STATE OF FLORIDA OCT Ih Cz AGENCY FOR HEALTH CARE ADMINISTRATION . mito AGENCY FOR HEALTH CARE BERS TTS CLERK ADMINISTRATION, ~ 2 Petitioner, a vs. AHCA No: 2004074351 DOAH No: 020696 = 1’ JACKSON HEIGHTS NH, LLC, d/b/a ey eed JACKSON HEIGHTS REHABILITATION Ch oheiéef = CENTER, Respondent. _/ FINAL ORDER The Agency for Health Care Administration, having received an Order Closing File from the Division of Administrative Hearings and a Stipulation and Settlement Agreement entered into by the parties to these proceedings, and being otherwise well advised in the premises, decides as follows: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order. 2. The Order Closing File entered by Claude B. Arrington Administrative Law Judge, dated June 3, 2002, closing the file that was opened in this matter by the division of Administrative Hearings is attached and made a part of this Final Order. THEREFORE, it is ORDERED and ADJUDGED that the parties have to comply with the terms of the Stipulation and Settlement Agreement. DONE and ORDERED this 27 day of Cbegdl 2002, in Tallahassee, Leon County, Florida. A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS TITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FIL- ING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN THIRTY (30) DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Nelson E. Rodney Assistant General Counsel Agency for Health Care Administration Manchester Building, 1st Floor 8355 NW 53rd Street Miami, Florida 33166 (Interoffice mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan drive, Mail Stop #9 Tallahassee, Florida 32308 (Interoffice mail) Jonathan S. Grout, Esquire GOLDSMITH, GROUT & LEWIS, PA 2180 Park Avenue North, Suite 100 Winter Park, Florida 32790-23011 (U.S. Certified mail) Hon. Claude B. Arrington Wendy Adans MO SD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy of the foregoing was furnished to the above named addresses on [ Waa [AL , 2002. har ee Tle. Ao¢Téaland McCharen, Adency Clerk Agency for Health Care 2727 Mahan Drive, Building #3 Tallahassee, Florida 32303 (850) 922-5865 Administration STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEATH CARE ADMINISTRATION, Petitioner, DOAH No: 02-0696 vs. AHCA No: 2001074351 JACKSON HEIGHTS NH, LLC, d/b/a JACKSON HEIGHTS REHABILITATION CENTER, Respondent. STIPULATION AND SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”) through their undersigned representatives, and Jackson Heights NH, LLC., d/b/a Jackson Heights Rehabilitation Center (hereinafter “Jackson Heights”) pursuant to Sec. 120.57(4), Florida Statutes (2001) each individually, a “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Jackson Heights is a nursing home facility licensed pursuant to Chapter 400, Part II, Florida Statutes (2001), and Chapter 59A-4, Florida Administrative Code, (2001); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over nursing homes pursuant to Chapter 400, Part II, Florida Statutes; and WHEREAS, the Agency served Jackson Heights with an administrative complaint dated April 30, 2002, notifying the party of its intent to impose an administrative fine of $2,500.00 for violations based on the survey of November 30, 2001, and; WHEREAS, Jackson Heights requested a formal administrative hearing in a petition to the Agency dated May 9, 2002; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; and NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Jackson Heights agrees to a withdrawal of its Petition for Formal Administrative Proceedings; agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. 4. Upon full execution of this Agreement, Jackson Heights agrees to pay two thousand and five hundred ($2,500.00) to the Agency within 30 days of the entry of the Final Order. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 5. Jackson Heights neither admits nor denies the allegations raised in the administrative complaint referenced herein. The Agency agrees that it will not impose any further penalty against Jackson Heights as a result of the November 30, 2001 survey, however, no agreement made herein shall preclude the Agency from imposing a penalty against Jackson Heights for any deficiency identified in a future survey of Jackson Heights, which constitutes a “repeat” deficiency from the November 30, 2001 survey. The -pertics—ageecthat—_in—sich—repertcase—tire 6. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 7. Each party shall bear its own costs and attorney's fees. 8. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 9, Jackson Heights for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Jackson Heights or related facilities. 10. This Agreement is binding upon all party’s herein and those identified in the aforementioned paragraph nine (9) of this Agreement. 11. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 12. This Agreement contains the entire understandings and agreements of the parties. 13. This Agreement supercedes any prior oral or written agreements between the parties. 14, This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. co > om Elizageth Dudek athan S. Grout, Esq. Deputy} Secretary, GOLDSMITH, GROUT & LEWIS, P.A. Man d Care and 2180 Park Avenue North #100 Health Quality Assurance Post Office Box 2011 Agency for Health Care Winter Park, FL 32790-2011 Administration DATED: Of DATED: @-—SS-0D- ALL illiam H. Roberts Acting General Counsel, Agency for Health Care Admin. 2727 Mahan Drive Tallahassee, FL 32308 DATED: AST G-

Docket for Case No: 02-000696