: (850) 412-3630 Jan Mills Finance & Accounting Facilities Intake Unit Revenue Management Unit (Electronic Mail) (Electronic Mail) Thomas J. Walsh II George R. Huffman, Esq. 4 Office of the General Counsel Consulate Health Care Agency for Health Care Administration 5102 West Laurel Street (Electronic Mail) Suite 700 Tampa, FL 33607 (U.S. Mail) Hon. William F. Quattlebaum Administrative Law Judge Division of Administrative Hearings (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, : vs. Case Nos. 2014004524 WINTER HAVEN FACILITY OPERATIONS, LLC d/b/a CONSULATE HEALTH CARE OF WINTER HAVEN, 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 Winter Haven Facility Operations, LLC d/b/a Consulate Health Care of Winter Haven (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2014), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing March 31, 2014, and to impose administrative fines in the amount of two thousand . five hundred dollars ($2,500.00), based upon Respondent being cited for one (1) isolated State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2014). 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 EXHIBIT om led 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), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a one hundred twenty (120) bed nursing home, located at 2701 Lake Alfred Road, Winter Haven, Florida 33881, and is licensed as a skilled nursing facility license number 130470990. 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 rules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2013). 8. That Florida law provides the following: “‘Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(19), Fla. Stat. (2013). 9. That Florida law provides the following: “A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment.” Rule 59A-4.109(1)(c), Florida Administrative Code. 10. That on March 31, 2014, the Agency completed a complaint survey visit of Respondent’s facility. 11. That based upon the review of records and interview, Respondent failed to ensure residents 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, where, inter alia, Respondent failed to timely and appropriately respond to a noted significant change in condition and failed to assess and treat conditions and symptoms which Respondent knew or should have known increased risk related to dehydration, the same violating Respondent’s policy and procedure and minimum requirements of law. 12. That Petitioner’s representative reviewed Respondent’s policy and procedure entitled "Dehydration Prevention for Environmental or Medical Causes," last revised on 9/1/11, provided by the Director of Nursing (DON), and noted it provided as follows: a. "Policy" - "Appropriate medical and nursing care will be provided to residents when the temperature goes above 80 degrees Fahrenheit on resident care units and the air conditioning system is inoperable, or resident has medical condition that puts them at risk for dehydration, i.e: vomiting/diarrhea, elevated temperature, diuretic usage, etc.” "Procedure" - "If Medical Conditions such as: Fluid loss and increased fluids needs (i.e., diarrhea, fever, uncontrolled diabetes, hot weather, etc.) Step] - Unless fluids are restricted, they will be offered: 1. With each meal. 2. With each medication administration. 3. At least one other time on day and evening shift while resident is awake. ... Step 5: New dehydration risk factors demonstrated by the resident (ie. onset of fever, diarrhea, vomiting, significant change in intake/output, refusal to eat or accept fluids, significant increase in edema or weight, etc.) will be described in the PRN nursing notes, and the physician and responsible party will be notified in accordance with the facility notification of change policy. " 13. That Petitioner’s representative reviewed Respondent’s records related to resident number three (3)-during the survey and noted as follows: a. The resident is an eighty-seven (87) year old admitted to the facility on February 13,2014. Diagnoses included leukocytosis, diabetes mellitus, dementia, urinary tract infection, hypertension and weakness. The seven day minimum data set assessment, dated February 20, 2014, revealed under Section C a Brief Interview for Mental Status (BIMS) score of “4” which indicated impaired orientation and recall; Section D revealed the resident independent with eating and drinking with set- up help only; Section H documented incontinent of bowel and bladder; and Section K documented no swallowing disorder. A "Nursing Home to Hospital Transfer Form," dated March 5, 2014, indicated that the resident was discharged when transported to an acute care hospital, twenty (20) days after admission, with a diagnosis of altered mental status. The initial physician's orders, dated February 13, 2014, indicated that the resident was to receive a regular, mechanically soft diet with no added salt, and may drink thin liquids. The Certified Nursing Assistant (CNA) Tracking Form for February and March 2014 reflected as follows: i. The Bowel Function area for February 14 through 28, 2014, indicated that the resident was incontinent of stool at least thirty-seven (37) times during those fourteen (14) days. ii. The Bowel Function area for March 1 through 5, 2014, indicated that the resident was incontinent of stool at least twenty-five (25) times for those five (5) days. Adding these two sums together reflects that over the course of nineteen (19) days the resident had documentation that the resident was incontinent of stool sixty-two (62) times. Lab results reflected a Serology test result dated February 28, 2014; the resident was positive for Clostridium Difficile. A Basic Metabolic Profile, dated March 5, 2014, documented the resident developed an electrolyte and acid/base imbalance. The "Fluids Offered" section of the certified nursing assistant Tracking Form for March, 2014, reflected no documentation that fluids were offered on March 1, 2014, for the 7:00 p.m. to 3:00 p.m. shift, no documentation that fluids were offered on March 2, 2014, for the 3:00 p.m. to 11:00 p.m. shift, and no documentation that any fluids were offered to the resident for both shifts from 7:00 a.m. to 11:00 p.m. on March 3 to 4, 2014, when the resident was made "non per ora” (NPO — nothing by mouth) and was receiving no food, fluids or medications by mouth due to a mental status change so severe that she was no longer swallowing. There was no intake recorded at all for breakfast and lunch on March 1, 2014, and nothing recorded for dinner on March 3, 2014. The "Daily Skilled Nurse's Notes” for February, 2014, reflected no documentation that indicated fluid status and the prevention of dehydration was being addressed. The "Daily Skilled Nurse's Notes” for March, 2014, reflected as follows: i. March 1, 2014 - "No Problems" was checked under the section for "Bowel." ii. Although the certified nursing assistants had been documenting frequent iii. vi. vii. viii. xi. stools, and the resident was diagnosed as having an active C-diff infection, there was no assessment that included checking the resident for signs and symptoms of dehydration, and no interventions documented to provide additional fluids. March 2, 2014 - "No Problems” was checked again under the section for “Bowel,” although the resident's intake continued to be poor, and diarrhea continued. iv. March 3, 2014 - An entry timed 12:55 p.m. indicated that the patient was noted to be "weak and feet cyanotic," and pulse was "irregular." There was no documentation that the family was notified for this change in condition. There was no documentation of what the physician said when he was notified. There were no further orders, and no apparent follow-up of this condition change. March 4, 2014 - A narrative entry timed 10:00 a.m. on Side 2 indicated that the resident began choking when medications in applesauce had been given. The nurse indicated that she notified speech therapy. There was no documentation that the physician and family were notified at that time, only speech therapy. The next entry timed, 1:30 p.m., indicated that speech therapy recommended that the resident not receive anything by mouth. A subsequent entry, timed 2:30 p.m., indicated that the physician was then xii. xiii. xiv. notified and orders were received for intravenous fluids and lab tests the following morning. March 5, 2014 - An entry timed 8:00 a.m. indicated that normal saline was being infused intravenously as per the orders. The next entry, timed 12:00 p.m., indicated that the resident was transported to the emergency department for further evaluation for dehydration and altered mental status. An SBAR Communication Form dated March 5, 2014, indicated that the physician was called and the request included, "Patient noted being lethargic, change in mental status, unable to swallow. Patient made NPO. Normal saline at 75ml/hour. Family concerns regarding patient condition and wants patient sent to ER." 14. That Petitioner’s representative interviewed, on March 19, 2014, the physician for resident number three (3) regarding the resident, and the physician indicated as follows: a. He did not recall the resident and referred the surveyor to his documentation in the clinical record that contained two progress notes dated February 19 and 26, 2014. He reviewed the lab results dated February 28, 2014, that indicated the resident had a C-diff bowel infection, and the basic metabolic profile dated March 5, 2014. He stated that it appeared that the resident became dehydrated and had a severe infection from the C-diff, and he reviewed his progress notes that included "Gastrointestinal/Abdomen" checked as "normal" on the February 19, 2014, History and Physical. On the February 26, 2014, progress note he had written, "last BM =?" There was no documentation in his progress notes regarding the resident's frequent stools and fluid management. He confirmed he had been unaware of the frequency of diarrhea stools and concerns regarding potential dehydration. He confirmed that he was made aware of the positive C-diff on February 28, 2014, and treatment began for the C-diff infection as per his orders. 15, That Petitioner’s representative interviewed, on March 19, 2014, Respondent’s unit manager where resident three (3) was located from admission through March 3, 2014, regarding the resident, and the manager indicated as follows: a. The resident "Came in with loose stools, but was negative for C-diff. But, the stool still had the smell of C-diff., so we did another one, and that one was positive. " She confirmed that residents with diarrhea are at risk for fluid loss and dehydration and such residents should be assessed and encouraged to drink to prevent complications of dehydration. She thought the resident was only having approximately one stool a day. She confirmed the documentation of frequent stools on the certified nursing assistant Tracking Form. She confirmed that “Dehydration/Fluid Management" was not checked as being implemented on the Admission Care Plan. She was working at the facility on March 4, 2014, and recalled when the resident had a change in mental status. g. Nursing staff was aware that the physician was going to come in the next day, and planned on ensuring that he would see the patient then. h. She could not locate any notes that spoke to the resident's fluid status and what was being done to prevent dehydration, since it was a common complication of C- diff. 16. That Petitioner’s representative interviewed, on March 19, 2014, Respondent’s nurse “B” regarding resident number three (3) and the nurse indicated as follows: a. She was assigned to the resident on March 4, 2014. b. It was important to ensure a resident's fluid intake was assessed and maintained when they have diarrhea to prevent dehydration. c. Nurses and certified nursing assistants are required to provide fluids with each meal and between meals, and assist the residents to drink if necessary. 17. That Petitioner’s representative interviewed, on March 31, 2014, Respondent’s nurse “A,” regarding resident number three (3), who indicated that she had meant to follow up with the physician and make sure that he received the message, but she was moved to the long term care unit. She stated that she gave report to Nurse B. 18. That Petitioner’s representative interviewed, on March 21, 2014, Respondent’s unit manager where resident three (3) was located from March 3 through 5, 2014, regarding the resident, and the manager confirmed that C-diff is a infection of the gastro-intestinal system associated with severe diarrhea with the potential complication. 19. That the above reflects Respondent’s failure to ensure residents receive adequate and appropriate health care and protective and support services, including social services; mental 10 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, where Respondent failed to timely and appropriately respond to a known significant change in condition and knew or should have known a resident suffered from disease and or symptoms indicating increased risk of dehydration, but failed to assess and treat this increased risk of dehydration in violation of facility policy and procedure and law. 20. That the Agency determined that this deficient practice has 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. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency, 21. That Respondent was cited for an isolated Class II deficient practice. 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), Florida Statutes (2013). COUNT I 22. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. 23. Based upon Respondent’s cited State Isolated Class II deficiency, it was not in 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)(a), Florida Statutes (2013). i 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 (2013) commencing March 31, 2014. “7 Respectfully submitted this & ¢ day of August, 2014. Lf Thomas J.Walsh II, Esquire Fla Bar. No. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) walsht@ahca.myflorida.com DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2013), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an 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. CERTIFICATE OF SERVICE THEREBY CERTIFY that a true and correct copy of the foregoing has begn served by USS. Certified Mail, Return Receipt No: 7013 2250 0001 4950 4766 on August “C__, 2014 to Tyrus Hawkins, Administrator, Winter Haven Facility Operations, LLC d/b/a Consulate Health Care of Winter Haven, 2701 Lake Alfred Road, Winter Haven, Florida 3388 1, and by Regular U.S. Mail to Corporation Service Company, Registered Agent for Winter Haven Facility Operations, LLC 1201 Hays Street, Tallahassee, FL 32301-2525. j Thornas J. Walsh, II, Esquire Copies furnished to: Patricia R. Caufman, FOM 13 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Winter Haven Facility Operations, LLC CASE NO. 2014004524 d/b/a Consulate Health Care of Winter Haven ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for 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 to the allegations of facts 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. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) | I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, 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 too severe or that the fine should be reduced. OPTION THREE (3)__—S—=iI dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. 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 Administrative Code, which requires that it contain: 1. Your name, address, and 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 statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(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 licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RICK SCOTT ELIZABETH DUDEK GOVERNOR SECRETARY June 6, 2014 Tyrus Hawkins, Administrator File Number: 35960929 Consulate Health Care Of Winter Haven License Number: 130470990 2701 Lake Alfred Rd Provider Type: Nursing Home Winter Haven, FL 33881 RE: 2701 Lake Alfred Rd, Winter Haven Dear Administrator: The enclosed Nursing Home license with license number 130470990 and certificate number 18900 is issued for the above provider effective March 31, 2014 through September 30, 2014. The license is being issued for a status change to Conditional. Review your certificate thoroughly to ensure that all information is correct and consistent with your records. If errors are noted, please contact the Long Term Care Unit. Please take a short customer satisfaction survey on our website at ahca.myflorida.com/survey/ to let us know how we can serve you better. Additional licensure information can be found at http://ahca.myflorida.com/longtermcare. If we may be of further assistance, please contact me by phone at 850-412-4427 or by email at Kathleen.Munn @ahca.myflorida.com. Sincerely, 4. aie air Kathleen Munn Health Services and Facilities Consultant Long Term Care Unit Division of Health Quality Assurance 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 Visit AHCA online at ahca.myflorida.com PlOc/0¢/60 *ALVC NOILVUIdXxA pl0z/1¢/60 ALVG AALLOSAAA osueyD snes Sddd 0¢cl “IV.LOL I88€Ee Tq “Weary JOpUT AA, Pa PTV SAT LOL NHAVH YaINIM AO daAVO HLTVEaH ALVTIASNOD :SUIMOTIOJ oy} aeIJado 0} pazLIOyIN SI SSUdOT] OY) SB pue ‘soINIeIS ePLOL] ‘TT Wed ‘OOP Jeldeyy ur pozoyne ‘uoNENsrMMpY aeD YoY Joy Souesy ‘epopy Jo aeig oy) Aq pordope suone[nZaz pue separ oy WIM porpduroo sey OTT ‘SNOLLVaadO ALTTIOW NUAVH SALNIM Jeu WJUOO 0} SE STYLE TVNOLLIGNOD AINOH ONISHIN AONVUNSSV ALIIVNO HLTVSH AO NOISIAIG NOILLVULSININGV FaVO HLTVAH YOd AONADV BPLIO] JO 3381S O660LP0CTANS *# USNHOMT 00681 *# ALVOIWILYAO FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION. RICK SCOTT ELIZABETH DUDEK GOVERNOR SECRETARY June 6, 2014 Tyrus Hawkins, Administrator File Number: 35960929 Consulate Health Care Of Winter Haven License Number: 130470990 2701 Lake Alfred Rd Provider Type: Nursing Home Winter Haven, FL 33881 RE: 2701 Lake Alfred Rd, Winter Haven Dear Administrator: The enclosed Nursing Home license with license number 130470990 and certificate number 18901 is issued for the above provider effective May 1, 2014 through September 30, 2014. The license is being issued for approval of a status change back to Standard. Review your certificate thoroughly to ensure that all information is correct and consistent with your records. If errors are noted, please contact the Long Term Care Unit. Please take a short customer satisfaction survey on our website at ahca.myflorida.com/survey/ to let us know how we can serve you better. Additional licensure information can be found at http://ahca.myflorida.com/longtermcare. If we may be of further assistance, please contact me by phone at 850-412-4427 or by email at Kathleen.Munn@ahca.myflorida.com. Sincerely, A Tuer Kathleen Munn Health Services and Facilities Consultant Long Term Care Unit Division of Health Quality Assurance 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 Visit AHCA online at ahca.myflorida.com ‘ALVC NOI PplOZ/T0/S0 ALVG HALLOdsA asueyy smjeis Sada 071 “TVLOL TS8E€ Ty “WeseH Jol Pa PATTY FT TOLZ NHAVH YALNIA JO TAVO HLTVaH ALVINSNOD :BUIMOTIOF oy] ayerodo 0} pozioy ne $I soSUaor] Ou se PUR ‘saINIeIS EPLIOLZ ‘TT Veg ‘OOP IerdeyD UT pozuoYINe ‘uoTeNsTUNUpY TED Wee JO,J Aouesy ‘epHojy Jo 81S amp Aq paidope suonepngar pur sorna oy qyas porduroo sey OTT ‘SNOLLVUAdO ALIMOVA NAA VH YALNIA 12u) WATFGOO OF SE SIEL CUVANV.LS HINOH ONISHAIN AONVANSSV ALITVNO HLIVAH AO NOISTIAIG NOLLVULLSININGY davo HL TVaH AOA ADNADV BPLIOLy JO 9381S T0681 *# ALVOMILAEO authority over Respondent, pursuant to Chapters 400, Part II, and 408, Part Il, Florida Statutes; | ‘STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. DOAH CASE NO. 14-4350 AHCANO. 2014004524 WINTER HAVEN FACILITY OPERATIONS, LLC d/b/a CONSULATE HEALTH CARE OF WINTER HAVEN, Respondent. / SETTLEMENT AGREE iT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Apency”), through its undersigned representatives, and Respondent, Winter Haven Facility Operations, LLC d/b/a Consulate Health Care of Winter Haven (hereinafter “Respondent”), pursuant to Section 120.57(4), Florida Statutes, each individually, a “party,” collectively as “parties,” hereby enter into this Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Respondent is a nursing home licensed pursuant to Chapters 400, Part II, and 408, Part II, Florida Statutes, Section 20.42, Florida Statutes and Chapter 59A-4, Florida Administrative Code; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing and _ WHEREAS, the Agency served Respondent with an administrative complaint on or about august 23, 2014, notifying the Respondent of its intent to impose administrative fines in EXHIBIT FEB 19 2015 “9 the amount of two thousand five hundred dollars ($2,500.00) and to impose conditional licensure status commencing March 31, 2014; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals herein are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties, 3. Upon full execution of this Agreement, Respondent agrees to waive any and all appeals and proceedings to which it may be entitled related to this state proceeding including, but not limited to, an informal proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 120.68, Florida — Statutes; and declaratory and all writs of relief in any court or quasi-court of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled, provided, however, that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement. 4, Upon full execution of this Agreement, Respondent agrees to pay two thousand dollars ($2,000.00) to the Agency within thirty (30) days of the entry of the Final Order. Respondent also accepts the imposition conditional licensure status commencing March 31, ~ 2014, and ending May 1, 2014. 3. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida. 6. By executing this Agreement, Respondent denies, and the Agency asserts the validity of the allegations raised in the administrative complaint referenced herein. No agreement made herein shall preclude the Agency from imposing a penalty against Respondent for any deficiency/violation of statute or rule identified in a future survey of Respondent, pursuant to the provisions of Chapters 400, Part II, 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code, including a “repeat” or “uncorrected” deficiency identified in the Survey. In said event, Respondent retains the right to challenge the factual allegations related to the deficient practices/ violations alleged in the instant cause. 7. No agreement made herein shall preclude the Agency from using the deficiencies from the surveys identified in the administrative complaint in any decision regarding licensure of Respondent, including, but not limited to, a demonstrated pattern of deficient performance. The Agency is not precluded from using the subject events for any purpose within the jurisdiction of the Agency. Further, Respondent acknowledges and agrees that this Agreement shall not preclude or estop any other federal, state, or local agency or office from pursuing any cause of action or taking any action, even if based on or arising from, in whole or in part, the facts raised in the Survey. This agreement does not prohibit the Agency from taking action regarding Respondent’s Medicaid provider status, conditions, requirements or contract. 8. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and closing the above-styled case. 9. Each party shall bear its own costs and attorney's fees. 10. This Agreement shall become effective on the date upon which it is fully executed by all the parties. ll. Respondent for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent or related facilities. . 12. This Agreement is binding upon all parties herein and those identified in paragraph eleven (11) of this Agreement. 13. In the event that Respondent was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G-9.070, Florida Administrative Code. 14. Respondent agrees that if any funds to be paid under this agreement to the Agency are not paid within thirty-one (31) days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Respondent in the Final Order, or any portion thereof, owed by Respondent to the Agency from any present or future funds owed to Respondent by the Agency, and that the Agency shall hold a lien against present and future funds owed to Respondent by the Agency for said amounts until paid. 15. The undersigned have read and understand this Agreement and have the authority to-bind their respective principals to it. 16. | This Agreement contains and incorporates the entire understandings and agreements of the parties. 17. This Agreement supersedes any prior oral or written agreements between the parties. 18. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. 19. All parties agree that a facsimile signature suffices for an original signature. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. Deputy Secretary Healy Qualify Afsurance Agency for Health Care Administration 2727 Mahan Drive, Building #1 - Tallahassee, Florida 32308 DATED: 7 bis ~ t Stuart F, Williams, General Counsel Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 Florida Bar No. 670731 DATED: George 8. Huffinan, Esq. Counsel for Respondent $102 West Laurel Street -Suite700- Tampa, Florida 33607 Florida Bar No. 140955 DATED: re \ ? Title: Winter Haven Facility Operations, LLC DATED: aos, HS . a é Thomas J, Walsh I, Senior Attorney Officé of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330G St. Petersburg, Florida 33701 Florida Bar No. 566365 fof
