STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION C, “ y . ‘. Dye, STATE OF FLORIDA wt, “Po a AGENCY FOR HEALTH CARE Bf ey ADMINISTRATION, ar Petitioner, AHCA NO. 2003004814 °°.” 2003005688 vs. 2004000115 I DOAH NO. 03-3814 FLD (Nose. GAIL K. DELLINGER, ADULT FAMILY, 03-3864 CARE HOME, d/b/a KING MANOR, RENDITION NO.: AHCA-04- 9154-S-OLC Respondent. ee ees——‘“‘“(i‘(‘(‘s FINAL ORDER Having reviewed the administrative complaints dated August 1, 2003, (Ex. 1) and January 9, 2004, (Ex. 2) attached hereto and incorporated herein, 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. 3), 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. 2. The Respondent agrees to never apply for a license to operate a health care facility, including an adult family care home, in the State of Florida and waives all right and entitlement to do so in the future. 3. Petitioner waives fines imposed against King Manor, for Case #2003004814 and #2004000115, in the amount of $2,500.00. DONE and ORDERED this = day of _/ Next tA , 2004, in Tallahassee, Leon County, Florida. Agency for Health Care Administratioh 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 PRESCRIBEC 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. Copies furnished to: Nicholas F. Tsamoutales, Esq. Attorney for King Manor 1900 Palm Bay Road, NE, #G Palm Bay, FL 32905 (U. S. Mail) Katrina D. Lacy, Esq. AHCA, Senior Attorney 525 Mirror Lake Dr. N. #330G St. Petersburg, FL 33701 (interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop Code #14 Tallahassee, Florida 32308 (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) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Fred L. Buckine, ALJ Div. of Administrative Hearings The DeSoto Bidg. 1230 Apalachee Parkway Tallahassee, FL 32399-3060 (U.S. 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 Xx? day of ZY ib, 2004. a —_ \ f ZY) Micrel iy” 4; Lealand McCharen, /agency Clerk 7/ i | Agency for Health Care Administration . 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 EXHIBIT STATE OF FLORIDA i AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2003004814 GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MANOR, Respondent. , ee AMENDED ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Amended Administrative Complaint against GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MAN OR, hereinafter referred to as “Respondent,” pursuant to Section 120.569, and 120.57, Florida Statutes (2002), and alleges: NATURE OF THE ACTION Se ACTION 1. This is an action to revoke the license and impose an administrative fine in the amount of $2,000.00, against the Respondent, pursuant to Sections 400.6196(1) and 400.618(2), Florida Statutes (2002); and Rule 58A-14.004(4)(a), Florida Administrative Code (2002). 2. The Respondent was cited for deficiencies during the complaint investigation, conducted on or about June 3, 2003. JURISDICTION AND VENUE JURISDICTION AND VENUE 3. This tribunal has jurisdiction over the Respondent pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 4. Venue shall be determined pursuant to Rule 28-] 06.207, Florida Administrative Code (2002). PARTIES 6. The Respondent is an adult family-care home located at 3255 Fell Road West, facility under Chapter 400, Part VII, Florida Statutes, and Chapter 58A-14, Florida Administrative Code, having been issued license number 6905558. COUNT I Respondent failed to Provide assistance with, or supervision of the self-administration of medication, or medication administration. Fla. Admin. Code R. 58A-14.007(1)(b) (2002) CLASS I DEFICIENCY 7. AHCA repeats, re-alleges, and incorporates Paragraphs one (1) through six (6) as if fully set forth herein. 8. On or about June 3, 2003, AHCA conducted a complaint investigation at the Respondent’s facility. AHCA cited the Respondent for a deficiency, based on the findings below, to wit: During interview on June 2, 2003, it was revealed that the resident was administered dosages of Ativan and that the medication belonged to another person. Further record review revealed that Ativan was not listed on the resident's list of current medications. Respondent’s nurse/provider Stated, on June 3, 2003, that the resident was not sleeping and was anxious and she called the facility's doctor (who is not the resident's primary care physician) and requested Ativan. According to her statement, the physician agreed to prescribe the Ativan for a few days until the resident's daughter brought Seroquel, the resident's usual medication. Respondent’s nurse/provider told the physician that she had Ativan on hand that belonged to a boarder and she would use those for the resident (#1). Further record review revealed that a physician's order for Ativan was not in the resident's record. Respondent’s nurse/administrator stated on June 3, 2003 that she usually picks up the scripts at the physician's office, but since she had the Ativan available, there was no need to Pick up the script. Respondent’s nurse/provider stated that since the boarder has so many meds and PRN (as needed), he/she would not notice a few pills missing. During the course of the survey, a fax order dated April 11, 2003 for the Ativan was received from the facility’s doctor. Record review on June 5, 2003 at 2:00 PM of the physician’s (resident #1’s primary care physician) Progress notes, dated April 2, 2003, lists the resident's medications as: Imdur, Norvasc, Lopressor, Levothroid, Aricept, Nitrostat, Miacalcin, Imodium, Seroquel, Ultracet, Coumadin, and Nystatin Powder and begin a new medication Lopressor. Progress note from patient visit April 17, 2003 indicates that a new medication, Lortab as needed, was added to the other medications. There is no mention of the Ativan. Interview on June 5, 2003, at around 10:30 AM, revealed that the provider, a family member and the resident went together to the resident’s primary care physician on April 17, 2003 for a follow-up visit. The nurse reviewed the medications for any additions, deletions or problems. The use of Ativan was not disclosed to the nurse. The physician entered the room and asked if there were any changes in the medications (additions or deletions) , and again the use of Ativan was not disclosed to the resident's primary physician. The progress note indicates back pain not fully relieved by Ultram, hence the order for Lortab. There is no mention of sleeplessness. Imdur, Sythroid, Coumadin. Lopressor, Dilantin, Aricept, and Seroquel. There was no mention of the Ativan that the nurse/provider stated the doctor had prescribed on April 11, 2003, nor was there any mention of the resident's inability to sleep and excessive pain. A faxed Tequest to the facility doctor from the nurse/provider (fax receipt date April 25, 2003) for "0.5 Ativan BID/PRN, administer only 4/13.4/14, 4/15”. Patient is anxious and unable to sleep. Verbal Orders April 11, 2003". The Physician signed and faxed the request for Ativan back to the nurse/provider on April 25, 2003, per Transmission Verification Report in patient file. 9. The Respondent failed to provide assistance with, or supervision of the self. administration of medication, or medication administration, as required by Fla. Admin. Code R. 58A-14.007(1)(b) (2002). 10. For this deficiency, AHCA provided the Respondent a mandated correction date of June 3, 2003. 11. The Agency seeks to revoke Respondent's license pursuant to Section 400.6194(2), Florida Statutes (2002). 12. The foregoing deficiency constitutes a Class I deficiency. Since the Respondent was previously cited for this deficiency on January 13, 2003, a fine is warranted in the amount of $1,000.00. COUNT II Respondent failed to ensure that each resident lives in a safe and decent living environment, free from abuse and neglect. Section 400.628(1)(a), Fla. Stat. (2002) CLASS I DEFICIENCY 13. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 14.) Onor about June 3, 2003, AHCA conducted a complaint investigation at the Respondent’s facility. AHCA cited the Respondent for a deficiency, based on the findings below, to wit: a) b) c) qd) Interview on June 3, 2003 and signed statements dated June 5, 2003 reveal that resident #1 had been administered dosages of Ativan without the knowledge of the statement dated June 5, 2003 States that on April 16, 2003, the resident was still sleeping when a phone call was made to him/her at 10:00 AM. The resident was Respondent’s nurse/provider was present at that physician’s visit and did not disclose the use of the Ativan. Statement dated April 18, 2003 from Director/RN at the day care center reveals that the resident attended and also states that the resident "was quite sedated and lethargic". It was noted that he/she was carrying a zip lock baggie of various pills. Some of the pills looked different from what the resident usually took. The resident’s primary care physician was called to verify medications on file. Respondent’s nurse/provider was contacted by phone and stated "the only other pills in that baggie are vitamins". When concem was expressed by the RN, that the pills did not look like vitamins, Respondent’s nurse/provider again stated that they were vitamins. The family was called and concem was expressed. The medications were not given to the resident that day and were returned to the daughter when she picked up the resident. Interviews on June 3-5, 2003 revealed that, on April 21, 2003, the unusual pill from the baggie was taken to her usual pharmacist for identification, who identified it as Ativan. Signed statement June 5, 2003 indicates: that two Police officers visited the home on April 22, 2003 to discuss the administration of Ativan to resident #1. Respondent nurse/provider, at that time, that no Prescription medications other than those prescribed by the resident’s primary care physician were to be administered to resident #1. to her statement, the physician agreed to prescribe the Ativan for a few days until the e) resident's daughter brought Seroquel, the resident's usual medication. The nurse/provider stated on June 3, 2003 that she told the facility doctor that she had Ativan on hand that belonged to a boarder and she would use those for the resident (#1). Further record review revealed that a physician's order for Ativan was not in the no need to pick up the script from the boarder without his/her knowledge because the boarder has so many meds and PRN (as needed), that he/she would not notice a few pills missing. Medication review on June 3, 2003 revealed a bottle of Ambien 10mg —“take one pill at bedtime as needed for sleep- may repeat 1 time only if needed.” The prescription container is dated May 9, 2003 and belonged to resident #1 which had not been prescribed by his/her primary care physician. Review of the facility doctor’s medical record for resident #1, revealed a request on May 8, 2003 for "sleep Aid-Anti Anxiety Klonopin Img QHS or Ambien", which was faxed from the nurse/provider. Resident record review on June 3, 2003 revealed no documentation concerning any changes in the resident's behavior or sleep patterns, which would indicate the need for the medication Ambien. A review of resident medications as listed on the resident’s primary care physician’s patient progress notes dated April 2, 2003, April 17, 2003, May 5, 2003, and May 12, 2003 revealed that resident #1 was already taking Seroquel img | twice a day and Lortab 5-500 1/2 - 1, 4 times a day as needed. Respondent’s nurse/provider failed to inform the family and the resident's primary care physician that, in her opinion, the resident needed Ambien. Resident’s primary care physician’s : progress notes dated May 12, 2003 document that he had not been made aware of the use of Ambien at any time, as Ambien was not listed as one of the currently prescribed medications. Per nurse/provider's statement on June 3, 2003, the following are physician's orders. They do not contain the name of the physician whom the order was from, nor did it contain the signature of the nurse or the physician. The documentation reads as follows: April 28, 2003-the resident has a "small open wound to right stump, will follow up with orthotics on 4/29/03 at 4PM, any special orders? Can you or called assistant by name come and check him/her out-history of PVD." Unsigned physician's order, May 6, 2003-"Per home visit - continue current wound care to right BKA (below knee amputation), wet to dry , (BID) twice daily, normal saline, hold prosthesis wear x 2 weeks, then apply stump shrinker x 4 days and follow up with orthotics. Right anterior thigh red area- apply warm moist compresses using Epson salt BID cover area with Band -aid", Primary care physician’s Progress notes document that the resident had been in the office on May 5, 2003. However, the nurse/provider continued to contact the facility doctor for confirmation rather than the resident’s primary care physician. g) The nurse/provider stated on June 3, 2003 that the facility doctor was called on April 11, 2003 and May 9, 2003 because both days were Friday's and the resident's primary care physician was not available, so the facility's doctor was called. h) Per interview on June 4, 2003 and signed statements dated June 5, 2003, the resident's family specifically requested that all care issues be addressed with the resident's primary care physician to ensure the resident's well being and avoid contraindications in medications and treatments. i) During interview, it was revealed that the resident died on May 16, 2003, at the facility, of a massive heart attack. No written documentation is available to confirm the events leading to the resident's death. The nurse/provider stated on June 3, 2003 that she started CPR and a staff member called 911. Fire rescue called the Sheriff's office, the medical examiner and the facility's doctor. Family members were called and were present when the resident’s death was pronounced by fire rescue and the facility’s doctor. The nurse gave no reason as to why the resident's primary care physician was not contacted. 15. The Respondent failed to ensure that each resident lives in a safe and decent living environment, free from abuse and neglect, as required by Section 400.628(1)(a), Fla. Stat. (2002). 16. For this deficiency, AHCA provided the Respondent a mandated correction date of June 4, 2003. 17. The Agency seeks to revoke Respondent’s license pursuant to Section 400.6194(2), Florida Statutes (2002). 18. Additionally, the foregoing deficiency constitutes a Class I deficiency and a fine is warranted in the amount of $1,000.00. WHEREFORE, AHCA demands the following relief: 1, Enter factual and legal findings as set forth in the allegations of Count I and Count D; 2. Impose a license revocation, for the violations cited in Counts I and II, against the Respondent, pursuant to §400.6194(2), Florida Statutes (2002); and 3. Impose a fine in the amount of $2,000.00, for the referenced violations. Submitted on this_/g+ day of Luguet 2003. ) Katfina D. Lacy, Senior Atto ey Fla. Bar. No. 0277400 Agency for Health Care Administration 525 Mirror Lake Dr.,, Sebring Bldg., 330G St. Petersburg, Florida 3370] (727) 552-1525 (office) (727) 552-1440 (fax) NOTICE The Respondent, GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MANOR, is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 323 08, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ne ere a i Nt erate CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0007 8499 6355 to Gail K. Dellinger, Owner/Administrator, 3255 Fell Road West, Melbourne, FL 32904 dated on August /s+ , 2003. wha D. Lacy, Senior Attorney Copies furnished to: Gail K. Dellinger Owner/Administrator 3255 Fell Road West Melbourne, FL 32904 (U.S. Certified Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, Fl 33701 ~ 9 are en EXHIBIT STATE OF FLORIDA a. oe AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2004000115 GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MANOR, Respondent. / $s ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MANOR, hereinafter referred to as “Respondent,” pursuant to Section 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $500.00, against the Respondent, pursuant to Section 400.6196(1) (b), Florida Statutes (2003); and Rule 58A-14,008(2)(a)2, Florida Administrative Code (2003). 2. The Respondent was cited for the deficiency during an appraisal visit, conducted on or about December 9, 2003. JURISDICTION AND VENUE 3. This Court has jurisdiction over the Respondent pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 4. Venue shall be determined pursuant to Rule 28-106, Florida Administrative Code (2003). PARTIES 5. Pursuant to Chapter 400, Part VII, Florida Statutes (2003), and Rules 58A-14, Florida Administrative Code (2003), AHCA is the licensing and enforcing authority with regard to adult family-care home laws and rules. 6. The Respondent is an adult family-care home located at 3255 Fell Road West, Melbourne, Florida 32904. At the time of the appraisal visit on December 9, 2003, Respondent’s license (#6905558) to operate as an adult family care home under Chapter 400, Part VII, Florida Statutes (2003) and Chapter 58A-14, Florida Administrative Code (2003), had expired as of September 26, 2003. COUNT I RESPONDENT FAILED TO MEET MINIMUM REQUIREMENTS OF LICENSURE BY FAILING TO RESIDE IN THE HOME. R. 58A-14.008(2)(a)2, Florida Admin. Code (2003) CLASS II DEFICIENCY 7. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through six (6) as if fully set forth herein. 8. On or about December 9, 2003, an appraisal visit was conducted at Respondent’s facility. 9. Based on observation and interview, it was determined that the provider had not resided in the home since November 16, 2003. Findings: During an appraisal visit to the home on December 9, 2003, the provider was not present. In interview with relief staff on December 9, 2003, at 12:30 PM, it was confirmed that the provider re er UA EN tia etm ase had gone to South Carolina to work (itinerant nursing) on November 16, 2003. When asked why he/she did not report this to the surveyor on November 18, 2003, relief staff stated that the provider had told him/her not to. 10. The above actions or inactions are a violation of Rule 5 8A-14.008(2)(a)2, Florida Administrative Code (2003), which requires, among other things, that an adult family care home provider live in the home. ll. Respondent was provided a mandated Correction date of December 10, 2003. 12. Said violation constitutes the grounds for the imposed Class IT deficiency in that it directly threatens the physical or emotional health, safety, or security of the residents of the adult family care home. A class II violation is subject to an administrative fine in an amount not less than $250 and not exceeding $500 for each violation. A citation for a class II violation must specify the time within which the violation is required to be corrected. If a class II violation is corrected within the time specified, no civil penalty shall be imposed, unless it is a repeated offense. 13. Pursuant to Section 400.6196(1)(b), Florida Statutes (2003), the Agency is authorized to impose a fine in the amount of five hundred dollars ($500). WHEREFORE, AHCA demands the following relief: l. Enter factual and legal findings as set forth in the allegations of Count I; and 2. Impose a fine in the amount of $500.00, for the referenced violations. he Katrina D. Lacy, or Attorney Fla. Bar. No. 0277400 Agency for Health Care Administration 525 Mirror Lake Dr., Sebring Bldg., 330G St. Petersburg, Florida 3370] (727) 552-1525 (office) Submitted on this GH day of January, 2004. A een NOTICE The Respondent, GAIL K. DELLINGER ADULT FAMILY CARE HOME d/b/a KINGS MANOR, is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (85 0) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE SALE OF SERVICE T HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Retum Receipt No. 7003 1010 0003 0279 3778 to Gail K. Dellinger, Owner/Administrator, 3255 Fell Road West, Melbourne, FL 32904 dated on January GfK Hex Senior Attorn ry 2004. Copies furnished to: Gail K. Dellinger Owner/Administrator 3255 Fell Road West Melbourne, FL 32904 (U.S. Certified Mail) Nicholas F. Tsamoutales, Esq. Attorney for Respondent 1900 Palm Bay Road, NE Suite G Palm Bay, FL 32905-7538 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FI 33701 LL RA ee pe pn EXHIBIT STATE OF FLORIDA 8 3 AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003004814 2003005688 v. 2004000115 GAIL K. DELLINGER ADULT FAMTLY DOAH No.: 03-3814 CARE HOME, d/b/a KING MANOR, 03-3864 Respondent. STIPULATION AND SETTLEMENT AGREEMENT =k AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”) through their undersigned representatives, and Gail K. Dellinger Adult Family Care Home, (hereinafter “King Manor”) Pursuant to Sec. 120.57(4), Plorida Statutes (2002) each individually a “party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, King Manor ig an Adult Family Care Home licensed pursuant to Chapter 400, Part VII, Florida Statutes (2003), and Chapter 58A-14, Florida Administrative Code, (2003); and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over King Manor pursuant to Chapter 400, Florida Statutes (2003); and WHEREAS, the Agency served King Manor with an Amended Administrative Complaint (#2003004814) on August 4, 2003, notifying the party of its intent to impose a fine in the amount of $2,000 and revoke King Manor’s Adult Family Care Home license. The Agency served a Notice of Intent to Deny License (#2003005688) on August 13, 2003; and WHEREAS, the Agency served King Manor with an Administrative Complaint (#2004000115) on January 21, 2004, notifying the party of its intent to impose a fine in the amount of $500; and WHEREAS, King Manor requested a formal administrative hearing in petitions to the Agency for the following cases: #2003004814, #2003005688 and #2004000115. 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 without the Respondent admitting to any of the allegations set forth in the above- Cited petitions. 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, King Manor agrees to withdraw 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, a formal proceeding under Subsection 120.57(1), an informal Proceeding under Subsection 120.57(2), appeals under Section 120.68, Plorida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) before which Respondent is entitled to a hearing pursuant to the Provisions of Chapter, 120, Florida Statutes. 4. King Manor further agrees that the Principals of King Manor, including Ms. Gail Dellinger: a. Has no desire and will never apply for a new license to Operate a health care facility, including an Adult Family Care Home facility in the State of Florida, and waive all right and entitlement to do so in the future. b. Agrees that She shall not be involved directly ane eae =n NS RSRAEEE ine or indirectly as an administrator of any health care facility, including an Adult Family Care Home, and the right of the Petitioner to impose any fines against King Manor or Gail Dellinger, for Case Nos. 2003004814 and@ 2004000115, are waived by Petitioner. ‘This Provision does not preclude Ms. Dellinger from working in any Capacity as a nurse, so long as she maintains current licensure under the requirements of Florida law. c. 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 of Leon County, Florida. 5. Neither Gail Dellinger nor King Manor admite the allegations in the administrative complaint referenced herein. The Agency agrees that it will not impose any further penalty against King Manor as a result of the Surveys subject of this agreement. 6. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and withdrawing the above-styled case from formal administrative hearing jurisdiction. 7. Bach party shall bear its own costs and attorney fees. 8. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 9. King Manor 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 King Manor or related facilities, 10. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph (9) of this Agreement. 11. This Stipulation and Settlement Agreement cannot be used against Gail Dellinger in any other judicial, departmental, administrative Or any other Cype of hearing or investigation of any type regarding Gail Dellinger, ana — es a a ESSER 12. The undersigned have read and understand thie Agreement and have authority to bind their respective principals to it. 13. This Agreement contains the entire understandings and agreements of the Parties. 14. This Agreement supersedes any prior oral or written agreements between the parties. iS. 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 -Agre mene - o , YD ——— icHolas F. Tsamoutales, Esq. Esq. Attorney for King Manor Deputy) Secretary Healt. Quality Assurance 1900 Palm Bay Rd., NE, Suite G Agency for Health Care Palm Bay, FL 32905 Administration 2727 Mahan Drive / _ Z Vie é) Y Tallahassee, Florida 32308 Dated: Dated: -39f} OC Valda Clark Christian General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Dated: ReZ//54

Docket for Case No: 03-003864