STATE OF FLORIDA olde AGENCY FOR HEALTH CARE ADMINISTRATION 9 -- + -> STATE OF FLORIDA, AGENCY FOR RS EN PP Oy HEALTH CARE ADMINISTRATION, DOAH Case Nos. 04-3164 Petitioner, AHCA Nos. 2004003076 2004003077 vs. CAREGIVERS OF PENSACOLA, INC. d/b/a SOUTHERN OAKS, ™ _ Respondent. we FINAL ORDER Ge ay The Agency for Health Care Administration, having entered into ‘@ Joint Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, decides as follows: The attached Joint Stipulation and Settlement Agreement is approved and adopted as a part of this Final Order and the parties are directed to comply with the terms of the Joint Stipulation and Settlement Agreement. THEREFORE, it is ORDERED that: 1. The parties hereto are directed to comply with terms of the Joint Stipulation and Settlement Agreement. 2. The sum of $3,750.00 is hereby imposed upon the Respondent. This amount is due and payable within thirty (30) days of the date of rendition of this Order. 3. The Agency shall rescind Southern Oaks’ conditional license, for the period of March 24, 2004 through March 31, 2004. 4. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to this Case number, should be sent directly to Jean Lombardi Agency for Health Care Administration Office of Finance & Accounting 2727 Mahan Drive, Mail Stop #14 Tallahassee, FL 32308 5. Unpaid fines will be subject to statutory interest and may be collected by all methods legally available. 6. | The above styled case is hereby dismissed. DONE and ORDERED this Laay of Stent, 2005, in Tallahassee, Leon County, Florida. - ah fa. Alan Levine, Secretary Agency far 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 AGENCY CLERK AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, IN 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: Michael O. Mathis, Esq. Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., Suite 3808-D Tallahassee, Florida (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bldg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (Interoffice Mail) Gene Church, Administrator Southern Oaks 600 West Gregory Street Pensacola, FL 32502 (U.S. Mail) P, Michael Ruff Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399 (Inter-office Mail) Wendy Adams (Inter-office Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy of the foregoing was mailed to the above-named addressees on this AS~day of _ “Jere. _, 2005. —=—2o7 a Sane a Richard Shoop, Agency Cférk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32303 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Case No. 04-3164 Petitioner, AHCA Case nos. 2004003076 2004003077 vs. CAREGIVERS OF PENSACOLA, INC. d/b/a SOUTHERN OAKS, Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (“hereinafter the “Agency”) through their undersigned representatives, and Caregivers of Pensacola, Inc., d/b/a Southern Oaks, (hereinafter “Southern Oaks”) and pursuant to Sec. 120.57(4), Florida Statutes (2004) each individually, a “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Southern Oaks is a nursing home facility licensed pursuant to Chapter 400, Part II, Fla. Stat (2003:, and Chapter 59A-4, Fla. Admin. Code (2003), and WHEREAS, the Agency has jurisdiction by virtue of being the regu_atory and licensing autnority over Southern Oaks pursuant to Chapter 120.569 and 120.57, Fla. Stat. (2003); and WHEREAS , the Agency served Southern Oaxs with an “administrative Complaint” on June 25, 2004, notifying the party of its intent to impose a fine in the amount of Five Thousand Dollars ($5,000), for failure to comply with state minimum— staffing requirements on multiple occasions, pilus a condition licensure for the period from March 24, 2004 through March 31, 2004, oased on the survey of March 24, 2004, pursuant to Sections 400.23(3) (a), 400.23(7), and Section 400.23(8) (b), Fla. Stat. (2003), 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, Southern Oaks agrees to a withdrawal of its Petition for a formal administrative proceeding; agrees to waive any anc all appeals and proceeding; agrees to waive compliance with the form of the Final Order (findings of facc 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, Flerida 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, Southern Oaks agrees to pay the sum of Three Thousand Seven Huncred and Fifty dollers ($3,750.00) to the Agency with 30 days of the entry of the Final Order. 5. 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 been County, Florida. 6. Southern Oaks Kéither admits nor denies the allegations raised in the “Administrative Complaint” dated June 25, 2004, and referenced herein. The Agency agrees that it will not impose any further penalty against Southern Oaxs as a result of the survey conducted on March 24, 2004, however no agreement made herein shall preclude the Agency from imposing a penaity against the facility for any deficiency/violation of statute or rule identified in a future survey of the facility, which constitutes a “repeat” deficiency from the survey of March 2004. cosy The varties agree that in such a “repeat” case, the deficiencies from the survey of March 24, 2004, shall be deemed found without further proof. 7. Upon full execution of this Agreement, the Agency shall rescind Southern Oaks conditional license to standard for the period from March 24, 2004 through March 31, 2004. 8. 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. 9. Each party shall bear its own costs and attorney fees. 10 This Agreement shall become effective on the date upon which it is fully executed by all the parties. 11. Southern Oaks 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 che 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 £ OM $30u ' E NM is) 4 FRI t THER! <3 x NO. = Apr s FA ia 858 437 3733 pr. @5 2085 @6:539AM PS -26-2085 G@B21 GENCY HEAL. CARE ADMIN @ 921 158 P , APR-BE- AGENCY HEALTH CARI esa ¢ G6 of this agreemant, by or cn nrehalf of southern Oako OF related facilities. 12, This Agrecment dy binding upon wll party’s nerain and tnose {denlified in the aforementioned paragraph (ii) af thie Agre ement. 137. Tho undersigned have cead and understand this Agreement and haves authority te bind ther respaclive principals to ity 1a, This Agreement conlains the entlie understandings and agroements of the parties. 1s. This Aaroement aupercedes any prior oral or written agreements betwecn the parties. 16. Thig Agreesent may not be amendcd excapt ln writing. Any attemptec as3igument ot this Ayceament anall ke void. shay are the following representatives hereby acknowledge thet duly authorized to enter inte Lhis Agreement. — DATED! & S ato beh Deputy cCrelary, DATED: Cafe Church, Admin utnern Oaks Managed care and 600 West Gregory Street Yeaith Quality Aszurance pensacola, Florida 39502 — DATED: 3/15 DATRO: Wee [25 a“ . CA Cope NA Michacl O. Mathis, Bsq- William I. Roberts Retiig General counsel agency for Health Case Admindeatration Senior ALtoLiny Agency for Heaith Care Aaministrai ion ——_ — “Total P.as

Docket for Case No: 04-003164