STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR Se pe IA HEALTH CARE ADMINISTRATION, Poy TS DOAH Case Nos. 05-0122 Petitioner, AHCA Nos. 2004008226 2004007451 vs. CAREGIVERS OF PENSACOLA, INC. . d/b/a SOUTHERN OAKS, Ok Respondent. FINAL ORDER Wee 3 The Agency for Health Care Administration, having entered into'a 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 $2,500.00 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 July 19, 2004 through October 13, 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 _% day of ____, 2005, in Tallahassee, Leon County, Florida. 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: 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 /¢“day of a _, 2005. Richard Shoop, AgencyClerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32303 (850) 922-5873 LEROM 3S3UTHERN OAKS FAX NO. :858 437? 3733 Apr. @5 2805 06:55AM PS APP-@6-2885 @B:22 AGENCY HEALTH CARE ADMIN a38@ 321 8158 P.@2 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Case Nos. 05-0122 Petitioner, 05-0341 vs. AHCA Case nos. 2004008226 2004007451 CAREGIVERS OF PENSACOLA, INC. d/b/a SOUTHERN OAKS, Respondent. { ST TI ND EMEN 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 entet into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Southem Oaks is a nursing home facility licensed pursuant to Chapter 400, Part IJ, Fla. Stat (2003), and Chapter 59A-4, Fla. Admin. Code (2003), and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Southern Oaks pursuant to Chapter 120.569 and 120.57, Fla. Stat. (2003); and WHEREAS, the Agency served Southem Oaks with an “Administrative Complaint” on December 6, 2004, notifying the ‘party of its intent to impose a fine in the amount of Five Thousand dollars ($5,000), for failure to prevent occurrences of resident to resident abuse and failed to implement effective interventions to avoid reoccurrence of ongoing resident to resident abuse resulting in resident injury (lacerations and bruising on the face) for 2 of 6 sampled FROM: s53.JTHERN QAKS FAX NO. :85@ 437 3733 Apr. 85 2005 @7:98AM PS APR-26-28@5 08:22 AGENCY HEALTH CARE ADMIN 858 921 @158 P.@3 residents, based on the survey of July 19, 2004, pursuant to Section 42 CFR. 483.13(e)(1)(), and Sections 400.23(7), and Section 400.23(8)(b), Fla. Stat. (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 trua 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 and all appeals and proceeding; agrees to waive compliance with the form of the Fina) 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, Southern Oaks agrees to pay the sum of Two Thousand Five Hundred dollars ($2,500.00) 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 Leon County, Florida. FROM 3 S0THERN OAKS FAX NO. 7858 437 3733 Apr. @5 2805 @7:e0AM P1G APR-26-2885 98:23 AGENCY HEALTH CARE ADMIN @58 921 8158 P.@4 Wh) se 6. Southern Oaks qeither—eximits Tor denieg the allegations raised in the “administrative Complaint” dated December 2, 2004, and referenced herein. The Agency agrees that it will not impose any further penalty against Southern Oaks 28 @ result of the survey conducted on July 19, 2004, however no agreement made herein shall preclude the Agency from imposing & penalty against the facility for any deficiency/violation of statute or rule identified in a foture survey of the facility, which constitutes a “repeat” deficiency from the survey of July 19, 2004. The parties agree that in such a “repeat” case, the deficiencies from the survey of July 19, 2004, shall be deemed found without further proof. 7. Upon full execution of this Agreement, the Agency shall rescind Southern Oaks condition licensing to standard for the period from July 19, 2004 through October 13, 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 ghall 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. Southem Oaks for itself and for its related or resulting organizations, its successors or transferees, attomeys, 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 wey 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 ar administrative forum, including any claims arising out of this agreement, by or on behalf of Southern Oaks or related facilities. FROM SOUTHERN OAKS APR-06-2085 a?23 12. This Agreement is binding aforementioned paragraph (11) of this Agreement. FAX NO. 13. The undersigned have read and bind their respective principals to it. 14. This Agreement contains the enti 1858 437 3733 Apr. AGENCY HEALTH CARE ADMIN @6 2085 @?7:G0AM Pil e5@ 921 8158 upon all party’s herein and those identified in the understand this Agreement and have authority to ro understandings and agreements of the parties. 15, This Agreement supercedes any prior oral or written agreements between the parties. 16. This Agreement ma assignment of this Agreement shall be void. Agreement. DATED: Elizabeth Dudek Deputy Secretary. Managed Care and Health Quality Assurance DATED: CR ee < William H. Roberts Acting General Counsel Agency for Health Care Administration y not be amended except in writing, Any attempted The following representatives hereby acknowledge that they are duly authorized to enter into this patep: 444% Zoey hurch, Administrator Southern Oaks 600 West Gregory Street Pensacola, Florida 32502 a pater: _ W#e/S. Michael O. Mathis, coe Nv Senior Attorney Agency for Health Care Administration TOTAL. P.@5

Docket for Case No: 05-000122