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ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number

Palm Court NH, LLC, d/b/a Wilton Manors Health and Rehabilitation Center/CON #10056

3922 Coconut Palm Drive, Suite 102 Tampa, Florida 33619

Authorized Representative: William (Bill) Mando Vice President & CFO

Greystone Healthcare Management (813) 675-2319

2. Service District/Subdistrict District 10 (Broward County) B. PUBLIC HEARING

No public hearing was held or requested on the proposed project to add 29 community nursing home beds at 118-bed community skilled nursing facility (SNF) Wilton Manors Health and Rehabilitation Center (Wilton Manors) through the delicensure of the 29 inactive beds at Mercy Manor North.

Letters of Support

The applicant submitted 11 support letters. Project Summary, page #vi, Exhibit PS-1 includes letters from: John C. Johnson, President and CEO, Holy Cross Hospital; Shawn Erisman, Director of Case Management, Kindred Hospital-Fort Lauderdale; Joan Martin, MSW, North Broward Hospital District and Dr. Rajendra Gupta, Medical Director, Wilton Manors Health & Rehabilitation Center (Wilton Manors). All four letters

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license, if the project is approved. Agency for Health Care Administration licensure records confirm Holy Cross Long Term Care, Inc. holds the Inactive license for the 29-bed Mercy Manor North facility. Mr. Erisman indicated his facility works closely with and has had many positive discharge experiences with Wilton Manors, regarding the placement of higher acuity patients that require complex care. Ms. Martin of North Broward reiterated similar comments. Dr. Gupta of Wilton Manors reported she works closely with Greystone Healthcare Management leadership in the promotion of positive outcomes for residents, family members and staff.

The seven support letters found under Volume 2/Tab 10 (Additional Information) were all signed with a June 4, 2009 date. Four of the seven letters had North Broward letterhead and three had Wilton Manors

letterhead. All seven of these letters were of a form letter variety, very similar to the one from Ms. Martin of North Broward.

C. PROJECT SUMMARY

Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation Center (CON #10056)proposes to add 29 community nursing home beds at the 118-bed community skilled nursing facility, Wilton Manors Health and Rehabilitation Center through the delicensure of the 29 inactive beds at 29-bed Mercy Manor North, Broward County, Florida. The project will result in no change in the number of community nursing beds in the district or subdistrict.

Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation Center is affiliated with Greystone Tribeca Acquisition, LLC, NH Florida Realty, LLC and Greystone Healthcare Management Corporation. The applicant indicates that these companies own 14 SNFs with 1,779 beds and four assisted living facilities (ALFs) with 335 units in Florida; and operate another nine facilities in two other states.

According to the applicant the two facilities are reportedly approximately four miles apart. The 29-bed addition is to be connected to Wilton

Manors by a corridor and the site of the 29-bed addition is to replace the existing Hidden Palms, a 40-bed (30-unit) ALF that is adjacent to Wilton Manors.

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The ALF is set to be delicensed to make way for the 29-bed addition (25 private patient rooms and two semi-private patient rooms). The

applicant contends that there are only 17 community nursing home beds for every 1,000 residents aged 65 and over within Broward County,

compared to an average of 25 beds per 1,000 elderly residents statewide. Therefore, the applicant concludes the project will preserve all currently licensed beds to make the best use of a limited resource and not reduce access by the loss of 29 licensed beds. Greystone Healthcare

Management Corporation is also stated to be implementing improved quality improvement mechanisms to raise quality standards and outcomes, through this project.

The project involves 19,821total gross square feet (GSF) with 230 GSF of new construction and 19,591 GSF of renovation. Total construction cost is $1,149,730. The total cost of the project is $1,917,885. Total project costs include: land; building and equipment; project development and start-up.

The applicant proposes no conditions to this project. The facilities do not presently have any conditions.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes. These criteria form the basis for the goals of the review process. The goals represent

desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by assessing the responses provided in the application, and independent information gathered by the reviewer.

Applications are analyzed to identify strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict), applications are comparatively reviewed to determine which applicant best meets the review criteria. Section 59C-1.010(3)(b), Florida Administrative Code, allows no

application amendment information subsequent to the application being deemed complete. The burden of proof to entitlement of a certificate

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As part of the fact-finding, the consultant, Steve Love, analyzed the application in its entirety with consultation from the Financial Analyst, Derron Hillman, who evaluated the financial data and the Architect, Scott Waltz, who evaluated the architecturals and the schematic drawings as part of the application.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicate the level of conformity of the proposed project with the criteria and application content requirements found in Florida

Statutes, Sections 408.035, and 408.037; applicable rules of the State of Florida, Chapter 59C-1 and 59C-2 and Florida Administrative Code. 1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed need pool? Or does the project proposed seek beds or services in excess of the fixed need pool? Rule 59C-1.008(2), Florida

Administrative Code.

Pursuant to Florida Statutes 408.0435(1), the Florida Legislature extended a moratorium until July 1, 2011 on the issuance of any certificate of need (CON) for increases in the number of community nursing home beds around the state. Due to the moratorium, a fixed need pool was not published by the Agency and the number of

community nursing home beds will remain constant statewide. This project, if approved, will not change the bed count in the planning area. b. If no Agency policy exists, the applicant will be responsible for

demonstrating need through a needs assessment methodology, which must include, at a minimum, consideration of the following topics, except where they are inconsistent with the applicable statutory or rule criteria:

Population demographics and dynamics;

Availability, utilization and quality of like services in the district, subdistrict or both;

Medical treatment trends; and Market conditions.

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Population demographics and dynamics

There are 33 community nursing homes in District 10, Broward County, with a total of 4,229 community nursing home beds1. District 10

(Broward County) averaged 83.06 percent occupancy for the 12-month period ending December 31, 2008. Broward County is the only county in the district.

The table below illustrates the annual utilization for the SNF planning to delicense the 29 inactive beds (Mercy Manor) and the SNF planning to correspondingly license the 29 beds (Wilton Manors), in the same district and subdistrict:

Annual Utilization Total

Palm Court NH, LLC d/b/a Wilton Manors Nursing and Rehabilitation Center District 10 (Broward County)

January 2008-December 2008

Facility Bed Days Patient Days Occup. Total Medicaid Days Medicaid Occup.

Mercy Manor* 10,614 0 0.00% 0 0.00% Wilton Manors 43,188 39,445 91.33% 27,979 70.93%

District 10 1,547,814 1,285,682 83.06% 814,756 63.37%

Source: Agency for Health Care Administration publication Florida Nursing Home Utilization by District and Subdistrict January 2008-December 2008, issued April 3, 2009.

* Mercy Manor’s 29 beds have been inactive since August 2, 2007.

For the 12-month period ending December 31, 2008, Wilton Manor’s averaged 91.33 percent occupancy. Wilton Manors is approximately 4.19 driving miles2 to the southwest of Mercy Manor. The project would

increase the community nursing home beds at Wilton Manors from 118 to 147 and zero out the number of beds at Mercy Manor.

Below is a map showing the location of both Wilton Manors and Mercy Manors location. The facilities are approximately four miles apart.

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Microsoft MapPoint

The Agency for Health Care Administration published population projections for District 10, Broward County, indicating the following:

Population Growth January 2010 to January 2015

District 10 (Broward County)

January 2010

Population January 2015 Population Five-Year Growth

Population Age Ranges 65+ 75+ 65+ 75+ 65+ 75+

Broward County 260,410 136,790 293,628 138,260 12.76% 1.07% Statewide Total 3,352,359 1,692,137 3,943,962 1,850,034 17.65% 9.33%

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The above table indicates by January 2015, Broward County’s (District 10’s) 65 years of age and older population is expected to grow at a rate of 12.76 percent but at a slower rate than the state overall rate of 17.65 percent. Broward County’s 75 years of age and older population is

expected to also experience growth (at a rate of 1.07 percent) but again at a slower rate than the state overall (at a rate of 9.33 percent).

The applicant cites Broward County’s total population of 1,775,101 as of July 1, 20083 and that District 10 (Broward County) is the most densely populated health planning district in the state4. The applicant further states that Wilton Manors is centrally located within the district and is within a 20-minute drive time for 1,186,428 (or about 66 percent) of the district’s population, using Claritas data (Figure 1-3, 2008 Total

Population by Zip Code, Need Analysis, page #1-7). The applicant

emphasizes that this maximizes access for the 29 beds that, without the project, would be lost under the moratorium.

The applicant indicates that by 2013, the Broward County age 65 and over population will rise to 283,709 residents and its 75 and over population will rise to 138,121 residents. As shown previously,

populations for these age cohorts are expected to continue to rise at least through January 2015. The applicant estimates that with an increase in the county’s 65+ population, demand for skilled nursing services will continue.

Availability, utilization and quality of like services

Concerning availability, there are 33 community nursing homes in District 10, Broward County, with a total of 4,229 community nursing home beds5. The applicant points out these figures exclude the

Alexander Nininger State Veterans’ Nursing Home, the Children’s

Comprehensive Care Center and sheltered beds. The applicant stresses that in 2008, Broward County realized a ratio of only 17 community nursing home beds per 1,000 residents and this ratio is expected to decline to 15 per 1,000 residents by 2013. It has been shown that the elderly population is not expected to decline in the area at least through

3Agency for Health Care Administration Population Estimates, published September 2008

4 Broward County consists of 1,209 square miles and with a population of 1,782,573 is the second

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2015. The applicant again emphasizes the importance of every available bed remaining licensed to meet continued demand and that this project will contribute to satisfying that need.

Concerning utilization, the district experienced a total nursing home bed occupancy rate of 83.06 percent for the 12-month period ending

December 31, 2008. The applicant projects that if nursing home patient days grow at the same rate as the elderly population, the projected

nursing home bed occupancy rate would rise to 92.41 percent, within five years which is also year three of the project Wilton Manors

experienced a 91.33 percent occupancy rate for the 12 months ending December 31, 2008 compared to a district-wide average of 83.06 percent for the same period. Project approval would enhance availability at one of the more occupied facilities in the area.

Concerning quality of like services, the applicant states that in some instances, the Agency’s current scoring mechanism for quality

assessment does not accurately measure the actual quality of services. The applicant supports this conclusion by showing that in the May 2009 update to the Agency’s Nursing Home Guide, the Agency issued an

overall two of a possible five stars to affiliate SNF Lexington Health and Rehabilitation Center (in Pinellas County) when the facility realized five of a possible five stars in all five of the inspection components used to

realize an overall rating, with those five components as follows: nutrition and hydration; restraints and abuse; pressure ulcers; decline and

dignity. The applicant reports that Greystone Healthcare Management Corporation is in the process of making renovations and improvements at some of its existing facilities around the state and that if approved, the project is set to realize similar quality improvements. The applicant states that Wilton Manors already accepts higher acuity patients and that three of its especially higher level services include dialysis, HIV and tracheotomy care. Support letters indicate that Wilton Manors is

recognized as a source of placement for higher acuity patients. The applicant states that Wilton Manor’s 24-hour registered nurse (RN) coverage is an indicator of the high quality of care provided by the facility. Wilton Manor’s plan to provide 25 of the 29 beds in private rooms that will be designed to be handicap accessible with showers in each bathroom are cited as support for its contention that the project will enhance quality care.

Medical treatment trends

The applicant states that as hospital-based skilled nursing units began to close following changes in Medicare reimbursement, demand

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short-term rehabilitation and convalescent days. The project is set to accommodate this trend by creating a rehabilitation unit in the renovated space and accept more short-term rehabilitative patients while not

sacrificing its existing ability to absorb higher acuity patient placements. The applicant contends that the Long-Term Care Community Diversion Program has also impacted care in Broward County and projects

continued downward pressure on Medicaid occupancy rates in Broward County and statewide in spite of a rise in Medicaid occupancy rates over the period (from 60.31 percent in 2001 to 63.37 percent in 2008). For CY 2004 through 2008, the applicant shows that Wilton Manors had a higher Medicaid occupancy rate than the district or the state for each of the four years. It is reiterated that the applicant does not propose any conditions pursuant to project award. The applicant believes the proposed 29-bed addition to Wilton Manors will allow the facility to continue serving the same number of Medicaid eligible residents while increasing service to short-term rehabilitative residents.

Market conditions

The applicant believes its project will better enable it to compete for the trending demand of higher acuity and short-term rehabilitative patients. Palm Court NH, LLC shows that from 2004 through 2008, Wilton Manors realized annualized total occupancy rates consistently exceeding the average of those for the district. The applicant shows that in this five-year period, its lowest occupancy rate (85.69 percent in 2006) still exceeded the district’s highest average occupancy (83.95 percent in 2007). Wilton Manors also states that five hospitals are within

approximately five miles of its facility. The cumulative total facility bed count for the five listed hospitals (Broward General Medical Center, Florida Medical Center, Holy Cross Hospital, Imperial Point Medical Center and Plantation General Hospital) is 2,214 beds, with 1,843 being acute care beds. The Agency notes that none of these five hospitals are licensed to operate skilled nursing units. The space planned for this project will absorb existing ALF services which the applicant indicates are currently well provided within the district as compared to the state overall. The applicant believes operating efficiencies will be enhanced through the project by placing into service currently inactive licensed community nursing home beds at a facility with a history of higher acuity patient placements. The applicant indicates there is availability at

nearby ALFs within similar price ranges so that ALF residents that will be impacted by the project may be placed.

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2. Agency Rule Preferences

Does the project respond to preferences stated in Agency rules? Please indicate how each applicable preference for the type of

service proposed is met. Chapter 59C-1.036, Florida Administrative Code.

Chapter 59C-1.036 of the Florida Administrative Code does not contain preferences relative to community nursing home beds nor does the Agency for Health Care Administration publish specific preferences for these facilities. However, the rule does contain standards the Agency utilizes in assessing the applicant’s ability to provide quality care to the residents.

a. Geographically Underserved Areas. In a competetitive

certificate of need review within the nursing home subdistrict as defined in 59C-2.200, Florida Administrative Code, the Agency shall award a certificate of need if the applicant meets all applicable criteria for a geographically undeserved area as specified in subsection 408.032(18), Florida Statutes (Florida Statutes), and if the applicant meets the applicable statutory certificate of need review criteria specified in section 408.035, Florida Statutes, including bed need according to the relevant bed need formula contained in this rule. If the applicant is awarded a certificate of need based on the provisions of this paragraph, the applicant shall agree that the nursing facility will be located in a county without a nursing facility, or in the center of an area within the subdistrict of a radius of at least 20 miles which meets the definition of a geographically

undeserved area. The center of the geographically undeserved area shall be the proposed nursing home location in the

application.

The application is not submitted in order to remedy a

geographically underserved area as described by rule and statutes. b. Proposed Services. Applicants proposing the establishment of

Medicare-certified nursing facility beds to be licensed under Chapter 400, Florida Statutes, shall provide a detailed

description of the services to be provided, staffing pattern, patient characteristics, expected average length of stay, ancillary services, patient assessment tools, admission policies, and discharged policies.

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Wilton Manors is stated to participate in both the Medicare and Medicaid Programs and the 29-bed addition will be certified to accept such residents as needed. The applicant indicates the new 29-bed unit will be geared toward short-term rehabilitative patients whose primary payer is Medicare. The applicant includes a list of 25 services it already provides to its current SNF residents and a brochure to describe its services is included in an attached

brochure (Wilton Manors Health & Rehabilitation Center –

Restoring Health/Enhancing Life). An additional seven amenities are also shown in the application. The applicant indicates that a preliminary plan of care is developed with 24 hours of admission and that the care plan is developed within seven days of

completion of a comprehensive assessment in accordance with the minimum data set (MDS). An interdisciplinary team is composed of a list of 11 health care and allied-health practitioners and staff. Resident and family members are reportedly encouraged to

participate in the health care planning process. According to the applicant, the care plan is reviewed at least quarterly and other assessment tools are utilized. Goals and objectives are stated to lead to the highest possible level of independence.

Outpatient rehabilitation is also stated as available to those who require it. The applicant’s Agency Rule Conformity, page #2-8, Exhibit 2-1, Policies and Procedures for Care Planning,

Admissions, Transfers and Discharges, describes the facility’s admission, readmission, transfer, discharge and related activities. An in-depth “Resident Rights Materials” protocol is found in the applicant’s Agency Rule Conformity, page #2-9, Exhibit 2-2.

The applicant states the 29-bed addition will primarily be used as a Medicare rehabilitation unit. The applicant estimates an

incremental 261 admissions in year one (ending September 30, 2011) and 303 admissions in year two (ending September 30, 2012), with an incremental 9,055 patients days in year one and 9,882 patient days in year two. The applicant proposes an

additional 39.4 FTEs from year one to year two to the existing staff compliment, with a staffing pattern as illustrated in the table immediately below.

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Palm Court NH, LLC, d/b/a

Wilton Manors Health and Rehabilitation Center - CON #10056 Staffing Patterns

Year One and Year Two of Operation

Position

Year One FTEs Year One Ending

09/30/2011

Year Two FTEs Year Two Ending 09/30/2012 Administration Administrator 1.0 1.0 Director of Nursing 1.0 1.0 Admissions Clerk 2.0 2.0 Bookkeeper 2.0 2.0 Secretary 2.0 2.0

Medical Records Clerk 1.0 1.0

TOTAL 9.0 9.0 PHYSICIANS Medical Director 2.0 2.0 TOTAL 2.0 2.0 NURSING RN’s 7.5 9.5 LPN’s 18.0 22.0 Nurses Aides 57.5 71.5

Other (Nursing Admin – Indirect) 10.0 11.5

TOTAL 93.0 114.5

ANCILLARY

Physical Therapist and PTA 5.5 12.7

Speech Therapist 1.5 2.5

Occupational Therapist and OTA 3.0 6.8

Rehab Manager 1.0 1.0 Other 3.0 3.0 TOTAL 11.0 23.0 DIETARY Dietary Supervisor 1.0 1.0 Cooks 4.0 5.0 Dietary Aides 7.0 8.5 TOTAL 12.0 14.5 SOCIAL SERVICES

Social Worker Director 1.0 1.0

Activities Director 1.0 1.0

Activities Assistant 0.5 1.0 Other: Social Services Assistant 0.5 1.0

TOTAL 3.0 4.0 HOUSEKEEPING Housekeeping Supervisor 1.0 1.0 Housekeepers 8.0 9.7 TOTAL 9.0 10.7 LAUNDRY Laundry Supervisor 1.0 1.0 Laundry Aides 3.0 3.7 TOTAL 4.0 4.7 PLANT MAINTENANCE Maintenance Supervisor 1.0 1.0 Maintenance Assistance 1.0 1.0 TOTAL 2.0 2.0 GRAND TOTAL 145.0 184.4

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The incremental 39.4 FTE increase over the existing staff

compliment is accounted for through the following additional FTEs: 2.0 registered nurses (RNs); 4.0 licensed practical nurses (LPNs); 14.0 nurses aides; 1.5 nursing administration-indirect; 7.2 physical therapists and PTAs; 1.0 speech therapists; 3.8

occupational therapists and OTAs; 1.0 cooks; 1.5 dietary aides; 0.5 activities assistants; 0.5 social services assistants; 1.7

housekeepers and 0.7 laundry aides. All other staff do not change from the existing Wilton Manors staff.

Chapter 400.23, Florida Statutes, currently requires a minimum licensed nursing staffing of 1.0 hours of direct care for each resident per day and a minimum certified nursing assistant staffing of 2.9 hours of direct care for each resident per day. The calculations below are based on the applicant’s proposed staffing from Schedule 6A and projected occupancy from Schedule 5 of the application.

Palm Court NH, LLC, d/b/a

Wilton Manors Health and Rehabilitation Center - CON #10056 Minimum Staffing Requirements

FTE

Nurses/Aides RequirementMinimum 1 st Year

2011 2

nd Year 2012

Nurses 1.0 hours of direct care per resident 1.31 1.29 Aides

2.9 hours of direct

care per resident 2.98 2.92

Sources: Extracted from Schedule 5 & 6 of CON Application #10056.

As shown in the above table, the applicant’s projected staffing patterns satisfy the minimum requirements outlined in Section 400.23 (3)(a), Florida Statutes for nurses and for nurses’ aides. c. Quality of Care. In assessing the applicant’s ability to provide

quality of care pursuant to s. 408.035(1), Florida Statutes, the Agency shall evaluate the following facts and circumstances: 1. Whether the applicant has had a Chapter 400, Florida

Statutes, nursing facility license denied, revoked, or suspended within the 36 months prior to the

application.

The applicant states it has not had a nursing home license denied, revoked, or suspended.

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2. Whether the applicant has had a nursing facility placed into receivership at any time during the period of

ownership, management, or leasing of a nursing facility in the 36 months prior to the current application.

The applicant states it has not had a nursing facility placed into receivership at any time.

3. The extent to which the conditions identified within subparagraphs 1 and 2 threatened or resulted in direct, significant harm to the health, safety, or welfare of the nursing facility residents.

The applicant states that since there have been no violations this provision is not applicable.

4. The extent to which the conditions identified within subparagraph 3 were corrected within the time frames allowed by the appropriate state agency in each

respective state and in a manner satisfactory to the agency.

The applicant states that since there have been no violations this provision is not applicable.

(4) (f) Harmful Conditions. The Agency shall question the ability of the applicant to provide quality of care within any nursing facility when the conditions identified in subparagraph (e) 1 and (e) 2 result in the direct, significant harm to the health, safety, or welfare of a nursing facility resident, and were not corrected within the time frames allowed by the appropriate state agency in each respective state and in a manner satisfactory with the Agency.

The applicant states that since there have been no violations, this provision is not applicable. Refer to quality of care discussion below in section E.3.b. of this report.

(5) Utilization Reports. Within 45 days after the end of each

calendar quarter, facilities with nursing facility beds licensed under Chapter 400, Florida Statutes shall report to the Agency, or its designee, the total number of patient days, which occurred in each month of the quarter, and the number of such days that were

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The applicant states it will continue to provide the required data to the Broward Regional Health Planning Council, Inc. and to the Agency. 3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care, efficiency, accessibility and extent of utilization of existing health care facilities and health services in the applicant's service area? ss. 408.035 (1)(b) and (e), Florida Statutes.

As stated previously, there are 33 community nursing homes in District 10, Broward County, with a total of 4,229 community nursing home beds6. District 10 averaged 83.06 percent occupancy for the 12-month period ending December 31, 2008. The applicant reports that the bed supply has held relatively constant since 2001 to 2008 and will either remain constant or possibly decrease under the moratorium. With a growing elderly population, the applicant contends that additional demand will be placed on the bed supply. The applicant’s major

contention is that preservation of nursing home beds ensures continued availability, where there is a moratorium and a growing elderly

population environment.

Per the applicant, though the facility (Wilton Manors) has historically performed low on survey results Greystone has developed and

implemented quality assurance improvements. A particular quality consideration the applicant denotes is that the project will create 25 private and two semi-private rooms at Wilton Manors and that this will lead to better rehabilitation and complex care for patients. The applicant indicates renovations of the entire facility will meet or exceed all

minimum size requirements and modernize the unit with all handicap accessible bathrooms with showers in each patient room. See section E.3.f regarding handicap accessible toilets and showers in each patient room.

Regarding geographic access, the applicant reports that considering that District 10 (Broward County) is the most densely populated health

planning district in the state, location is not a factor in access. The greater issue, per the applicant, is to preserve the number of community nursing home beds in the district, which is the project’s objective. The project will delicense 29 inactive community nursing home beds and

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Broward County, more centrally locating the beds within the district. The applicant reports that Wilton Manors participates in both the Medicare and Medicaid programs and will continue to do so with this project. It is stated the project will primarily be used as a rehabilitation unit. The new unit that will accommodate the 29 beds from Mercy Manor North will increase the proportion of Medicare, while the payer mix at the remaining and currently licensed 118-bed Wilton Manors will maintain approximately the same payer mix. Regarding utilization, the applicant points out that Wilton Manors has consistently been highly utilized and the project will serve to provide additional capacity at a highly utilized facility without adding bed supply to the district overall. The applicant elects to respond to additional criteria - the Health Care Access Criteria, as stated in Chapter 59C-1.030(2). Below are the applicant’s volunteered responses.

(a) The need that the population served or to be served has for the health or hospice services proposed to be offered or

changed, and the extent to which all residents of the district, and in particular low income persons, racial and ethnic

minorities, women, handicapped persons, other underserved groups and the elderly are likely to have access to those services.

The applicant projects 50,116 total patient days in year one and 51,240 total patient days in year two. In year one, the Medicaid patient days are projected at 26,678 and the Medicare and

Medicare HMO patient days are projected at 20,153. In year two, the Medicaid patient days are projected at 26,563 and the

Medicare and Medicare HMO patient days are projected at 21,383. This reflects a decline of 115 Medicaid patient days from year one to year two and an increase of 1,230 Medicare and Medicare HMO patient days for the same period. Per the applicant’s Schedule 7, for the entire 147-bed proposed Wilton Manors for year one, the anticipated Medicaid percent of patient days is 53.2 and for year two, the anticipated Medicaid percent of patient days is 51.8. Both the 53.2 percent and 51.8 percent estimate are below the average Medicaid patient day percentage district-wide of 63.37 percent for the 12-month period ending December 31, 2008. However, the project is designed to accommodate short-term rehabilitation and complex care patients with Medicare as the primary payer.

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(b) The extent to which that need will be met adequately under a proposed reduction, elimination or relocation of a service, under a proposed substantial change in admissions policies or practices, or by alternative arrangements, and the effect of the proposed change on the ability of members of medically

underserved groups which have traditionally experienced difficulties in obtaining equal access to health services to obtain needed health care.

The applicant anticipates any change in geographic access will be minimal (driving distance between Mercy Manor North and Wilton Manors is approximately 4.10 miles). The applicant states that Wilton Manors will realize 25 more private rooms (with two semi-private rooms) and that the semi-private rooms will benefit those with complex needs as well as those requiring rehabilitation. The applicant states that the opportunity to transfer beds currently inactive improves access for the community, with additional private skilled nursing beds at a facility that is already experiencing high demand.

(c) The contribution of the proposed service in meeting the health needs of members of such medically underserved groups,

particularly those needs identified in the applicable local health plan and state health plan as deserving of priority. Wilton Manors states this is not applicable, as local health plans are no longer published.

(d) In determining the extent to which a proposed service will be accessible, the following will be considered:

1. The extent to which medically underserved individuals currently use the applicant’s services, as a proportion of the medically underserved population in the applicant’s proposed service area(s), and the extent to which

medically underserved individuals are expected to use the proposed services, if approved;

Wilton Manors provides a table to describe its contribution to reaching out to the medically underserved. For the

12-month period ending December 31, 2008, Medicaid patient days were 70.93 percent of Wilton Manors’ occupancy

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project is designed to be a rehabilitation and complex care patient unit, with appreciably no Medicaid reimbursement to be realized as a result of the 29-bed addition and 100

percent Medicare and Medicare HMO reimbursement for the added unit.

2. The performance of the applicant in meeting any

applicable Federal regulations requiring uncompensated care, extent to which medically underserved individuals currently use the applicant’s services, as a proportion of the medically underserved population in the applicant’s proposed service area(s), and the extent to which

medically underserved individuals are expected to use the proposed services, if approved;

Wilton Manors reports being active in the Medicare and Medicaid Programs and adheres to the conditions of

participation, in addition to being in compliance with state and federal regulatory agencies.

3. The extent to which Medicare/Medicaid and medically indigent patients are served by the applicant; and The applicant provides a table to describe Wilton Manors’ Medicare/Medicaid and self-pay/charity patient estimates (Conformity with Health Planning Factors, page #3-9, Table 3-3/Patient Days by Payer for Wilton Manors Health & Rehabilitation Center First Two Years of the 29-Bed

Addition). For the 147-bed facility, Wilton Manors estimates 26,678 Medicaid patient days in year one and 26,563

Medicaid patient days in year two. Wilton Manors states the majority of the facility’s patient days come from Medicaid patients. The calculations indicate that Medicaid is the single greatest funding source at 53.2 percent in year one and 51.8 percent in year two. Medicare and Medicare HMO is the second largest payer with 40.2 percent in year one and 41.8 percent in year two.

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4. The extent to which the applicant offers a range of

means by which a person will have access to its services. Wilton Manors indicates access to services available include: Medicaid, Medicare, contracts with major health

maintenance organizations; contracts for hospice care; local and state agency entitlement opportunities and community outreach programs.

b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? Is the applicant a Gold Seal Program nursing facility that is proposing to add beds to an existing nursing home? ss. 408.035 (1)(c) and (j), Florida Statutes.

As the licensee of Wilton Manors, Palm Court NH, LLC also reports affiliation with other Florida nursing homes and assisted living facilities, these are: Greystone Tribeca Acquisition, LLC, NH; Florida Realty, LLC and Greystone Healthcare Management Corporation. The applicant states the companies own and operate 14 SNFs with 1,779 beds and four ALFs with 335 units, throughout Florida. The applicant provides a table listing its 14 SNF affiliates (Applicant’s Quality of Care, page #4-1, Table 4-1/Florida Affiliated Nursing Homes of Greystone). Of these 14 facilities for the 12-month period ending December 31, 2008, Wilton Manors is listed as the only Greystone SNF in District 10, with a total occupancy rate of 91.33 percent. Again, of the 14 listed SNFs, the least occupied was Apollo Health and Rehabilitation Center in Pinellas County (at 81.84 percent) and the most occupied was Lady Lake Specialty Care Center in Lake County (at 96.75 percent). The most recent Agency inspection rating of Wilton Manors indicates an overall one-star rating (of a five possible star rating)7. This is as of an internet run date of June 11, 2009 with the Agency’s Nursing Home Guide last updated in May 2009. The applicant indicates the 14 SNFs have an average occupancy of 90.83 percent (CY 2008) and that this is above the statewide average nursing home occupancy rate of 87.35 percent for the same period. These occupancy rates are confirmed by the Agency. The applicant does not indicate any of its 14 affiliate SNFs are Gold Seal facilities and does not disclose their Agency quality ratings.

Palm Court NH, LLC provides Agency licensure for Wilton Manors

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certificate of membership in the Florida Health Care Association (FHCA). A 2009 American Health Care Association membership certificate is also included but does not name Wilton Manors, any of its affiliates or its parent as the certificate recipient. Also, an April 2009 Achievement Award is provided, naming Wilton Manors as the recipient of the 2008 Deficiency Free Life Safety Survey Award, but the issuer is not named. Wilton Manors states it (along with other Greystone affiliates) has recently taken advantage of the FHCA Quality Credentialing Program. The FHCA’s credentialing process includes an internal and external review process of quality issues, which the applicant discusses (Applicant’s Quality of Care, pages 4-2 to 4-7).

Wilton Manors includes quality improvement measures in its Quality of Care, page #4-13, Exhibit 4-2. This includes the BELIEVE Balanced Assessment tool, the Operation Make a Difference program and the Clinical Focus Leveling System (the latter being a five level monitoring protocol). The applicant also provides numerous periodic check-off materials to document relevant changes and on-going patient activities and needs (page #4-14, Exhibit 4-3/Quarterly System Review). The applicant further provides a mechanism to recognize and catalogue customer concerns and acknowledgements (page #4-15, Exhibit 4-4). Quality assurance guidelines are provided for Agency review (page #4-16, Exhibit 4-5,) along with July 2008 resident council meeting minutes, a sample June 2009 Wilton Manors newsletter and a month long activities calendar (page #4-17, Exhibit 4-6). These reflect the applicant’s

commitment to quality.

Agency records indicate 19 confirmed and three confirmed without deficiency complaints at Wilton Manors for the three-year period ending June 10, 2009. The 19 confirmed complaints were for the following complaint categories: resident rights (three); call lights, inappropriate discharge, medical records/charting, pressure sores and resident care (two each) and falls/injury, lack of assessment, medicine problem/ errors/formulary, nursing service, plan of care and untrained/ unqualified staff (one each). The three confirmed without deficiency complaints were for the following complaint categories: call lights, medical records/charting and medicine problem/errors/formulary (one each).

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c. What resources, including health manpower, management personnel and funds for capital and operating expenditures, are available for project accomplishment and operation? ss. 408.035(1)(d), Florida Statutes.

The financial impact of the project will include the project cost of $1,917,885 and incremental year two operating costs of $3,439,440. An audit of the applicant was not provided as required under Section 408.037(1)(c), Florida Statutes. In a meeting prior to the filing deadline, the applicant indicated that it could not provide an audit of the applicant because FIN 46(R) required that the applicant be included in the

consolidated financial statements of its parent company (Greystone Tribeca Acquisition, LLC). The applicant argues that requiring an audit of the applicant in this case would result in a disclaimer opinion from the auditor under Generally Accepted Accounting Principals (GAAP). The Agency disagrees with this interpretation of FIN 46(R). While the Agency agrees that FIN 46(R) requires the parent to report all variable interest entities, including the applicant, as part of its consolidated financial statements, it does not appear to preclude an audit of the applicant on a stand-alone basis.

In any event, funding for this project will be provided by the parent

company and audited financial statements of the parent were submitted. Although the parent audit does not meet the filing requirements for an audit of the applicant, the Agency was able to evaluate the applicant’s balance sheet and income statement for 2008 through an analysis of the consolidating schedules. The Agency could not analyze the applicant’s 2008 cash flow statement since it was not part of the consolidating schedules. The Agency believes this information substantially meets the statutory filing requirements and is sufficient to evaluate the applicant’s and parent’s ability to fund the project.

Audited financial statements for the periods ending December 31, 2007 and 2008, were analyzed for the purpose of evaluating the applicant’s and parent’s ability to provide the capital and operational funding necessary to implement the project.

Short-Term Position:

Applicant - The applicant’s current ratio of 5.0 is well above average and indicates current assets are approximately five times current liabilities, a

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could not be determined since the 2008 consolidated schedules did not include a cash flow statement. Overall, the applicant has a good short-term position. (See Table below).

Parent - The parent’s current ratio of 2.6 is above average and indicates current assets are approximately two and a half times current liabilities, a good position. The working capital (current assets less current

liabilities) of $21.5 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flows to current liabilities of 0.9 is well above average and indicates that operating cash flows is sufficient to cover 90 percent of current obligations, a good position. Overall, the parent has a good short-term position. (See Table below). Long-Term Position:

Applicant - The ratio of long-term debt to net assets of 0.0 indicates the applicant has no long-term debt and therefore has excess equity in which it could use to acquire additional debt if needed, a good position. The most recent year had $955,086 of revenue in excess of expenses, which resulted in an operating margin of 9.3 percent. As discussed above, 2008 cash flow information was not available. Overall, the applicant has a good long-term position. (See Table below).

Parent - The ratio of long-term debt to net assets of -9.5 indicates the parent has no positive equity to borrow against, a weak position. The majority of the debt is mortgage debt secured by substantially all of the personal property of the parent. The ratio of cash flow to assets of 9.7 percent is average and an adequate position. The most recent year had $9.2 million of revenue in excess of expenses, which resulted in an operating margin of 5.5 percent. Overall, the parent has a slightly weak but adequate long-term position. (See Table below).

Capital Requirements:

Schedule 2 listed capital projects totaling $2.2 million including this project.

Available Capital:

Funding for this project will be provided by the parent company. As discussed above, the parent has working capital of $21.5 million and $9.6 million in operating income. In addition, cash flow from operations was $12.6 million.

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Staffing:

Schedule 6A indicates, for both September 30, 2011 and for September 30, 2012 (the first year and second year of the proposed project,

respectively), the applicant forecasts 184.4 FTEs. As stated previously the project results in an incremental 39.4 FTEs added to the facility’s existing 145.0 total FTEs.

Conclusion:

Funding for this project and the entire capital budget should be available as needed.

CON #10056 - December 31, 2008 Audited Financial Statements Parent Applicant

Current Assets $35,361,115 $2,580,532 Cash and Current Investment $8,663,669 $1,077,945 Assets limited to use $1,342,093 $0 Total Assets $130,286,623 $4,414,572 Current Liabilities $13,858,666 $512,505 Total Liabilities $144,013,566 $512,505 Net Assets ($13,726,943) $3,902,067 Total Revenues $167,260,448 $10,281,682 Interest Expense $7,296,189 $0

Excess of Revenues Over Expenses $9,183,597 $955,086 Cash Flow from Operations $12,626,658 N/A Working Capital $21,502,449 $2,068,027

FINANCIAL RATIOS

Parent Applicant

Current Ratio (CA/CL) 2.6 5.0 Cash Flow to Current Liabilities (CFO/CL) 0.9 N/A Long-Term Debt to Net Assets (TL-CL/NA) -9.5 0.0 Times Interest Earned (NPO+Int/Int) 2.3 N/A Net Assets to Total Assets (TE/TA) -10.5% 88.4% Operating Margin (ER/TR) 5.5% 9.3% Return on Assets (ER/TA) 7.0% 21.6% Operating Cash Flow to Assets (CFO/TA) 9.7% N/A

d. What is the immediate and long-term financial feasibility of the proposal? ss. 408.035(1)(f), Florida Statutes.

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achievable through the skill and management of the applicant). In

general, projections that approximate the median are the most desirable, balancing the opposing forces of feasibility and efficiency. In other

words, as estimates approach the highest in the group, it is more likely that the project is feasible, because fewer economies must be realized to achieve the desired outcome. Conversely, as estimates approach the lowest in the group, it is less likely that the project is feasible, because a much higher level of economies must be realized to achieve the desired outcome. These relationships hold true for a constant intensity of service through the relevant range of outcomes. As these relationships go

beyond the relevant range of outcomes, revenues and expenses may either go beyond what the market will tolerate or may decrease to levels where activities are no longer sustainable.

Comparative data was derived from skilled nursing facilities that submitted Medicaid cost reports in fiscal year 2007 and 2008. The Agency selected 10 similar sized skilled nursing facilities (including the applicant) with similar Medicaid utilization. Per diem rates are projected to increase by an average of 3.0 percent per year, through December 2012. The price adjustment factor used was based on the new CMS Market Basket Price Index as published in the 1st Quarter 2009 Health Care Cost Review.

Projected net revenue per patient day (NRPD) of $300 in year one and $312 in year two is between the control group median and highest values of $288 and $342 in year one and $296 and $352 in year two. With net revenues between the median and highest values in the control group, the facility is expected to consume health care resources in proportion to the services provided. (See Table below). In its 2008 Medicaid cost

report, the applicant reported NRPD of $256. The difference in the NRPD reported in 2008 and the year two projected NRPD of $312 results in an average compound annual increase of approximately 5.4 percent. This level of increase is above the inflation percentage outlined in the CMS Market Basket, 1st Quarter, 2009, index. It should be noted that the beds added by this project will be filled with Medicare patients. Medicare reimbursement rates are typically higher than the average revenue per patient day. Projected revenues appear to be reasonable.

Anticipated cost per patient day (CPD) of $261 in year one and $265 in year two is between the control group median and lowest values of $269 and $229 in year one and $276 and $236 in year two. With net revenues between the median and lowest values in the control group, projected costs are considered efficient. (See Table below). In its 2008 Medicaid cost report, the applicant reported CPD of $232. The difference in the CPD reported in 2008 and the year two projected CPD of $265 results in

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an average compound annual increase of approximately 3.6 percent. This level of increase is slightly above the inflation percentage outlined in the CMS Market Basket, 1st Quarter, 2009, index. It should be noted that the beds added by this project will be filled with Medicare patients. Medicare patients tend to receive rehab level services which are a higher cost than the average cost per patient day. Costs appear to be slightly overstated and therefore reasonable.

Section 400.23(3)(a)(2), Florida Statutes, specifies a minimum certified nursing assistant staffing of 2.9 hours of direct care per resident per day and a minimum licensed nursing staffing of 1.0 hour of direct resident care per resident day. Based on the information provided in Schedule 6, the applicant’s projected licensed nursing staffing and direct care

exceeds the minimum level required in year one and year two. The year two operating profit for the skilled nursing facility of $2.4

million computes to an operating margin per patient day of $47 which is above the control group highest value of $24. This suggests the level of profitability might be overstated. In 2008, the applicant reported a healthy operating margin of $24 per patient day or 9.3 percent. This project is not likely to have a negative impact on the applicant since it is an expansion of profitable operations.

Conclusion:

This project appears to be financially feasible based on the prior profitable operations of the facility.

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CON #10056 Sep-12 YEAR 2 VALUES ADJUSTED

SELECT FY 2007/2008 YEAR 2 ACTIVITY FOR INFLATION

COST REPORT DATA ACTIVITY PER PAT. DAY Highest Median Lowest ROUTINE SERVICES 13,354,950 261 300 238 195 ANCILLARY SERVICES 3,317,990 65 131 99 55 OTHER OPERATING REVENUE 10,000 0 8 1 -2

GROSS REVENUE 16,682,940 326 427 344 258

DEDUCTIONS FROM REVENUE 710,860 14 0 0 0

NET REVENUES 15,972,080 312 352 296 251 EXPENSES ADMINISTRATIVE 2,965,010 58 113 71 45 ANCILLARY 2,844,420 56 72 43 27 PATIENT CARE 6,806,790 133 156 131 123 PROPERTY 828,310 16 53 27 11 OTHER 123,960 2 13 4 2 TOTAL EXPENSES 13,568,490 265 343 276 236 OPERATING INCOME 2,403,590 47 24 11 -2 15.0%

PATIENT DAYS 51,240 VALUES NOT ADJUSTED TOTAL BED DAYS AVAILABLE 53,655 FOR INFLATION TOTAL NUMBER OF BEDS 147 Highest Median Lowest PERCENT OCCUPANCY 95.50% 95.6% 90.6% 78.2%

PAYER TYPE PATIENT DAYS % TOTAL

SELF PAY 3,294 6.4% MEDICAID 26,563 51.8% 69.0% 56.9% 40.6% MEDICARE 21,383 41.7% 31.6% 22.6% 12.3% INSURANCE 0 0.0% HMO/PPO 0 0.0% OTHER 0 0.0% TOTAL 51,240 100.0%

e. Will the proposed project foster competition to promote quality and cost-effectiveness? ss. 408.035(1)(g), Florida Statutes.

Competition to promote quality and cost-effectiveness is driven primarily by the best combination of high quality and fair price. Competition

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forces health care facilities to increase quality and reduce charges/costs in order to remain viable in the market. The health care industry has several factors that limit the impact competition has on promoting quality and cost effectiveness. These factors include a “disconnect” between the payer and the end user of health care services, and a lack of consumer friendly quality measures and information. These factors make it difficult to measure the impact this project will have on competition to promote quality and cost-effectiveness. However, the Agency can measure the potential for competition to exist in a couple of areas.

Provider-Based Competition:

This application is for a transfer of 29 skilled nursing facility beds in District 10 (Broward County). Considering this project is not adding beds to the district/subdistrict and the bed transfer is relatively small, this project is not likely to have a material impact on provider-based competition.

Price-Based Competition:

The impact of the price of services on consumer choice is limited to the payer type. The impact of price-based competition would be limited to payers that negotiate price for services, namely managed care

organizations, commercial insurers and increasingly individual health care consumers. Therefore, price competition is limited to the share of patient days that are under managed care plans and self-pay patients. The applicant is projecting 29.5 percent of its patient days from non-fixed price government payers. Therefore, the potential for price-based competition exists among 29.5 percent of the applicant’s projected patient days.

Conclusion:

This project is not likely to have a material impact on provider-based competition; however, the potential for price-based competition exists for 29.5 percent of the applicant’s projected patient days.

f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss.

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facility will be gained through the delicensure of an equal number of beds from Mercy Manor North (within the same district). The new beds would be located in a portion of Wilton Manors that is currently an ALF named Hidden Palms which would be closed and renovated as a SNF.

The construction type is not listed on the schematic floor plans or in the construction section of the application. The building materials are not described in the submission and there is no reference to existing or new fire resistant construction other than the possible addition of a four-hour wall. The unit where the 29 beds are to be added is currently licensed as an ALF. ALFs are classified as Occupancy Group R-4. As an R-4

occupancy, the permitted construction types and allowable building areas are less restrictive than that of a nursing home (Occupancy Group I-2). It may be necessary to upgrade the construction type to bring the facility in to compliance with current codes. A new wall and a pair of cross-corridor doors would be installed to sub-divide the facility into smoke compartments as required by code.

The planned 29 beds will be located in an existing L shaped building near the existing 118-bed nursing home. The applicant intends to make renovations necessary to support the additional 29 nursing homes beds and create a connector to the existing facility for access to additional required space that are not provided in the new portion of the facility. These renovations will widen the corridors to comply with current code requirements and create handicap accessible toilet/shower rooms in each resident room. Twenty-five of the beds will be located in private rooms and the other four will be in semi-private rooms. All resident rooms appear to meet current code requirements.

All required functional space have been provided and are adequately sized and located. The plan indicates that some required function spaces are located in the existing nursing home. Plans submitted for

subsequent reviews should show these spaces.

The application does not indicate whether or not the facility currently meets the disaster preparedness requirement for nursing homes. Depending on the age of the facility many of these requirements may have been in place when the facility was built. Compliance with these requirements will need to be verified as the project is developed.

The project summary on the plan indicates compliance with some of the more pertinent codes. Additional applicable codes must be listed on future submissions. Some additional architectural, mechanical and electrical physical plant standards will need to be addressed in greater detail as the project is developed, but the physical constraints of the

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spaces should accommodate these requirements. The resident rooms are adequately sized and the facility should be able to meet or exceed all code requirements. Some additional work may be required to upgrade the building construction type and to provide impact protection for exterior units (doors, window and louvers) and other disaster

preparedness requirements.

The estimated construction costs appear to be within the expected range. These costs may increase if additional work is required to bring the

building into code compliance.

The information provided in the project completion forecast appears to be reasonable.

The architectural review of the application shall not be construed as an in-depth effort to determine complete compliance with all applicable codes and standards. The final responsibility for facility compliance ultimately rests with the owner.

g. Does the applicant have a history of and propose the provision of health services to Medicaid patients and the medically indigent? ss. 408.035(1)(i), Florida Statutes.

Wilton Manors states intentions to continue to provide the same level of Medicaid as it has in the past, with the 29-bed addition to be primarily for rehabilitative care. While the proportionate amount of Medicaid is expected to go down slightly, actual Medicaid utilization is expected to remain about the same. The applicant indicates intentions to continue to care for all patients, regardless of payer source, with project

implementation. The following table compares annual occupancy rates for Wilton Manors, District 10 and the state, during January 2008 through December 2008.

CY 2008 Patient Days

Percent Total Occupancy & Medicaid

Total Medicaid

Wilton Manors Health & Rehabilitation Center 91.33% 70.93%

District 10 83.06% 63.37%

State 87.35% 60.69%

Source: Agency for Health Care Administration publication Florida Nursing Home

Utilization by District and Subdistrict January 2008-December 2008, issued April 3, 2009. The applicant has historically shown a commitment to the medically

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patient days from year one to year two and a corresponding increase in Medicare patient days for the same period. This accounts for the 29-bed addition seeking to accommodate rehabilitation and complex patient care demand, with Medicare as the primary payer. The applicant states all beds will be Medicare and Medicaid-certified.

F. SUMMARY

Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation Center (CON #10056) proposes to add 29 community nursing home beds at 118-bed community skilled nursing facility Wilton Manors Health and Rehabilitation Center through the delicensure of the 29 inactive beds at 29-bed Mercy Manor North, Broward County, Florida. The project, if approved, will result in no change in the number of community nursing beds in the district or subdistrict.

The project involves 19,821totalGSF with 230 GSF of new construction and 19,591 GSF of renovation. The applicant proposes $1,149,730 in total construction costs ($1,120,980 for renovation and $28,750 in new construction). The total cost of the project is $1,917,885. Total project costs include the following: land; building and equipment; project

development and start-up.

The applicant proposes no conditions to this project. Wilton Manors and Mercy Manor North do not have CON conditions.

Need:

Need analysis includes evidence that Wilton Manors averaged 91.33 percent in its 118 beds. Wilton Manors exceeded the district’s 83.06 percent average occupancy during the 12-month reporting period, ending December 31, 2008.

● Using Claritas data, the applicant shows that in 2008, some

1,186,428 residents (or about 66.0 percent) of the entire District 10 population of 1,785,344 residents, are within a 20-minute drive time radius of Wilton Manors. The project site is both centrally located geographically in Broward County and located within approximately a 20 minute drive time of 66.0 percent of the district’s population. The applicant further states that by 2013, the Broward County age 65 and over population will rise to 283,709 residents and its 75 and over population will rise to 138,121 residents. This shows continued growth of the elderly population at least for the next five years. The

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applicant concludes some of these residents will likely be in need of SNF care and the project will better accommodate access, availability and utilization.

● Agency records indicate total occupancy in the district at 83.06 percent for calendar year 2008, which is lower than the statewide average occupancy of 87.35 percent. However, Wilton Manors experienced a relatively high occupancy rate for the same period (91.33 percent). Wilton Manors was the ninth most occupied of the 33 facilities in the district for the period. Project approval would better utilize existing licensed beds in the district in that it would transfer inactive beds at Mercy Manor to a relatively high occupancy facility.

Quality of Care:

● As of a June 11, 2009 Wilton Manors had one of a possible five-star quality inspection rating, as issued by the Agency.

● As of the three-year period ending June 10, 2009, Agency records indicate 19 confirmed and three confirmed without deficiency

complaints at Wilton Manors. The 19 confirmed complaints were for the following complaint categories: resident rights (three); call lights, inappropriate discharge, medical records/charting, pressure sores and resident care (two each) and falls/injury, lack of assessment, medicine problem/ errors/formulary, nursing service, plan of care and untrained/ unqualified staff (one each). The three confirmed without deficiency complaints were for the following complaint categories: call lights, medical records/charting and medicine problem/errors/formulary (one each).

Financial Feasibility/Availability of Funds:

● Overall, the applicant and parent have good short-term positions and the applicant has a good long-term position while the parent has a slightly weak but adequate long-term position. Funding for the project and the entire capital budget should be available as needed. ● The project appears to be financially feasible based on the prior

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Medicaid/Charity Care:

● Wilton Manors is projecting the proposal will realize 115 fewer Medicaid patient days in year two than in year one but gain an estimated 1,230 Medicare and Medicare HMO patient days in year two. In year one, 53.2 percent of patient days are anticipated to be dedicated to Medicaid recipients and in year two, 51.8 percent of patient days are anticipated to be dedicated to Medicaid recipients. ● The applicant has a history of providing care to Medicaid recipients and the medically indigent, with 70.93 percent Medicaid for 2008. Broward County averaged 63.37 percent Medicaid occupancy in CY 2008.

● The applicant elects to propose no Medicaid percentage as a condition.

Architectural:

● The proposed 29 community nursing home bed addition is to be constructed in renovated space at the current ALF Hidden Palms and attached by a connector to Wilton Manors. Of the 29 beds, 25 will be located in private rooms and the remaining four will be in

semi-private rooms. All resident rooms appear to meet current code

requirements and will have handicap accessible toilet/shower rooms.

● The construction type is not provided for Agency review, the building materials are not described, there is no reference to existing or new fire resistant construction and the applicant does not indicate whether or not the facility currently meets disaster preparedness requirement for nursing homes. The applicant must ensure that Occupancy Code I-2 is met for a SNF addition, along with disaster preparedness prerequisites. The applicant proposes $1,149,730 in total construction costs.

● The estimated construction costs appear to be within the expected range and the project completion forecast appears to be reasonable.

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G. RECOMMENDATION

Approve CON #10056 to add 29 community nursing home beds at the 118-bed community nursing facility, Wilton Manors Health and

Rehabilitation Center, through the delicensure of the 29 inactive beds at 29-bed Mercy Manor North, Broward County, District 10. The proposed total project cost is $1,917,885. The project involves 19,821 total GSF with 230 GSF of new construction and 19,591 GSF of renovation and $1,149,703 in total construction costs.

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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration adopted the recommendation contained herein and released the State Agency Action Report.

DATE:

James B. McLemore

Health Services and Facilities Consultant Supervisor Certificate of Need

Jeffrey N. Gregg

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