15-001098 Agency For Health Care Administration vs. 1351 Golden, Llc, D/B/A Cross Terrace Rehabilitation Center Status: Closed Recommended Order on Friday, December 4, 2015.

Summary: Respondent, a skilled nursing facility, committed two Class III deficiencies and should be fined $1,000 per deficiency since they are isolated incidents related to a single resident.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Petitioner,

vs. Case No. 15 - 1098

1351 GOLDEN, LLC, d/b/a CROSS

TERRACE REHABILITATION CENTER,

Respondent.

_______________________________/

RECOMMENDED ORDER

A final hearing was held in this matter before Robert S.

Cohen, Administrative Law Judge with the Division of

Administrative Hearings, on June 2 3 and 24 , 2015, in Tampa ,

Florida.

APPEARANCES

For Petitioner: John E. Bradley, Esquire

Agency for Health Care Administration

The Sebring Building, Suite 330

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

For Respondent: Michael Brett Kornhauser, Esquire

Christopher M. David, Esquire

Fuerst, Ittleman, David and Joseph, P.L.

1001 Brickell Bay Drive, 32nd Floor

Miami, Florida 33131

STATEMENT OF THE ISSUE S

The issues are whether Respondent provided a dequate and

appropriate care and treatment for Resident No. 80, and whether

Respondent implemented a plan of care to treat Resident No. 80 Ós

skin condition. The ultimate issue is whether these two

deficiencies should result in a fine being imposed upon

Re spondent and changing its license to a conditional status.

PRELIMINARY STATEMENT

Petitioner, the Agency for Health Care Administration

( ÐPetitionerÑ or Ð AHCA Ñ ), conducted an annual survey at

RespondentÓs skilled nursing facility, known as Cross Terrace

Reh abilitation Center, from July 21 through 24, 2014. Petitioner

issued an Administrative Complaint against Respondent on

January 7, 2015, seeking to impose upon Respondent a $5,000

administrative fine based upon two Class II deficiencies

discovered during t he July survey inspection, and to change the

facilityÓs status to a conditional license beginning July 24 and

ending August 24, 2014.

Respondent timely executed an Election of Rights form

contesting the factual basis for AHCAÓs allegations and filed a

Requ est for Formal Hearing (Petition) with Petitioner. That

Petition was forwarded to the Division of Administrative Hearings

for assignment of an administrative law judge. The matter was

originally scheduled for hearing on May 11 and 12, 2015, but

after a c ontinuance requested by Respondent, the matter proceeded

to hearing on June 2 3 and 2 4 , 2015.

At the hearing, Petitioner presented the testimony of D

W; Carlos Arruda; Jillian Allane, a health facility

evaluator; Kathryn Hill, R.N.; Pankaj Joshi, M.D.; Deirdre Wells,

R.N.; and Patricia Freed, R.N. Nurses Hill and Freed were

accepted as experts in the field of nursing. Petitioner also

offered five exhibits ( Exhibit Nos. 1, 3, and 8-10) , which were

admitted into evidence. Respondent presented the testimony of

Dona Conde, R.N., its director of n ursing; Donna Gallant, R.N.,

its MDS coordinator; and Pankaj Joshi, M.D., its medical

d irector, and offered 17 exhibits (Exhibits A- N, Q, R, and V),

all of which were admitted into evidence, except Exhibit K.

A four - volume Transcript of the final hearing was filed on

July 20, 2015. Petitioner and Respondent filed their proposed

Findings of Fact a nd Conclusions of Law on August 31, 2015.

References to statutes are to Florida Statutes (2014) ,

unless otherwise noted.

FINDING S OF FACT

1. Petitioner is the regulatory agency responsible for

licensure of nursing homes and enforcement of applicable federal

regulations, state statutes, and rules governing skilled nursing

facilities pursuant to the Omnibus Budget R econciliation Act

of 1987, Title IV, Subtitle C (as amended); p art II of

chapters 400 and 408, Florida Statutes; and Florida

Administrative Code Chapter 59A- 4.

2. Respondent operates a skilled nursing facility with

104 beds , known as Cross Terrace Rehabi litation Center, which is

located at 1351 San Christopher Drive, Dunedin, Florida 34698.

Its license number is 11300961.

3. On January 7, 2015, Petitioner filed an Administrative

Complaint against Respondent alleging that Respondent failed to

provide ade quate and appropriate care and treatment for Resident

No. 80 (the Resident) and failed to implement a Ðplan of careÑ to

treat the ResidentÓs skin condition.

4. Petitioner cited both deficiencies as Class II

deficiencies as defined by section 400.23(8)(b). As a result,

Respondent sought to impose a fine in the amount of $5,000 and

assign Respondent conditional licensure status.

Count I: Adequate and Appropriate Care

5. A central issue concerning whether the Resident received

the appropriate care is wheth er an appropriate Ðresident care

planÑ existed for the R esidentÓs well - being and treatment.

6. According to the ResidentÓs dermatologist, Kathleen

Soe, M.D., the Resident suffered from n eurodermatitis p ruritus, a

psychogenic condition caused by the brain sending a signal for

the individual to itch, pick, scratch, dig, or otherwise mutilate

the skin, even though there is no physical cause for or need to

engage in such conduct. Dr. Soe stated that several services

would be helpful to maintain the ResidentÓs physical well - being:

educating the Resident regarding the cause and symptoms of the

skin condition , limiting the ability to irritate the affected

skin area through scratching , keeping the ResidentÓs nails

trimmed , using Geri - Sleeves to cover the affected area to prevent

exposure and scratching , and applying appropriate lotions or

creams to the affected areas as needed. The Resident suffered

from diabetes which prevented the use of steroidal medications.

7. The AHCA nurses testifying at the hearing, as well as

RespondentÓs m edical d irector, Dr. Joshi, agreed that the

recommended treatments for the R esidentÓs skin condition were

appropriate.

Count II: Resident Care Plan

8. Rule 59A - 4.109(1) states, in part, as follows:

(1) Each resident admitted to th e nursing

home facility shall have a plan of care. The

plan of care shall consist of:

(a) PhysicianÓs orders, diagnosis, medical

history, physical exam and rehabilitative or

restorative potential.

(b) A preliminary nursing evaluation with

physicianÓs or ders for immediate care,

completed on admission.

(c) A complete, comprehensive, accurate and

reproducible assessment of each residentÓs

functional capacity which is standardized in

the facility, and is completed within 14 days

of the residentÓs 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 residentÓs physical or mental

condition; and,

3. Revised as appropriate t o assure the

continued accuracy of the assessment.

9. A dispute over whether the treatments recommended by

Dr. Soe were implemented before the survey conducted by AHCA or

after the facility was cited for not following the treatment

protocols following th e survey became AHCAÓs focus during the

hearing.

10. Dr. JoshiÓs records revealed orders and a prescription

for Clobetasol cream and Sarna Lotion to help with the irritated

skin on April 25, 2014 , which was discontinued by his o rder dated

June 23, 2014 , and also noted in Nurse GallantÓs notes of that

date.

11. Another prescription cream, Triamcin o lone, was started

up again to deal with the ResidentÓs skin irritation on July 23,

2014, during the four - day period when the AHCA survey was taking

place. D r. Soe believed that the ResidentÓs anxiety caused by

participation in the AHCA survey of July 2014 could have

exacerbated the skin condition which provides an explanation for

Dr. Joshi restarting treatment.

12. Numerous notes from the nurses involved in daily care

of the Resident discussed matters such as keeping the ResidentÓs

nails trimmed and having the R esident wear shoes and socks to

avoid hurting his toes and feet.

13. Geri - Sleeves were given to the Resident in August, a

full month after the care p lan recommended their use for

protecting the affected skin areas.

14. Nurse Wells reviewed the care plan dated April 25,

2014, which she testified was not shown to her at the time of the

survey. She did review the care plan prior to the hearing, and

crit icized it in two areas she believes did not comply with

Florida law. The plan did not specifically state that the

affected area should be washed regularly with Dove soap, and that

regular cleansing of skin is a foundation of good nursing

practice. Also, she noted that re - education of the Resident in

proper care was not included in the plan.

15. Nurse Hill believed the original care plan did not meet

the requirements of Florida law, in part because it mentioned

nothing about the ResidentÓs scratching th e affected skin area or

of cutting the ResidentÓs nails. Nurse Hill testified that

RespondentÓs staff updated the plan after she notified them of

the deficiencies.

16. The plan was changed on July 23, 2014, in the midst of

the survey, to include the lang uage Ðkeep the nails cut short.Ñ

Additionally, the original plan did not include language about

monitoring the Resident for scratching, educating the R esident if

problems resurface, encouraging the Resident to use Geri - Sleeves,

or to contact the physician immediately if the rash recurs.

17. The MDS c oordinator, Nurse Gallant, testified that she

changed the care plan during the survey because the issue with

the ResidentÓs nails and scratching was a new problem or a

recurrence of a problem that had been re solved in June, a month

before the survey. The n ursing d irector, Nurse Conde, testified

that the Resident had suffered the skin problem the entire time

the Resident was in the facility.

18. Ms. Allane, one of AHCAÓs surveyors, noticed a skin

tear on the ResidentÓs arm on July 21, 2014, the first day of the

survey. Others among the survey team noticed that the ResidentÓs

nails were not cut short at the time of the survey.

19. Nurses Conde and Gallant testified that they cannot

force a resident to regular ly bathe and to allow nails to be kept

cut short. Residents are individuals who have rights, including

the right to refuse treatment or even hygienic measures taken by

staff to ensure a skin condition , such as the one suffered by the

Resident , is alleviat ed. RespondentÓs witnesses, the regular

caregivers and supervisors for the ResidentÓs care, testified

that the Resident often refused bathing and having nails cut

short. This testimony is credible and was not rebutted by the

surveyors or AHCAÓs nurses in volved in the surveying process. As

a result of the ResidentÓs refusal to bathe or have nails cut

short on a regular basis, when the ResidentÓs skin affliction

recurred, the result would be scratching with long nails that

would tear the skin and irritate the area. This was not the

, which made reasonable efforts to

care for the Resident.

20. The testimony and exhibits produced by Respondent

d irector of

n ursing testified that she provided the surveyors with the plan

of care during the survey. The surveyors testified they were not

provided with the care plan at the time of the July 2014 survey.

21. The ResidentÓs mother, Ms. W, testified she

observed scratches, open sores, and scabs on the Resident on

July 22, 2014, during the course of the survey. However, she

also acknowledged signing a letter which was admitted into

evidence at hearing in which she praised Respondent for providing

a willing -ness [sic] to address

try to resolve them and kept me

as the fact she seemed confused, at times, while testifying, lend

little credence to her testimony.

22. Ms. W and Nurse Hill both observed scabs and

sc

and 23, 2014, respectively.

23. Nurse Hill further observed that the Resident had

scratched the ResidentÓs arms severely and noted that scabs

indicated scratching that occurred at least two days p reviously,

based upon her more than 20 years of experience in nursing.

24. Nurse Wells testified she deemed the finding of scabs

and scratches and, in her view, the lack of a care plan for the

skin condition, to be Class II deficiencies.

25. PetitionerÓ s finding of Class II deficiencies is based

upon the personal observation of the surveyors, some of whom are

long - serving nurses, and their view that an adequate care plan

did not exist for the Resident. While both Nurse Hill and

Nurse Freed were offered and accepted as experts in the field of

nursing, the testimony they provided was factual , and their

opinions, while not based on scientific study or treatise, were

allowable as based upon their relevant personal expertise in

surveying nursing facilities an d having practiced in the field

for many years. The opinions offered were based upon sufficient

facts or data , are the product of reliable principles and

methods , and the witnesses applied the principles and methods

reliably to the facts of the case pursu ant to section 90.702,

Florida Statutes. Their professional opinions were based on

their personal observations of the Resident, the care documents

provided by Respondent, and their experience in conducting

surveys and applying what they and their team obs erve to the

applicable Florida law and rules.

26. Nurse Hill concluded that the itching and scratching

must have been present for at least a week, based upon her

experience. This testimony was based upon her years of

experience as a nurse, not upon any studies conducted by national

organizations or health care providers. She personally observed

the Resident scratching ÐfeverishlyÑ when she first came into the

room to meet with the Resident. She also testified the Resident

told her, in person, the itch ing and scratching had gone on for a

week and Ðkept [the Resident] up at night.Ñ She testified the

Resident told her that the nails had not been cut.

27. Dr. Joshi confirmed that evidence of a tear or scabs

would indicate the itching and scratching h ad occurred over a

period of time.

28. Nurse Hill believed that Dr. Soe, the dermatologist,

should have been contacted again about the recurrence of the

intense itching and scratching. Dr. Joshi believed that the care

plan was sufficient to address any r ecurrence of the skin

irritation. More weight is given to Nurse HillÓs cautionary

approach to the skin care in light of the ResidentÓs other

significant health issues.

29. The physicianÓs note dated April 25, 2014, stated that

the ResidentÓs nails should be kept short.

30. RespondentÓs staff members who were called to testify

stated that sometimes the Resident allowed staff to cut the

ResidentÓs nails, but at other times refused. The Resident

refused to allow staff to cut the nails at the time of the

survey.

31. Nurse Hill testified that a doctor was contacted on the

day of the survey, that the care plan was produced, and that the

ResidentÓs nails were cut short.

32. The Administrative Complaint in this matter cited

Respondent for failure to prov ide an appropriate Ðresident care

planÑ for the Resident pursuant to r ule 59A - 4.109(1). It also

alleged that a basis for violation of statute or rule was based

upon failure to provide a Ðcomprehensive care planÑ specifically

addressing the skin condition pursuant to r ule 59A - 4.109(2). The

comprehensive care plan dated November 7, 2013, noted, among

other conditions affecting the Resident, that the potential for

skin breakdown was a concern that should be monitored. Further,

paragraph 19 of the Administra tive Complaint alleges that the

MDS coordinator returned the comprehensive care plan to the

survey team on the afternoon of July 23, 2014, with updates to

that plan. The ResidentÓs care plan also was revised on that

date (or the next day) by RespondentÓs staff.

33. Respondent produced as evidence Comprehensive Nursing

Care Plans dated November 7, 2013, April 25, 2014, and revised on

July 24, 2014. The documentary evidence also includes updates

for several months following the July 2014 survey.

CONCLUSI ONS OF LAW

34. The Division of Administration Hearings has

jurisdiction over the subject matter of and the parties to this

proceeding. §§ 120.569 and 120.57(1), Fla. Stat.

35. Petitioner, as the party asserting the affirmative of

the issue in this proc eeding, has the burden of proof. Balino v.

DepÓt of Health & Rehabilitative Servs. , 348 So. 2d 349 (Fla. 1st

DCA 1977); DepÓt of Agric . & Consumer Servs. v. Strickland , 262

So. 2d 893 (Fla. 1st DCA 1972).

36. Pursuant to Florida law, Ð[f]indings of fact shall be

based upon a preponderance of the evidence, except in penal or

licensure disciplinary proceedings or except as otherwise

provided by statute, and shall be based exclusively on the

evidence of record and on matters officially recognized.Ñ

§ 120.5 7(1)(j), Fla. Stat.

37. Petitioner has the burden to establish by clear and

convincing evidence that the allegations contained in the

Administrative Complaint support the findings by the agency of

Class II violations and imposition of a fine. DepÓt of Ba nking &

Fin. v. Osborne Stern & Co. , 670 So. 2d 932 (Fla. 1996). The

clear and convincing standard of evidence has been described by

the Florida Supreme Court as follows:

[C]lear and convincing evidence requires that

the evidence must be found to be credi ble;

the facts to which the witnesses testify must

be distinctly remembered; the testimony must

be precise and explicit and the witnesses

must be lacking in confusion as to the facts

in issue. The evidence must be of such

weight that it produces in the mi nd of the

trier of fact a firm belief or conviction,

without hesitancy, as to the truth of the

allegations sought to be established.

In re Davey , 645 So. 2d 398, 404 ( Fla. 1994)( quoting Slomowitz v.

Walker , 429 So. 2d 797, 800 (Fla. 4th DCA 1983)).

38. P etitioner must also establish, by a preponderance of

the evidence, that the allegations of Class II deficiencies

warrant the imposition of a conditional license. Beverly

Enterprises - Florida v. Ag . for Health Care Admin. , 745 So. 2d

1133 (Fla. 1st DCA 1999 ). See also Fla. DepÓt of Transp. v.

J.W.C. Co . , Inc. , 396 So. 2d 778 (Fla. 1st DCA 1981); Balino v.

DepÓt of Health & Rehab ilitative Servs. , 348 So. 2d 349 (Fla. 1st

DCA 1977).

39. ÐPreponderance of the evidenceÑ has been defined as

follows:

[ T he] great er weight of the evidence, not

necessarily established by the greater number

of witnesses testifying to a fact but by

evidence that has the most convincing force;

superior evidentiary weight that, though not

sufficient to free the mind wholly from all

reas onable doubt, is still sufficient to

incline a fair and impartial mind to one side

of the issue rather than the other.

S. Fla. Water Mgmt . Dist. v. RLI Live Oak, LLC , 139 So. 3d 869,

872 (Fla. 2014)(citing BlackÓs Law Dictionary).

40. The clear and convi ncing standard of proof requires

more than a preponderance of the evidence , but less proof than

beyond and to the exclusion of a reasonable doubt. See generally

In re Ford - Kaus , 730 So. 2d 269 (Fla. 1999).

41. Patricia Freed and Kathryn Hill, both regist ered n urses

with many years of experience, were accepted as experts in

nursing which allowed them to offer opinion testimony in this

matter. Daubert v. Merrell Dow Pharmaceuticals , 509 U.S. 579

(1993), w as adopted in 2013 as the standard for qualifying an

expert in Florida. Under the Daubert standard, the requirements

for scientific testimony by a witness necessitate a greater

showing of expertise than previously by the counsel proffering

the witness. In this matter, the testimony relied upon from

these two experienced nurses was factual , based upon their

personal observations of the Resident, and reliable based upon

principles and methods used by nurses and surveyors from AHCA in

examining skilled nursing facilities in Florida. Their testimony

satisfies the requirements of section 90.702 and Daubert .

42. Section 400.23(8) defines the various classes of

deficiencies that may be imposed. For purposes of this analysis,

Classes II and III are relevant. They are defined as follows:

(b) A class II deficien cy is a deficiency

that the agency determines has compromised

the residentÓs 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. The fine amount shall

be doubled for each deficiency if the

facility was previously cited for one or more

class I or class II deficiencies during the

last licensure inspection or any inspection

or complaint investigation since the last

licensure inspection. A fine shall be levied

notwithstanding the correctio n of the

deficiency.

(c) A class III deficiency is a deficiency

that the agency determines will result in no

more than minimal physical, mental, or

psychosocial discomfort to the resident or

has the potential to compromise the

residentÓs ability to mainta in or reach his

or her highest practical physical, mental, or

psychosocial well - being, as defined by an

accurate and comprehensive resident

assessment, plan of care, and provision of

services. A class III deficiency is subject

to a civil penalty of $1,000 for an isolated

deficiency, $2,000 for a patterned

deficiency, and $3,000 for a widespread

deficiency. The fine amount shall be doubled

for each deficiency if the facility was

previously cited for one or more class I or

class II deficiencies during the l ast

licensure inspection or any inspection or

complaint investigation since the last

licensure inspection. A citation for a class

III deficiency must specify the time within

which the deficiency is required to be

corrected. If a class III deficiency is

c orrected within the time specified, a civil

penalty may not be imposed.

43. Holding a standard license in Florida requires that the

facility has no Class I or Class II deficiencies and has

corrected all Class III deficiencies within the time established

by the agency. § 400.23(7)(a), Fla. Stat. A license will

convert to conditional status due to the presence of one or more

Class I or II deficiencies, or any Class III deficiencies not

corrected within the time established by the agency.

44. The Resident clearly suffered from an ongoing skin

condition that is psychosomatic in origin, and brought on, at

times, by anxiety. The condition has been treated by

RespondentÓs staff when it has manifested itself , and the

evidence supports that the treatment has wo rked to alleviate the

symptoms of itching that led to excessive and forceful scratching

that broke the skin, resulting in tears and, ultimately, scabs as

the wounds healed. These conditions were observed by the

surveyors and nurses conducting the survey i n July 2014 on behalf

of AHCA.

45. Respondent produced substantial documents to prove the

diagnosis and plan of treatment for the ResidentÓs skin

affliction. This was clearly a resident who suffered from

multiple significant medical issues, n eurodermatit is p rurit u s

being just one of a long list of ailments. Respondent also

produced significant credible evidence that the Resident was a

difficult resident/patient at times. The Resident was known to

refuse bathing and the cutting of nails on more than one

occasion, including just before the survey conducted in

July 2014. After coaxing from the staff nurses and from at least

one of the AHCA nurses during the survey, the staff w as able to

cut the ResidentÓs nails before the surveyors completed their

work ons ite.

46. The Resident Care Plan and Comprehensive Plan of Care

were both adequate at the time they were originally prepared.

However, over time, the entries were less frequent, resulting in

inadequate documentation of flare - ups of the ResidentÓs skin

con dition. The fact that the surveyors personally witnessed the

Resident at a time when the skin condition had again manifested

itself may have been an unfortunate coincidence, but is more

likely the result of the ongoing treatment for the skin being

discont inued on June 23, 2014, one month prior to the survey.

There is clear and convincing evidence to support the fact that

the ResidentÓs skin affliction had manifested itself at least a

week prior to the survey, as evidenced by scabs and healing skin

tears o bserved by the nurses and Dr. Joshi. Further, clear and

convincing evidence supports that the Resident was suffering from

itching when the surveyors personally observed scratching to the

point where the skin was freshly torn.

47. The undersigned believes , from the evidence produced

and the professionalism of RespondentÓs witnesses, that

Respondent operates a high - quality skilled nursing facility and

that efforts were made to encourage the Resident to agree to

better hygiene , which included more frequent b athing and nail

trimming. When the Resident refused the treatment, the

documentation does not support that additional efforts were made

to strongly encourage and insist that the Resident agree to

better hygienic measures. Little, if any, documentation wa s

produced to support RespondentÓs staff efforts to persuade the

Resident to allow them to help prevent the itching and

scratching. The most substantial documentation of nursing and

medical involvement was provided to the AHCA surveyors during the

survey in the form of a revised and updated Resident Care Plan.

While this remedial measure was appropriate action by Respondent,

this type of documentation should have already been evident from

the ResidentÓs records at the initiation of the survey.

48. Clear and convincing evidence exists in the record to

support a finding of deficiencies at RespondentÓs skilled nursing

facility. The undersigned believes, however, that the

deficiencies will result in no more than minimal physical,

mental, or psychosocial disc omfort to the Resident in this case

and that this is an isolated case involving one resident of the

facility. Both the Resident Care Plan and the Comprehensive Plan

of Care must include better documentation and have more regular

entries for the Resident. This may have already been done

sufficiently when the updated plans were provided to the AHCA

surveyors during the July 2014 survey. If not, this is action

that should be taken immediately since documentation, especially

of the difficulties regarding the ResidentÓs compliance with

recommended care and treatment of the skin affliction, will

better support RespondentÓs defense of its actions, if required,

on subsequent surveys. It also appears that the Resident can be

cajoled into submitting to bathing and nail cutting on a more

frequent basis. This, of course, will require even more

attention on the part of staff, but it might avoid prolonged

flare - ups of the skin affliction in the future. The ResidentÓs

condition, at the time of the July 2014 survey, de monstrated that

best efforts were not made to ensure the condition was under

control. The active itching accompanied by skin tears and

scabbing could have been alleviated, at least to some extent,

with more persuasive tactics employed by RespondentÓs

prof essional staff.

49. Since the conclusion reached in this Recommended Order

is that no Class I or II deficiencies exist, there is no need to

further discuss the change in status of the license from standard

to conditional. It is expected the deficiencies will be quickly

corrected , if they have not already been corrected , by

Respondent.

50. For the foregoing reasons, Respondent has violated the

applicable statutes and rules by committing two Class III

deficiencies.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Agency for Health Care

Administration enter a f inal o rder finding that Respondent,

1351 Golden, LLC, d/b/a Cross Terrace Rehabilitation Center,

violated section 400.022(1)(l), Florida Sta tutes, for failure to

fully and adequately provide the care required by a resident care

plan and adequate and appropriate health care and protective and

support services; and violated Florida Administrative Code

Rule 59A - 4.109 concerning having an adequate plan properly

updated to treat the medical needs and adverse physical

conditions of the Resident. These two violations constitute

Class III deficiencies; should result in a fine to Respondent of

$1,000 per deficiency pursuant to section 400.23(8)(c); req uire

Respondent to correct the deficiencies within 30 days of the date

of the Final Order, unless they have already been corrected; and

maintain RespondentÓs status as a standard license holder.

DONE AND ENTERED this 4th day of December , 2015 , in

Tallahas see, Leon County, Florida.

S

ROBERT S. COHEN

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 684 7

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 4th day of December , 2015 .

COPIES FURNISHED:

Michael Brett Kornhauser, Esquire

Christopher M. David, Esquire

Fuerst, Ittleman, David and Joseph, P.L.

1001 Brick ell Bay Drive , 32nd Floor

Miami, Florida 33131

(eServed)

John E. Bradley, Esquire

Agency for Health Care Administration

The Sebring Building, Suite 330

525 Mirror Lake Drive North

St. Petersburg, Florida 33701

(eServed)

Richard J. Shoop, Agency Clerk

A gency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee , Florida 32308

(eServed)

Stuart Williams, General Counsel

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Elizabe th Dudek, Secretary

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 1

Tallahassee, Florida 32308

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of t his Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.