STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION A.D.M.E. INVESTMENT PARTNERS, LTD, d/b/a OCEANSIDE EXTENDED CARE CENTER, Petitioner, AHCA No. 2004004940 DOAH Nos<04-2448-—— Vs. FS REN : 05-MD?2.1. -<. AGENCY FOR HEALTH CARE DITION NO.: AHCA-05-COR & -S-OLC ADMINISTRATION, Respondent. FINAL ORDER The Agency for Health Care Administration, having entered into a Stipulation and Settlement Agreement, and being otherwise well advised in the premises, it is: ORDERED that: 1. The Stipulation and Settlement Agreement is attached hereto and made a part hereof. The parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. A fine of $375.00 is hereby imposed upon the Respondent. The fine is due and payable within thirty (30) days of the rendition of this Order. 3. Any payment by check or money order shali be made payable to the “Agency for Health Care Administration,” with a reference to this Case number, and sent directly to: Jean Lombardi Agency for Health Care Administration Office of Finance & Accounting 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 4. Unpaid fines will be subject to statutory interest, and may be collected by all methods legally available. atl DONE and ORDERED this day of Arsuay, 20077 in Tallahassee, Leon County, Florida. Alan Levine, Agency for Hgalth 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 AGENCY CLERK AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, 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: Lourdes A. Naranjo, Assistant General Counsel Agency for Health Care Administration Manchester Building, 1st Floor 8355 N.W. 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) Theodore E. Mack, Esq. Powell & Mack 803 North Calhoun Street Tallahassee, Florida 32303 (U.S. Certified Mail) Hon. Florence Snyder Rivas Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (U.S. Mail) Wendy Adams AHCA-Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy of the foregoing was furnished to the above-named addressees this _A%3 day of” i uae , 2005 eee ee 4 _ Foes, Richard Shoop, Agency Clerk _1EE, agency for Health Care clerk ¢ tration 2727 Mahan Drive Building 3 Tallahassee, Florida 32308 (850) 922-5873 a 2A cmt tate: STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Sy, A.D.M.E. INVESTMENT PARTNERS, LTD, d/b/a OCEANSIDE EXTENDED CARE CENTER, CASE No. 2004004940 Petitioner, DOAH No: 04-2448 vs. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent. STIPULATION AND SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency” ) through their undersigned representatives, A.D.M.E Investments Partners, LTD, d/b/a Oceanside Extended Care Center (hereinafter “Oceanside Extended Care Center”) pursuant to Sec. 120.57(4), Florida Statutes (2003), each individually, “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Oceanside Extended Care Center is a skilled nursing facility licensed Pursuant to Chapter 400, Part II, Florida Statutes (2003), and Chapter 59A-4, Plorida Administrative Code (2003); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Oceanside Extended Care Center pursuant to Chapter 400, Part II, Florida Statutes; and WHEREAS, the Agency served the Administrator of Oceanside Extended Care Center with a Notice of Intent to Impose Fine on May 27, 2004, notifying the party of its intent to impose a fine for $500.00, and; WHEREAS, Oceanside Extended Care Center requested a formal administrative hearing ina petition to the Agency dated June 8, 2004; 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 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, Oceanside Extended Care Center 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, Oceanside Extended Care Center agrees to pay $375.00 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. Oceanside Extended Care Center 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 Oceanside Extended Care Center as a result of the failure to submit the staffing information for the quarters ending December 31, 2003 and March 31, 2004, which was due by April 15, 2004. 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. Oceanside Extended Care Center, 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 Oceanside Extended Care Center or related facilities. 10. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph (9) of this Agreement. 11. The undersigned have read and understand this Agreement and have authority to bind their respective principals to at. 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. aD . fuer ’ Wiese ta Mags a be Elizabeth Dudek heodore E. Mack, Esq. Deputy Secretary, Powell & Mack Health Quality Assurance 803 North Calhoun Street Agency for Health Care Tallahassee, FL 32303 Administration DATED : “a S28by DATED: W//6/O Ki hhbe Loa eS Valda Clark Christian General Counsel, Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 of f DATED: LA LLELER

Docket for Case No: 04-002448