[DO N OT PUBLISH]

IN THE UN ITED STATES COURT OF APPEALS FOR THE ELE VENTH CIRCUIT

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__ __ __ __ __ __ __ __ __ __ __ __ Agen cy No. A-1 0- 76 AZALEACOURT, ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Pet it io ne r, vers us U.S. DEPARTMENT OF HEA LTH AND HUMAN SERVICES, CENTERS FOR MEDIC ARE & MEDICAI D SERVICES, ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Res po nd en t.

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__ __ __ __ __ __ __ __ __ __ __ __ Agen cy No. A-1 0- 76 W EST PALM BEACH HEALTH CARE ASSOCI ATES, LL C, f.k.a . Azale a Co urt, ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Pet it io ne r,

Case: 11-10619 Date Filed: 07/18/2012 Page: 1 of 5vers us

UNITED STAT ES DEPARTMENT OF HEAL TH AND HUMAN SERVICES, Cen te rs forMed ic are & Med ic ai d S erv ic es , ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Res po nd en t.

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__ __ __ __ __ __ __ __ __ __ __ __ Agen cy No. A-1 0- 76 W EST PALM BEACH HEALTH CARE ASSOCI ATES, LL C, f.k.a . Azale a Co urt, ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Pet it io ne r, vers us U.S. DEPARTMENT OF HEA LTH AND HUMAN SERVICES, CENTERS FOR MEDIC ARE AND MEDICAID SERVICES, ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Res po nd en t.

__ __ __ __ __ __ __ __ __ __ __ __ Pet it io ns forRev ie w of aDeci si on of t he Depa rtment o f Heal th an d Hu m anServ ic es

__ __ __ __ __ __ __ __ __ __ __ __ (J ul y 18 , 20 12 ) Befo re WILSON, ANDERSON andHIGGINBOTHAM, Cir cu itJu dg es . *
Honora ble Patrick E. Hig g inbotham, United States Circuit J udg e for the Fif th Circuit, * sitti ngby designation. 2 Case: 11-10619 Date Filed: 07/18/2012 Page: 2 of 5PER CURI AM:

Inth es e co ns ol id at edap pe al s we re vi ew a fi na l d eci si on of t he Secr et ary of Heal th an d Hu m anServ ic es th atup ho ld s t he im po si ti on of aciv il m on ey pe na lt y fo r a s ki ll ednu rs in g fa ci li ty’ s fa il ur e to m ai nt ai n c om pl ia nc e wit h M ed ic are pa rti ci pa ti on requi rem en ts co nc ern in g h eal th an d s afet y . W it h t he be ne fitof o ral arg um en t an d a fte r car efu ll y co ns id eri ng th e b rie fs an d t he reco rd , we di sm is s t he pe ti ti on s i n t he cas es nu m be red11 -1 06 19 an d 1 1- 13 07 2, an d we d en y th e p et it io n in th e cas e num

be red11 -1 42 10
. Sk il le d n ur si ng faci li ti es th atpa rti ci pa te in th e Me di care an d M ed ic ai d pr og ram s m ay

be subjec t t o c iv il m on ey pe na lt ie s i f th ey

are n otin subs tant ia l
co m pl ianc e wit h m in im

um st an da rd s o f car e. 42 U.S.C. § 1 39 5i -3 (h ). The Pet it io ne r, Azal ea Co urt, i s a s ki ll ednu rs in g fa ci li ty tha t p art ic ip at es in Med ic are an d M ed ic ai d. Mu lt ip le de fic ie nc ie s wer e id en ti fie d dur in g asu rv ey of Az al ea Co urt, an d t he Secr et ary co nc lu de d t ha t re si de nt s wer e in “ imm ed ia te jeop ardy .” Se e 42 C.F.R. § 48 8.3 01
. The fin di ng s o f fac t m ad e b y th e Sec ret ary are c on cl us iv e if supp orte d b y subs ta nt ia l ev id en ce. 4 2 U.S.C. § 13 20 a-7 a(e) . Sub st an ti al ev id en ce m ean s “ su ch rel ev an t ev id en ce as a reas on ab le m in d m ig htacce ptas a de qu at e to supp ort a co nc lu si on .” Rich ards on v. Pera les , 40 2 U.S. 3 89 , 40 1, 9 1 S . Ct. 1 42 0, 1 42 7 3 Case: 11-10619 Date Filed: 07/18/2012 Page: 3 of 5(1 97 1) (qu ot in g Co ns ol id at ed Ediso n C

o. v. NL RB , 30 5 U.S. 1 97 , 22 9, 5 9 S . Ct. 20 6, 2 17 (19 38 )). W e rev ie w th e Sec ret ary’ s co nc lu si on s o f law de no vo . Emera ld Sh or es Heal th Ca re Ass oc s. L.L.C. v. U.S. Dep ’t o f Hea lth & Huma n Se rvs. , 54 5 F .3d12 92 , 12 96 (11 th Cir . 20 08 ). As an in it ia l m at te r we ad dr es s o urjuri sd ic ti on to rev ie w th e th ree p et it io ns be fo re the Co urt. Each pe ti ti on ch al le ng es th e sa m e subs ta nt iv e co nc lu si on s, b ut each was fi le d a t a d iff

eren t t im e dur in g t he pro ceed in gs . Twice, we que st io ne d whe th er the Depa rtment Ap pe al s B oa rdof t he U.S. Departm en t o f Heal th an d Hum anServ ic es ha d i ss ue d afin al an d app eal ab le de ci si on . There is no di sp ut e, ho wev er, tha t the th irdpe ti ti on forrev ie w, No. 11 -1 42 10 , is ti m el y . Becau se we ha ve juri sd ic ti on ov er the th irdpe ti ti on an d e ach pe ti ti onis subs ta nt iv el y th e sa m e, we ne edno t ad dr es s wh ethe r we h av e juri sd ic ti on to rev ie w th e fi rs t t wo pe ti ti on s. Azal ea Co urt d ev ot es a subs ta nt ia l p orti on of i ts bri efs to th e arg um en t t ha t th e Sec ret ary di d n otpro pe rly all oc at e th e b ur de n o f pr oo f in th e ad m in is tra ti ve pr oc eed in gs . W e n eedno t d eci de th e is su e, ho wev er, b ecau se th e ev id en ce wei gh s he av il y infav orof t he ag en cy

an d we wo ul d d en y

th e p et it io n re gard le ss of wh o be ars th e b ur de n o f pr oo f. Azal ea Co urt h ada de fic ie ntsyste m forpre ve nt in g el op em en t. Itfai le d t o c on tro l the ha zard s o f res id en ts who sm ok e. Andit 4 Case: 11-10619 Date Filed: 07/18/2012 Page: 4 of 5ne gl ect edth e wou ndcare of R es id en t 3 . There is m or e th ansubs ta nt ia l ev id en ce

th atsupp orts each of t he Secr et ary’ s co nc lu si on s, an d we a gr ee tha t ea ch de fic ie nc y

ris es to th e le ve l o f imm ed ia te jeop ardy . Azal ea Co urt al so arg ue s t ha t t he Secr et ary act edarb it rari ly and cap ric io us ly by

ass es si ng a pe r di em

civ il m on et ary pe na lty

rathe r th ana pe na lt y ba se d o n aparti cu la r in st an ce o f no nc om pl ia nc e. W e fi ndno erro r in th e p en al ty im po se d. Th e Cen te r fo r Med ic are a ndMed ic ai d S erv ic es m ay im po se a ci vi l
m on ey pe na lt y for “ th e num be r of day s a f aci li ty is n otin subs ta nt ia l co m pl ia nc e wit h o ne or m or e p art ic ip at io n re qu ire m en ts . . . .” 42 C.F.R. § 48 8.4 30 (a). Azal ea Co urt’s n on co m

pl ia nc e p os edanimm ed ia te jeop ardy , andth e p er d ie m m on et ary pe na lt y

pro pe rly acco un ts for

each da y of n on co m

pl ianc e. 1 The pe ti ti on s i n t he cas es nu m be red11 -1 06 19 an d 1 1- 13 07 2 a re DISMI SSED , andth e p et it io n i n 1 1- 14 21 0 i s DENIE D .

We have not conside red Petitioner’ s argument that the re gulations are unc onstitut ionally 1 vague. The argument was ra ised for the first time in this appeal, and no e x traordina ry circ umstances e x ist that ex cuse the failure to preser ve the a rgument. See 42 U.S.C. 1320a-7a( e). 5 Case: 11-10619 Date Filed: 07/18/2012 Page: 5 of 5