STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DEPARTMENT OF VETERANS’ AFFAIRS, POS NY =! d/b/a EMORY L. BENNETT MEMORIAL NURSING HOME, AHCA No. DOAH CASE No. 03-0937 ESP 2002048460 Petitioner, vs. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / FINAL ORDER Having reviewed the Notice of Intent to Impose Late Fine dated November 14, 2002, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 2), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. bo 2. Petitioner shail remit to the Agency $3,750.00. This amount is due and payable within thirty (30) days of the date of rendition of this Order. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with reference to these case numbers, should be sent directly to: Jean Lombardi Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, Mail Stop # 14 Tallahassee, Florida 32308 4. The Petitioner shall withdraw its Request for Formal Hearing. 5. Unpaid assessments will be subject to statutory interest, and may be collected by all methods legally available. 6. Each party shall bear its own costs and attorneys fees. 7. The above-styled case is hereby dismissed. DONE and ORDERED this_// day of CG724* , 2005, in Tallahassee, Leon County, Florida. Alan Le\ine, Secretary ms Agency for Health Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. NM Copies furnished to: [ Brian T. Mulligan Senior Attorney 525 Mirror Lake Dr. N., 330L St. Petersburg, Florida 33701 (Interoffice Mail) Agency for Health Care Admin. David R. Herman, Esq. General Counsel Fla. Dept. of Veterans’ Affairs 4040 Esplanade Way, #180 Tallahassee, FL 32399 | (U.S. Mail) Jean Lombardi Finance & Accounting 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308 (Interoffice Mail) Agency for Health Care Admin. Elizabeth Dudek Deputy Secretary Agency for Health Care Admin. 2727 Mahan Drive, Bldg #1, MS #9 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (Interoffice Mail) Agency for Health Care Admin. Ella Jane P. Davis Administrative Law Judge Div. of Admin. Hearings 1230 Apalachee Parkway Tallahassee, FL 32399 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the 225“day of Prerl , 2005. Richard Shoop, Agency ee Agency for Health Care Administration 2727 Mahan Drive, Bidg #3, MS #3 Tallahassee, Florida 32308-5403 (850) 922-5873 C8) v4 JEB BUSH, GOVERNOR November 14, 2002 Administrator EXHIBIT FLORIDA AGENCY FOR HEALTH CARE ADMINGTRATION RHONDA M. MEDOWS. MD, FAAFP, SE " CERTIFIED MAIL RETURN RECEIPT REQUESTED (#7099 3400 0013 8446 5386) Emory L. Bennett Memorial Veterans’ Nursing Home 1920 Mason Avenue Daytona Beach, FL 321 17 NOTICE OF INTENT TO IMPOSE LATE FINE (Enforcement #2002048460) Dear Administrator: A fine of $5,000 is hereby imposed due to the late filing of the application for annual licensure renewal for Emory L. Bennett Memorial Veterans’ Nursing Home. The application for license renewal was due to the Agency for Health Care Administration by September 2, 2002. However, the application was received October 25, 2002, fifty-three (53) days late as the facility license expires November 13, 2002. Pursuant to section 400.111, Florida Statutes (F.S.), the Agency must assess a fine for license renewal applications that are not received at least 90 days prior tot 50% of the licensure fee in effect he license expiration date. A fee shall be in an amount equal to on the last preceding regular renewal date and is assessed for each day beyond the license due date, up toa maximum of $5,000. PAYMENT SHOULD BE SENT TO: (if paid within 21 days of receipt of notice) Agency for Health Care Administration Long Térm Care Unit, MS-33 2727 Mahan Drive Tallabassee, FL 32308 (Please include a copy of this Notice of Intent) E Pursuant to section 120.569, F.S., XPLANATION OF RIGHTS you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under 2727 Mahan Drive * Mail Stop #1 Tallahassee, FL 32308 visit AHCA online at www fdhe state. flus na section 120.57(1), F-S., your request for an administrative hearing must conform to the requirements in section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS Sincerely, g Molb/ McKinstry, Program Manager Long Term Care Uni Bureau of Long Term Care Services ce: Jacksonville Field Office J. Kemp, LTC unit Legal File, LTC unit EXHIBIT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DEPARTMENT OF VETERANS’ AFFAIRS, d/b/a EMORY L. BENNETT MEMORIAL NURSING HOME, Petitioner, AHCA No. 2002048460 vs. DOAH No. 232-0937 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Respondent, STATE OF FLORIDA, AGENCY FOR HEALTEK CARE ADMINISTRATION (hereinafter “Agency”), by and through its undersigned representatives, and Petitioner, DEPARTMENT OF VETERANS’ AFFAIRS d/b/a EMORY L. BENNETT MEMORIAL NURSING HOME, (herez:nafter “Petitioner”), through its undersigned representative, pursuant to § 120.57(4), Fla. Stat. (2004), each individually a “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (hereinafter “Agreement”) and agree as follows: WHEREAS, Petitioner operates a nursing home facility licensed by the Agency pursuant to Chapter 400, Part II, Florida Statutes (2004), and Section 59A-4, Florida Administrative Code, (2004); and, WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Petitioner pursuant to §§ 120.569 and 120.57, Fla. Stat. (2004); and, WHEREAS, the Agency served the Petitioner in this matter with a Notice of Intent to Impose Late Fine dated November 14, 2002, notifying the Petitioner of the Agency’s intent to impose a late fine in the amount of FIVE THOUSAND DOLLARS '$5,000.00); and, WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; 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 above are true and correct, binding, and expressly incorporated herein. 2. Upon full execution of this Agreement, Petitioner agrees: a) to forego any administrative review of the referenced administrative fine and to withdraw any such review sought during the pendency of the full execution hereof, including, but not limited to, any request under § 120.569, Fla. Stat. (2004), for an informal proceeding under § 120.57(2), Fla. 2 Stat. (2004), or for a formal proceeding under § 120.57(1), Fla. Stat. (2004), any appeal under § 120.68, Fla. Stat. (2004), and any declaratory relief or relief sought through any writ, of or from any court or administrative tribunal of competent jurisdiction; b) to waive any and all appeals or further proceedings regarding this matter; c) to waive any objections as to the form of the Final Order (e.g., regarding the presentation of findings of fact and conclusions of law). 3. Upon full execution of this Agreement, Pet:itioner agrees to pay the sum of THREE THOUSAND SEVEN HUNDRED FIFTY DOLLARS ($3750.00) to the Agency within thirty (30) days of the entry of a Final Order incorporating the terms of this Agreement. 4. venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall vest in the Circuit Court in Leon County, Florida. 5. 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. 6. Each party shall bear its own costs and attorney fees. 7. This Agreement shall become effective on the date upon which it is fully executed by all the parties designated below as signatories. 8. Petitioner for itself and for its related or resulting its successors or transferees, attorneys, heirs, 3 organizations, and executors or administrators, does hereby discharge the Agency, 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 cut of this Agreement, by or on behalf of Petitioner or related facilities. 9. This Agreement is binding upon all parties herein and those identified in Paragraph Nine (9), above. 10. This Agreement contains and incorporates the entire understandings and agreements of the parties. 11. This Agreement supercedes any prior oral or written agreements between the parties. 12. This Agreement may not be amended except in writing executed by all necessary parties. Any attempted assignment of this Agreement shall be void. 13. The parties agree that the Agency is authcrized to and shail submit a final order adopting and incorporating the terms and conditions of this Agreement without notice of hearing and that this Agreement shall be attached to the Final Order. 14. All parties agree that a facsimile signature contained herein shall be as valid and binding as an original signature. 4 15. The following representatives who have read and execute this Agreement hereby acknowledge that he/she/they is/are duly authorized to enter into this Agreement on behalf of the respective parties. Elizabeth) Dudek Deputy S¢cretary, Divisioén of Health Quality Assurance Agency for Health Care Administration par: __ 6p a Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee FL pLbilon 32308 DATED: Og Zip ho AZ Ht Puder — Uiamur/ddlen— Warren R. McPherson Colonel, U.S.M.C. (RET) Executive Director Florida Department of Veterans’ Affairs DATED: 2/) » Log a, ea David R. Herman, Zsq. General Counsel Florida Departmen: of Veterans’ Affairs 4040 Esplanade Way, Suite #180 Tallahassee, Florida 32399 BNI les~ DATED:

Docket for Case No: 03-000937