STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 2b AGENCY FOR HEALTH CARE amos SEP 15 AWE? ADMINISTRATION, Petitioner, . AHCA No.: 2002008113, ie “, vs. DOAH No.: 04-0745 EB) By cn (ELsel oo eure . PALMS VILLA RETIREMENT HOME, AHCA No.: 2003 00925: ‘ ° INC. d/b/a PALMS VILLA RETIREMENT DOAH No.: 04-0995 *: HOME, INC., Respondent. / FINAL ORDER The Agency for Health Care Administration, having 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 is approved and adopted as a 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. A total fine of $3,500.00 is hereby imposed upon Palms Villa Retirement Home, Inc. The fine 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 a reference to this case number, 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. Unpaid fines will be subject to statutory interest and may be collected by all methods legally available. DONE and ORDERED this /“day of Hefileabiec , 200% in Tallahassee, Leon County, Florida. Alan Levine, Secr: on “ 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 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: Margaret Julien, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52"? Terrace - Suite 103 Miami, Florida 33166 (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 and Accounting Agency for Health Care Administration 2727 Mahan Drive - Mail Stop # 14 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Errol H. Powell Administrative Law Judge Division of Administrative Hearings 1230 Apalachee Parkway Tallahassee, Florida 33399-3060 (U.S. Mail) John E. Aurelius, Esq. 4367 North Federal Highway - Suite 101 Ft. Lauderdale, Florida 33308 (U.S. Certified Mail) CERTIFICATE OF SERVICE I] HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named persons and entities by U.S. Mail, or the method designated, on this /©. day of , 2004. FOR Agengy Clerk “———™ Agency for Health Care Administration 2727 Mahan Drive, Building #3, MSC #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003008113 DOAH No.: 04-0745 Vv. PALMS VILLA RETIREMENT HOME, INC. AHCA No.: 20013009252 d/b/a PALMS VILLA RETIREMENT HOME, DOAH No.: 04-0995 INC., Respondent. STIPULATION AND SETTLEMENT AGREEMENT Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the “Agency”), by and through their undersigned representatives, and Palms Villa Retirement Home, Inc. d/b/a Palms Villa Retirement Home, Ine. (hereinafter “Palms Villa Retirement Home, Inc.”) pursuant to Section 120.57(4), Florida Statutes (2003) each individually, a “party”, ccliectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Palms Villa Retirement Home, Inc. is an assisted living facility licensed pursuant to Chapter 400, Part III, Florida Statutes (2003) and Chapter 58A-5, Florida Administrative Code, (2003); and Page 1 of 6 WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes; and WHEREAS, the Agency served Palms Villa Retirement Home, Inc. {AHCA Mo.: 2003008113] with an administrative complaint on December 17, 2004 notifying the party of its intent to impose an administrative fine of $7,000.00 for violations cited by the Agency on the survey conducted September 26, 2003; and WHEREAS, the Agency served Palms Villa Retirement Home, Inc. [AHCA No.: 2003009252] with an administrative complaint on January 8, 2004 notifying the party of its intent to impose an administrative fine of $1,000.00 for violations cited by the Agency on the surveys conducted September 26, 2003 and November 24, 2003; and WHEREAS, Palms Villa Retirement Home, Inc. requested a formal administrative hearing in a petition to the Agency on February 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 Page 2 of 6 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, Palms Villa Retirement Home, Inc. agrees to a withdrawal of its Petition for Formal Administrative Proceedings; agrees tc 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, Palms Villa Retirement Home, Inc. agrees to pay $3,500.00 in administrative fines to the Agency within thirty (30) days Page 3 of 6 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. Palms Villa Retirement Home, Inc. 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 Pelms Villa Retirement Home, Inc. as a result of the surveys conducted on September 26, 2003 and November 24, 2003, however, no agreement made herein shall preclude the Agency from imposing a penalty against Palms Villa Retirement Home for any deficiency identified in a future survey of Palms Villa Retirement Home, Inc., which constitutes é “repeat” deficiency from the surveys conducted on September 26, 2003 and November 24, 2003. 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 fees. 8. This Agreement shall become effective on the date upon which it is fully executed by all the parties. Page 4 of 6 9. Palms Villa Retirement Home, Inc. 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 tne 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 Palms Villa Retirement Home, Inc. or related facilities. 10. This Agreement is binding upon all parties 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. Page 5 of 6 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. Lett ¥ 2 fee Elizabeth Dudek Deputy Secretary Division of Health Quality 4367 N. Federal Highway Assurance. Suite 101 Agency for Health Care Ft. Lauderdale, Florida 33308 Administration 2727 Mahan Drive Tallahassee, Florida 32308 Dated: Vil fo Dated: MD, a SY oy alda Clark Christian General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Dated: g (24 /0y Page 6 of 6

Docket for Case No: 04-000745