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HomeMy WebLinkAbout14-1938 Supreme Cou '. of Pennsylvania Cour oCOCommo Pleas For Prothonotary Use Only: Cl�ilver�Sh t r S i _ Docket No: T I l. Cu MB ND 44 County 1 The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service ofpleadings or other papers as required by late or rules of court. Commencement of Action: S ( Complaint J Writ of Summons Petition J Transfer from Another Jurisdiction J Declaration of Taking E C Lead Plaintiff's Name: Lead Defendant's Name: Diakon Lutheran Social Ministries Cumberland Crossings Winnifred B. Beam T Dollar Amount Requested: � within arbitration limits I Are money damages requested? El Yes ❑❑ No (check one) J outside arbitration limits O N Is this a Class Action Suit? r_1 Yes No Is this an MDJAppeal? ® Yes Xl No A Name of Plaintiff /Appellant's Attorney: id Check here if you have no attorney (are a Self - Represented 1Pro Sel Litigant) Nature of the Case Place an "X" to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT (do not include Mass Tort) CONTRACT (do not include Judgments) CIVIL APPEALS Intentional 0 Buyer Plaintiff Administrative Agencies dJ Malicious Prosecution 0 Debt Collection: Credit Card ❑ Board of Assessment G' Motor Vehicle Debt Collection: Other Board of Elections ® Nuisance IJ Dept. of Transportation S Q Premises Liability r7 Statutory Appeal: Other Product Liability (does not include mass tort) � Employment Dispute: E � Slander /Libel/ Defamation Discrimination C Other: ❑❑ Employment Dispute: Other 7 Zoning Board , El Other: I JI Other: O MASS TORT 0 Asbestos N 0 Tobacco 0 Toxic Tort - DES Toxic Tort - Implant REAL PROPERTY MISCELLANEOUS ❑❑ Toxic Waste Ejectment ❑o Common Law /Statutory Arbitration B Other: © Eminent Domain /Condemnation 0 Declaratory Judgment Ground Rent Mandamus ❑ Landlord/Tenant Dispute g Non- Domestic Relations Mortgage Foreclosure: Residential Restraining Order PROFESSIONAL LIABLITY Mortgage Foreclosure: Commercial Quo Warranto J Dental CI Partition Replevin Legal J Quiet Title Other: Medical Other: ❑0 Other Professional: Updated 1/1/2011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION Plaintiff(s) & Address(es) Diakon Lutheran Social Ministries d /b /a Cumberland Crossings 1 Longsdorf Way Carlisle, PA 17015 H - 111 Case No. Civil Term VS. Civil Action Defendant(s) & Address(es) Winnifred B. Beam ` 1090 Centerville Rd. Newville, PA 17241 PRAECIPE FOR WRIT OF SUMMONS' ACC) Sa,, TO THE PROTHONOTARY /CLERK OF SAID COURT:.. t7 Issue summons in the above case Writ of Summons shall be issued and forwarded to Atto /Sh riff. a se Circle choice Date: - I ignature of Attorney Print Name: Brian K. Zellner Address: 2608 North 3rd Street Harrisburg, PA 17110 Telephone #: 717 - 774 -1357 Supreme Court ID Number: 95262 WRIT OF SUMMONS TO: Winnifred B. Beam YOU ARE NOTIFIED THAT THE ABOVE -NAMED PLAINTIFF(S) HAS /HAVE COMMENCED AN ACTION AGAINST YOU. Prothonotary/Clerk, Civil Division Date: � I � Deputy 37 �` IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL MINISTRIES, d /b /a CUMBERLAND CROSSINGS, Plaintiff v. WINNIFRED B. BEAM, Defendants NO. lH'i°t 3S CIVIL ACTION PRAECIPE FOR LIS PENDENS TO THE PROTHONOTARY: Please issue a Lis Pendens against the real property owned by Winnifred B. Beam located at 1090 Centerville Rd., Newville, Cumberland County, Pennsylvania. See attached hereto as Exhibit "A" the legal description for the subject property. Date: 3/31 l I1 Brian K. Zellner, Esquire Hynum Law, P.C. 2608 N. 3rd Street Harrisburg, PA 17110 717 - 774 -1357 Attorney for Plaintiff 61/p.'5Dfdai et--# 753 k/-/- 30 37Yo 101•AT— Worreey Deal, Shod Parra, Ad or 1001. 11mr7 FUJI. Inc., Ir41,ne, Yr. V.. MADE THE ` day of of our Lord one thousand nine hundred and seventy- e (1973). in the year 77ETWEEN JULIA. M. KECK, single woman, of Riverdale, Maryland, Grantor , • and •CALVIN A. BEAN, SR. and WINNIFRED V, B. BEAM, his wife, of. • Penn Township, Cumberland County, Pennsylvania', Grantees: WJTNESSETH, that in consideration of Three thousand five hundred ($3,500.00) N0 /X.'C - - -- Dollars, in hand paid, the receipt whereof is hereby acknowledged, the said grantor des hereby grant and convey to the said granter, s, their heirs and assigns, ALL those two small tracts of land situate in Penn Township, Cumberland County, Pennsylvania, bounded and described as follows': . TRACT (a) BEGINNING at a point in the center of public road leading from i'ewvil.le to Pine Grove Furnace; thence along the right of way of the Philadelphia, Harrisburg and Pittsburgh Division of the Reading Railway Company, South 82 degrees West,a distance of 169.7 feet to a post; thence along lands now.or formerly of J. M. Tritt, North 5• degrees East a distance of'350 feet to a point in the center of the public roadaliove mentioned; thence by center of the public road, South 24 degrees East a distance of 370 feet to a point; the place of Beginning. CONTAINING 65/100 Acre. This tract is located North of the Philadelphia, Harrisburg and Pittsburgh Division of the Reading' Railway Company Rita: of Way and is improved with a 2 1/2 Story frame, dwelling house. TRACT (b) BEGINNING at a point in the center of the public road leading from Ne vi11e to'Pine Grove Furnace;' thence by land now or. formerly 'of John Zinn, North 77 degrees West a distance of 356 feet to a post; thence.by the same, North 5 degrees East a distance of 192.5 feet to e. post; thence along the right of way of the Philadelphia, Harrisburg and Pittsburgh Division of the Reading Railway Company,•Sout_h 82 degrees East a distance of 196,5 feet to a point in the public road, above mentioned; thence by center of the public road, South 24 degree.. East . . a distance of 315 feet, more or less, to a point, the place of Beginning. CONTAINING 1.41 Acres. This tract is. located South of the Philadelphia, Harrisburg and Pittsburgh Division of the Reading Railway Company Bight of Way. LESS, HOWEVER; 0.556 acres, more or less, taken for railway crossing, etc., by order o .Commonwealth of Pennsylvania, Public Utility Commission dated December. 28, 1970, and recorded in said Recorder's.Office in Deed Book "Y11, Vol. 23, ?age 397. BOOXt-25PACE 156 IT BRING the same premises that Lulu A. Thomas and David . Thomas, her husband, by deed dated June 20, 1972, and recorded in the Office of the Recorder of Deeds in and for Cumberland County, Pennsylvania, in Deed Book "R ", Vol., 24, Page 367, granted and conveyed to Julia M.Keck, Grantor herein. /i. , J:^ /J/ Schod(Disr /COmb, CO., Ps. B..i «idTnrofar T.. J•Y. tt•.l WO. Tr.mbr Tor sL J t. Amt, /26'° nd• e' 7) A.0.1 '1 ... b.m4, Cq. Oi.t. Cql, Aqt. . s:.mo. Co. Oist. Col. Aqt. lordship of '' /� 1! Cumb. Co., Pa. ecocF 25PACt 157 • • AND the said grantor hereby covenant s and agree that she will warrant generally the properly hereby conveyed. IN WITNESS WHEREOF, said prantor the day and year first above written. Oioneb, ftealeb sob pt Uinta in the Presenre of • her ha and seal la -121::-Wet State of Naryland County of On this, the //,.a day of the undersigned officer, personally appeared 88. 1 hereby certify that the Reaisteoce awl Post Cffiec of within Grantee:la %Z.4., /-72-ii Grand or A before me, Jtilia N. Keck, single woman, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN yiTNEss,WIIEREOF, I hereunto set- my hand and official scat • • oLL • ga-•x2- • • , • ca . • i < : • ) ••:>Z<. e • 6 R i; t k itj BOOK F25PliCE 158 &Officer. q 7 "71 Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY QF4ICE O+Fi THESHERIFF 1 HE PRQTHQNQ1 1/, E V n.14 NY -8 P11 2: 52 CUMBERLAND COUNTY PENNSYLVANIA Diakon Lutheran Social Ministries d/b/a Cumberland Crossings vs. Winnifred B Beam Case Number 2014-1938 SHERIFF'S RETURN OF SERVICE 05/02/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry for the within named Defendant to wit: Winnifred B Beam, but was unable to locate the Defendant in his bailiwick. The Sheriff therefore returns the within requested Writ of Summons as "Not Served" at 1090 Centerville Road, Penn Township, Newville, PA 17241. Eight attempts at service were made but deputies were unable to make contact with anyone at the residence to make service before the Complaint expired. SHERIFF COST: $69.17 SO ANSWERS, May 02, 2014 RONIN? R ANDERSON, SHERIFF (c) : ;ountySuito Sheriff, Te eosoft. Inc. J Brian K. Zellner, Esquire Hynum Law Supreme Court ID #59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 OF l ` PRO TN ONOTA 2014JUL /4 PM 2: cLrn 8C �� 05 PENN AND COUNT)/ DIAKON LUTHERAN SOCIAL MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff v. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PA • : NO. 14-1938 WINNIFRED B. BEAM, Defendant : CIVIL ACTION - LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 USTED HA SIDO DEMANIDADO EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de is proximos viente (20) dias despues de la notification de esta Demanda y aviso radicando personalmente o por rnedio de un abogado una comparecencia escrita y radicando en Ia Corte por escritosus defenses de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tornar accion como se escribe anteriormente, el caso puede proceder sin usted y un fallo por qualquier suma de dinero reclamada en Ia demandaa o cualquier otra reclamacion o remedio solicitado por el demandanta puede ser dictado en contra suya por Ia Corte sin mas aviso adicional. Listed puede perder dinero o propiedad y otros direchos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTAOFICINA PUEDE PRO VEERLE INFORMACION A CERCA DE COMO CONSEGLJTR UNABOGADO. ST USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSSIBLE QUE ESTA OFICINA LE PUEDA PRO VEER INFORMACION SOBRE AGENCIES QUE OFREZCAN SERVTCIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUECUALIFICAN. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 Brian K. Zeliner, Esquire Hynum Law Supreme Court ID #59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 DIAKON LUTHERAN SOCIAL MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff v. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PA : NO. 14-1938 WINNIFRED B. BEAM, Defendant : CIVIL ACTION — LAW COMPLAINT 1. Plaintiff Diakon Lutheran Social Ministries d/b/a Cumberland Crossings is a non-profit continuing care community located at 1 Longsdorf Way, Carlisle, PA 17015. 2. Defendant Winnifred B. Beam is an adult individual who resides at 1 Longsdorf Way, Carlisle, PA 17015. 3. The Defendant Winnifred B. Beam has been a resident of the Plaintiff's Personal Care residence since January 14, 2013. 4. The Plaintiff is owed $30,576.36 for room, board and other services rendered to the Defendant Winnifred B. Beam. Attached hereto as Exhibit A is a true and correct copy of the current Statement. COUNT I -- BREACH OF CONTRACT 5. Paragraphs 1 through 4 are incorporated herein by reference as though set forth at length. 6. On January 14, 2013, Plaintiff and the Defendant Winnifred B. Beam entered into a written agreement pursuant to which Plaintiff agreed to admit her into its Personal Care residence, in consideration for her agreement to pay for room, board and other services. See attached hereto as Exhibit "B" is a true and correct copy of the Admission Agreement. 7. The Defendant Winnifred B. Beam is $30,576.36 in arrears on payments to Plaintiff. Despite repeated demands by Plaintiff for payment, the Defendant has failed and refused to pay this amount. 8. The failure to remit to Plaintiff the amount owed is a material breach of the agreement between the parties. 9. The breach, as aforesaid, has caused Plaintiff injury in the amount of $30,576.36. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against the Defendant in the amount of $30,576.36; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; and c. Granting Plaintiff interest at the statutory rate. COUNT II — BREACH OF IMPLIED CONTRACT In the event it is determined that no written contract between Plaintiff and the Defendant as alleged in Counts I, the Plaintiff alleges as follows: 10. Paragraphs 1 through 9 are incorporated herein by reference as though set forth at length. 11. On January 14, 2013, the Defendant agreed to pay Plaintiff for room, board and other services. 12. On January 14, 2013, the Plaintiff, with Defendant's knowledge and assent admitted herself into its Personal Care residence. 13. The facts, as set forth herein, establish an implied in law and implied in fact contract. 14. Due to the existence of the implied in law and implied in fact contract, the Plaintiff is entitled to compensation for providing room, board and other services to the Defendant Winnifred B. Beam. 15. Plaintiff has demanded payment under the terms of the implied in fact and implied in law contract by sending invoices, but the Defendant has refused to make payment. 16. Plaintiff has been damaged by the refusal of the Defendant to pay for her room, board and other services, in breach of the implied in law and implied in fact contract. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against the Defendant in the amount of $30,576.36; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate; and d. Granting such other relief as the Court deems equitable and just. COUNT III — UNJUST ENRICHMENT -QUANTUM MERUIT In the event it is determined that no written contract and no implied -in -fact contract existed between Plaintiff and the Defendant as alleged in Counts I and II, the Plaintiff alleges as follows: 17. Plaintiff hereby incorporates paragraphs 1 through 16 of this Complaint as if set forth at length herein. 18. As more fully described herein, Plaintiff's expectation of payment from the Defendant was reasonable. 19. The Plaintiff has conferred a substantial benefit upon the Defendant. 20. The Defendant retained the benefit of the bargain with Plaintiff. 21. The Defendant has been unjustly enriched at the expense of the Plaintiff. 22. Due to Defendant's unjust enrichment, the Plaintiff is entitled to proper compensation. 23. The Defendant's unjust enrichment at the Plaintiff's expense has damaged the Plaintiff. 24. The fair market value of said services at the time they were furnished is $30,576.36. 25. The Defendant has refused to pay Plaintiff the fair market value for the room, board and other services. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against the Defendant in the amount of $30,576.36; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate; and, d. Granting such other relief as the Court deems equitable and just. Date: '?/(r `y Brian K. Zellner Attorney ID 59262 Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 [717] 774-1357 Attorney for Plaintiff DIAKON LUTHERAN SOCIAL. MINISTRIES Cumberland Crossings Personal Care 1 Longsdorf Way Carlisle, PA 17015-7623 Facility # (717) 245-9941 Business Office # (717) 240-6040 Ken Beam 1225 Thompson Avenue Annville, PA 17003 Winnifred B Beam Ken Beam STATEMENT Page: 1 of 1 Invoice # Account # Date 393829 3831CCPC 05/31/2014 Due Date Amount Due Amount Paid 6/23/2014 $30,576.36 Resident Name Beam, Winnifred B Please make check payable to Diakon Lutheran Social Ministries Cumberland Crossings Personal Care 05/31/2014 Date Description Units j INet Balance From Through Charges I Credits • RESIDENT RESPONSIBILITY 06/01/2014 05/31/2014 05/31/2014 04/30/2014 06/30/2014 05/31/2014 05/31/2014 Balance Forward Studio Level 3 Phone - Basic Service Phone Basic Service Sales Tax Sales Tax 30.00 Day 1.00 Month 1.00 Each 5,310.00 23.58 1.42 $25,241.36 TOTAL BALANCE DUE $30,576.36 EXHIBIT MANY HANDS. ONE HEART. DIAKON LUTHERAN SOCIAL MINLSTRIES PERSONAL CARE HOME ADMISSION AGREEMENT f This Prsonal Care Home Admission Agreement ("Agreement") is made on this d day of J7111.1.- , 2013 by and between Cumberland Crossings Retirement Community, Carlisle, Ivennsylvania, a Diakori Lutheran Soojal Ministries senior living community ("Cumberland Crossings"), and Willt\i dVl- ) " (referred to below as "You"). I A. Cumberland Crossings includes a licensed personal care home offering services to individiiais 55 years of age and older. Exceptions to the age restriction may be made pursuant to Cumberland Crossings policies. B. You are an individual in need of the services that Cumberland Crossings provides and You desire to be admitted to Cumberland Crossings for the provision of those services within the capability of Cumberland Crossings. NOW THEREFORE, in consideration of the terms and covenants contained in this Agreement, the parties agree as follows: 1. Residence. You will reside in 41 14 (room/apartment number/suite) in Cumberland Crossings ("Residence"). 2. Dat of Residency. You desire to occupy Your Residence onZh 20i-1("Date of Residency"). You are responsible to begin paying the Dail Rate (see Paragraph 4) on the Date of Residency, even if You have riot yet moved into Your Residence. 3. Services. a. Cumberland Crossings shall provide to You assistance with Activities of Daily Living ("ADLs"), which include eating, drinking, ambulating,transferring in and out of a bed or chair, toileting, bladder and bowel management; personal hygiene (including bathing, oral hygiene, hair grooming and shampooing; dressing, undressing and care of clothes, shaving, nail care, foot care and skin care), securing health care, managing health care, self-administering medication and proper turning and positioning in a bed or chair. These assistance services shall be provided as part of the daily room rate ("Daily Rate"), which also includes room and board, linen laundry service, and activities designed to PA PCH admission agreement - Rev. 10/09 EXHIBIT 14'. promote Your active involvement with other residents, Your family and the community. . b. Your Support Plan, Based on Cumberland Crossings's assessment of You, Cumberland Crossings shall develop and implement a support plan, which is a written document that describes Your care, service or treatment needs, when the care, service or treatment will be provided, and by whom ("Support Plan"). c. If, in the clinical judgment of Cumberland Crossings, based on the outcome of Your Support Plan, You need services beyond normal assistance with ADLs to enable you to remain in Cumberland Crossings, You will receive "enhanced care," which includes additional assistance with bathing, dressing and toileting, incontinence care, extraordinary housekeeping services, medication administration and recording and/or physical assistance for mobility needs. You will be notified in the event Cumberland Crossings concludes You need "enhanced care." d. Cumberland Crossings also provides additional services ("Additional Service?) such as personal laundry, transportation, beauty and barber services, etc. e. Cumberland Crossings does not offer assistance with financial management (e.g. helping residents to write checks, balance checkbooks, pay bills, etc.). However, Cumberland Crossings does offer residents the opportunity to participate in the Resident Fund Management Service, which enables a resident to set up an interest-bearing resident fund account and to receive other optional services associated with the account (e.g. direct deposit, automatic payments to Cumberland Crossings for monthly charges, access to funds for personal use, etc.). If You, wish to participate in the Resident Fund Management Service, You must sign an "Authorization and Agreement to Handle Resident Funds" which contains detailed information about Your account and which will become an addendum to this Agreement. f. Pursuant to Your Support Plan, You may need other services, such as physical, occupational and/or speech therapy, physician, dentist and/or podiatrist services, medications (both prescription and over-the-counter), ambulance transport, etc. These services are not included in any of the rates and charges of Cumberland Crossings. They may be covered in whole or in part by third party insurers. Cumberland Crossings provides for some of these services at scheduled times on site; however, You are not restricted to using on-site providers. Providers will bill You separately. g. You hereby acknowledge that You have been advised verbally of the current Daily Rate, the Enhanced Care Charge and charges for Additional Services and PA PCH admission agreement - Rev. 10/09 that a written schedule of rates and charges is. being provided to You as an addendum to, and incorporated into, this Agreement (attached as Exhibit C). 4. Payment for Services. a_ Daily Rate. You shall be responsible to pay the Daily Rate for Your Residence. b. Enhanced Care Charge. if you have been determined by Cumberland Crossings to require enhanced care, You shall be responsible to pay the Enhanced Care Charge. c. Additional Services. You shall also be responsible for payment of Additional Services provided to You. d. Payment Dates. Each month, You will receive a statement that includes the monthly fee due for the current month's room and board (at the Daily Rate), the Enhanced Care Charge for the current month, if applicable, and any charges for Additional Services from the previous month. The statement will also reflect all payments deposited in the bank by the last day of the previous month:_ All bills • by Cumberland Crossings to You are due and payable upon receipt Payments may be made at Cumberland Crossings or mailed to Cumberland Crossings's Iockbox in Philadelphia using the return envelope accompanying Your monthly statement e. Other Payers. i. Another individual,. who has legal authority to access Your financial resources, may handle the payment of Your bills out of Your funds. If another individual will be handling the pay ent of Your bills that individual's name must be indicated here - M'j and that individual must also sign this Agreemen ii. If another individual is paying for services provided to You. under this Agreement out of his/her own funds, that individual must execute a separate Guaranty Agreement, which will be attached to this Agreement as an exhibit. f. Collections/Late Payments. You shall be responsible to pay all actual attorney's fees and costs incurred by Cumberland Crossings relative to the collection of any amounts ninety (90) days past due. g. Resident Funds. You certify that You have at least $85.00 available per month for personal expenses. PA PCH admission agreement - Rev. 10/09 h. Change in Charges. Cumberland Crossings reserves the right to increase or decrease the Daily Rate, Enhanced Care Charge and charges for Additional Services provided to You. Cumberland Crossings shall notify You not less than thirty (30) days prior to the expected increase or decrease. i. Failure to pay for services. In the event You do not pay for services provided by Cumberland Crossings, You shall be discharged for nonpayment of stay, subject to Paragraph 3.j. below. Benevolent Care. Cumberland Crossings, through its parent corporation, Diakon Lutheran Social Ministries, offers financial assistance ("Benevolent Care") to residents who, through no fault of their own, become unable to pay the Daily Rate due under this Agreement. In order to qualify for Benevolent Care, You must not have impaired Your ability to meet financial obligations by transferring assets, other than in good faith and for value to meet ordinary and customary living expenses, and mustnot have materially misrepresented financial or other relevant information during the application and/or admission process or any other required disclosures: Further, You must provide adequate and timely information to Cumberland Crossings to justify consideration. for Benevolent Care and must apply for and utilize all governmental resources, programs, etc., Which may be available to assist You in meeting expenses. Residents who are or who become beneficiaries of Diakon's Benevolent Care policy will be accommodated in semi -private rooms. 5. Admission Information. a. Application Forms. You will complete an application for admission and a confidential financial statement. b. Required medical evaluation. You must have a medical evaluation by a physician, physician's assistant or certified registered nurse practitioner documented on a form specified by the PA Department. of Public Welfare within 60 days prior to admission or within 30 days after admission. c. Disclosure of Financial Information. Cumberland Crossings reserves the right to require You, upon request, to update the financial information disclosed at the time of admission. d. Transfers of Assets. You represent that You have not transferred, and shall not transfer after the execution of this Agreement, any of Your assets such that Your ability to meet Your financial obligations under this Agreement is impaired. PA PCH admission agreement. Rev. 10109 6. Assessments, Medical Evaluations and Support Plan. a. Initial Assessment. Cumberland Crossings will perform an initial assessment on You within 15 days of Your admission to' Cumberland Crossings. This assessment and Your required medical evaluation will be used to develop a Support Plan for You. b. Medical Evaluations. You will be required to have a medical evaluation at least annually or if Your medical condition changes prior to the annual medical evaluation. c. Annual Assessments. You agree to. undergo additional assessments at least annually, if your condition significantly changes prior to the annual assessment, or if the Department of Public Welfare believes that an update is required. d. Revisions to Your Support Plan: Cumberland Crossings will. revise Your Support Plan following an assessment or if Your needs change. 7. Transfers, Discharges and Termination of Agreement. a. Termination by You. i. You may rescind this Agreement in writing within seventy-two (72) hours after You sign it (See Exhibit D for "Notice of Right to Rescind" form). If You rescind this. Agreement, You willbe responsibleto pay only for the services You. received from Cumberland Crossings. ii. After the seventy-two (72). hour rescission period has ended, You may terminate this Agreement for any reason upon thirty (30) days' written notice to Cumberland Crossings. Except in the case of an emergency transfer or death, if You do not give the required thirty (30) days' written notice, You will be responsible for payment of the Daily Rate for each day of the required notice, regardless of whether You still resided at Cumberland Crossings. If You desire,. Cumberland Crossings will provide assistance to You in relocating to Your own home or to another residence that will meet Your needs. b. Grounds for transfer or discharge of You by Cumberland Crossings. Cumberland Crossings has the right to transfer or discharge You for the following reasons: i. if You are a danger to Yourself or others; ii. if Cumberland Crossings determines that Your needs can no longer be met at Cumberland Crossings; PA PCH admission agreement -Rev. 10/09 iii. if meeting Your needs would require a fundamental alteration in Cumberland Crossings's program or building site or would create an undue financial or programmatic burden on Cumberland Crossings; iv. if You fail to pay for services under this Agreement and Cumberland Crossings has made reasonable efforts to collect Your outstanding amounts due; v. repeated violations by You of Cumberland Crossings's rules; or vi. if the PA Department of Public Welfare doses Cumberland Crossings. c. Notice of Transfer or Discharge. Cumberland Crossings shall provide You with not less than thirty (30) days' written notice prior to Your transfer or discharge, unless a delay in transfer or discharge would jeopardize the health, safety or well-being of You or others in Cumberland Crossings. d. Closure of Cumberland Crossings. Cumberland Crossings reserves the right to terminate this Agreement upon closure of Cumberland Crossings, In the event that Cumberland Crossings intends to close, Cumberland Crossings shall provide You with thirty (30) days' written notice of intent to dose. You shall be responsible to pay all fees incurred prior to the date of termination. 8. Effect of Termination. Upon termination of this Agreement neither party shall have any further obligations except obligations incurred prior to the date of termination and as otherwise set forth in this Agreement. 9. Temporary transfers; extended absences. In the event that You require hospitalization or nursing home care or are absent from Cumberland Crossings for an extended period of time, You may retain Your Residence at Cumberland Crossings by continuing to pay the Daily Rate. a. Meal Credits. If You are temporarily transferred to a hospital, nursing home, or other health care facility, You will receive a daily meal credit beginning on the first day of Your temporary transfer. If you are absent from Cumberland Crossings for an extended period of time for other reasons (e.g. vacation), You will begin receiving a daily meal credit after the seventh (79 day of Your absence (ie. on the eighth (8th) and subsequent days). 10. Refunds. In the event of Your death, Cumberland Crossings shall refund the following amount to Your personal representative or guardian within thirty (30) days of the date Your room is cleared of Your personal property: a. the amount of the difference between any payment made by You for monthly charges for "elder care services" (as defined below) and the cost of the "elder care services" actually provided to You. PA PCH admission agreement - Rev. 10/09 elder care services are services or treatment provided to meet a resident's need for personal care or health care, including, but not limited to, assistance with activities of daily living, physical, occupational or speech therapy, and medical social services. Room and board is not included in elder care services. 11. Inventory and storage of Your personal property after death. Cumberland Crossings shall contact Your representative or guardian within twenty-four (24) hours of Your death to arrange for an inventory of Your personal property. a. If Your representative or guardian is unable to claim Your personal property within ten (10) business days after Your death, Cumberland Crossings may place Your personal property in storage for up to thirty (30) days. b. If Your property is unclaimed after the storage period of thirty (30) days, Cumberland Crossings shall send notice by certified mail stating that Your personal property will be disposed of at the end of an additional fourteen (14) day period. c. If Your personal property is unclaimed following the additional fourteen (14) day period, Cumberland Crossings shall dispose of the property. 12. Furniture and Furnishings provided by Cumberland Crossings. You will be provided with a bed and mattress, a chair, pillows, bed linens,and blankets, a chest of drawers and closet space, a bedside table or shelf, a mirror, a lamp, towels and washcloths. If You prefer to provide some or all of Your own furniture and/or furnishings, You will be permitted to do so. a. Please note: Pennsylvania Department of Public Welfare regulations establish specific guidelines regarding the types of equipment (e.g., enabler bars, siderails) that may be attached to resident beds in personal care homes. No equipment may be attached to Your bed, whether the bed has been provided by You or Cumberland Crossings, without the express written permission of Cumberland Crossings following a safety evaluation. 13. Your Personal Property. You shall be permitted to keep and use personal clothing and possessions as space in Cumberland Crossings permits unless to do so would infringe upon the rights of other residents, as reasonably determined by Cumberland Crossings. You understand that Cumberland Crossings is not responsible for lost items and that You are advised not to have valuables such as large amounts of money, jewelry, etc. in Cumberland Crossings. 14. Visitors. You shall be permitted to have visitors at Cumberland Crossings seven days a week, twenty-four hours a day. PA PCH admission agreement - Rev. 10/09 15. Indemnification. You will defend, indemnify and hold Cumberland Crossings harmless from any and all claims, liabilities, damages, costs or expenses (including reasonable attorneys' fees) arising from or resulting in any manner from any of Your acts or omissions which damage or injure any person or the property of any person or of Cumberland Crossings. 16. Miscellaneous. a. Non -Discrimination. Cumberland Crossings shall not discriminate against You on the basis of Your sex, race, color, creed, national origin, sexual orientation, handicap or any other class protected by law. b. No Smoking Policy. Cumberland Crossings is a smoke-free building. Smoking is not permitted inside Cumberland Crossings or Your Residence. Smoking is permitted in designated areas outside. c. Pets. Pets (domesticated small dogs cats, birds and fish) are permitted at _ Cumberland Crossings, only if approved by Cumberland Crossings administration. Please request a copy of Cumberland Crossines etidits - — and Pet Application if You wish to have a pet. d. Fire Drills. Cumberland Crossings is required by law to conduct fire drills at least monthly. You hereby agree to participate in all fire drills. e. Senior Citizens Rebate and Assistance Act. A property tax/rent rebate program is available to qualified seniors and permanently disabled citizens of Pennsylvania. If You choose to claim a rebate from the Department of Revenue, Cumberland Crossings will not seek any portion of any rebate You receive. Cumberland Crossings will not provide assistance with completing rebate claims, but, upon request, will provide documentation of rent paid by You. f. Compliance with Laws. Cumberland Crossings shall comply with all applicable federal and state laws, including laws related to the confidentiality of Your records and health information. g. Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania, notwithstanding any conflict of laws provisions to the contrary. h. Severability. If any term or provision of this Agreement or the application thereof to any person or circumstance shall to any extent be invalid or unenforceable, the remainder of this Agreement or the application of such term or provision to persons or circumstances other than those to which it is held invalid or unenforceable shall not be affected, and each term and provision of the Agreement shall be valid and enforceable to the fullest extent permitted by law. PA PCH admission agreement - Rev. 10/09 i. Assignment. You may not assign this Agreement Waiver. The waiver by Cumberland Crossings of a breach of any provision of this Agreement by You shall not operate or be construed as a waiver of any subsequent breach by You. k Notices. Any notice required or permitted to be given under this Agreement shall be deemed properly given if in writing and if mailed by regular mail in the case of notices to Your legal representative, delivered to Your residence in the case of notices to You, or to the principal office of Cumberland Crossings in the case of notice to Cumberland Crossings. The effective date of any such notice shall be the date of mailing or the date of personal delivery, whichever is applicable. The address to which notice shall be sent may be changed by a written notice given pursuant to this Paragraph. L Entire Agreement. This Agreement contain.s the entire Agreement of the parties relatinglo the subLect matter hereof. This Agreement supersedes and replaces in its entirety any existing agreement between You and CumberlandCrossings regarding Your admission to Cumberland Crossings, and may not be waived, changed, modified, extended or discharged except by a writing executed by Cumberland Crossings and by the party against whom enforcement of any such waiver, change, modification, extension or discharge is sought. m. Change in Law. Cumberland Crossings reserves the right to amend this Agreement upon thirty (30) days' written notice to You if any change in federal, state and local laws, regulations, policy and/or interpretation of the same, shall impair the continuing validity and/or effectiveness of any material provisions of this Agreement n. Headings. The headings of the Paragraphs hereof are for convenience only and shall not control or affect the meaning or construction or limit the scope or intent of any of the provisions' of this Agreement. o. Acknowledgment of Resident Rights and Complaint Procedure. You hereby acknowledge that You have been informed of Your Resident Rights and Cumberland Crossings's Complaint Procedure and that copies of Your Resident Rights and Cumberland Crossings's Complaint Procedure have been provided to You as Exhibits A and B, respectively, to this Agreement. PA PCH admission agreement - Rev. 10/09 p. Acknowledgment of Receipt of Notice of Privacy Practices, Resident Handbook. You acknowledge receipt of Cumberland Crossings's HIPAA Notice of Privacy Practices and a Resident Handbook. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ THE FOREGOING AGREEMENT AND THAT YOU HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THE AGREEMENT. IN WITNESS WHEREOF, the parties have executed this Agreement as of the date first above written. RESIDENT or RESIDENTS LEGAL REPRESENTATIVE By: Name(printed) If another individual is handling payment of Resident's bills pursuant to Paragraph 4(e): OTHER PAYER By:)t Name(printed) Relationship -D If this Agreement is being executed by someone other than the Resident (i.e. the Resident's agent under a Power of Attorney or the Resident's guardian), a copy of the Power of Attorney document or Orphans' Court appointment of the guardian must be provided to Cumberland Crossings at the time this Agreement is signed. PA Pat admission agreement - Rev. 10109 'EXHIBIT A" RESIDENT RIGHTS A resident may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, sexual orientation, national origin, age or sex. A resident may not be neglected, intimidated, physically or verbally abused, mistreated, subjected to corporal punishment, or disciplined in any way. A resident shall be treated with dignity and respect. A resident has the right to question or refuse a medication if the resident believes there may be a medication error. A resident shall be informed of the rules of the home and given 30 days' written notice prior to the effective date of the new home rule. A resident shall have access to a telephone in the home to make calls in privacy. Non -toll calls shall be without charge to the resident. A resident has the right to receive and send mail. Outgoing mail may not be opened or read by staff persons unless the resident requests. Incoming mail may not be opened or read by staff persons unless upon the request of the resident or the resident's designated person. A resident has the right to communicate privately with and access the local ombudsman. A resident has the right to practice the religion or faith of the resident's choice, or not to practice any religion or faith. A resident shall receive assistance in accessing health services. A resident shall receive assistance in obtaining and keeping clean, seasonal clothing. A resident's clothing may not be shared with other residents. A resident and the resident's designated person, and other individuals upon the resident's written approval, shall have the right to access, review and request corrections tothe resident's record. A resident has the right to furnish his room and purchase, receive, use, and retain personal clothing and possessions. A resident has the right to leave and return to the home at times consistent with the home rules and the resident's support plan. PA PCH admission agreement - Rev. 10/09 RESIDENT RIGHTS (continued) A resident has the right to relocate and to request and receive assistance, from the home, in relocating to another facility. The assistance shall include helping the resident get information about living arrangements, making telephone calls, and transferring records. A resident has the right to freely associate, organize, and communicate with others privately. A resident shall be free from restraints. A resident shall be compensated in accordance with State and Federal labor laws for labor performed on behalf of the home. Residents may voluntarily and without coercion perform tasks related directly to the resident's personal space or common areas of the home. A resident ban the right to_receiv_e_visitors_for_a_minimum of_32 hours thily1. 7 damper week. A resident has the right to privacy of self and possessions. Privacy shall be provided to the resident during bathing, dressing, changing, and medical procedures. A resident has the right to file complaints with any individual or agency and recommend changes in policies, home rules, and services of the home without intimidation, retaliation, or threat of discharge. A resident has the right to remain in the home, as long as it is operating with a license, except as specified in 2600.228 (relating to notification of termination). A resident has the right to receive services contracted for in the resident -home contract. A resident has the right to use both the home's procedures, and external procedures, if any, to appeal involuntary discharge. A resident has the right to a system to safeguard a resident's money or property. A resident has the right to choose his own health care providers without limitation by the home. This includes the right to select his own pharmacist provided that the pharmacy agrees to supply medications in a way that is compatible with the home's system for handling and assisting with the self -administration of resident medications. PA PCH admission agreement - Rev, 10/09 "EXHIBIT B" COMPLAINT PROCEDURE (Pursuant to PA Department of Public Welfare ("Department") regulations - 55 Pa. Code §2600.44) 1. Prior to admission, Cumberland. Crossings shall inform the resident and the resident's designated person of the right to file and the procedure for filing a complaint with the Department's personal care home regional office, local ombudsman or protective services unit in the area agency on aging, Pennsylvania Protection & Advocacy, Inc. or law enforcement agency. 2. Cumberland Crossings shall permit and respond to oral and written complaints from any source regarding an alleged violation of resident rights, quality of care or other matter without retaliation or the threat of retaliation. 3. If a resident indicates that he/she wishes to make a written complaint, but needs assistance in reducing the complaint to writing, Cumberland Crossings shall assistthe resident in writing the complaint. 4. Cumberland Crossings shall ensure investigation and resolution of complaints. Cumberland Crossings shall designate the staff person responsible for receiving complaints and determining the outcome of the complaint. 5. Within 2 business days after the submission of a written complaint, a status report shall be provided by Cumberland Crossings to the complainant. If the resident is not the complainant, the resident and the resident's designated person shall receive the status report unless contraindicated by the support plan. The status report must indicate the steps that Cumberland Crossings is taking to investigate and address the complaint. 6. Within 7 days after the submission of a written complaint, Cumberland Crossings shall give the complainant and, if applicable, the designated person, a written decision explaining Cumberland Crossings' investigation findings and the action Cumberland Crossings plans to take to resolve the complaint. If the resident is not the complainant, the affected resident shall receive a copy of the decision unless contraindicated by the support plan. If Cumberland Crossings' investigation validates the complaint allegations, a resident who could potentially be harmed or his/her designated person shall receive a copy of the decision, with the name of the affected resident removed, unless contraindicated by the support plan. 7. The telephone number of the Department's personal care home regional office, the local ombudsman or protective services unit in the area agency on aging, Pennsylvania Protection & Advocacy, Inc., the local law enforcement agency, the Commonwealth Information Center and the personal care home complaint hotline shall be posted in large print in a conspicuous and public place at Cumberland Crossings. (Please see next page for contact information) PA PCH admission agreement - Rev. 10109 Contact information for resident complaints Department of Public Welfare Regional Office Central Region Field Office 1401 N. Seventh St, 4th Floor Harrisburg PA 17102 1-800-882-1885 Area Agency on Aging Human Services Building 16 W. High Street Carlisle PA 17013-2922 1-717-240-6110 Pennsylvania Protection & Advocacy, Inc. 1414 N. Cameron Street, Suite C Harrisburg PA 17103 1-800-692-7443 1-877-375-7139 (TYY) Local Police Pennsylvania State Police 1538 Commerce Avenue Carlisle PA 17013 1-717-249-2121 Commonwealth Information Center 1-800-932-0784 Monday -Friday, 8 a.m.-5 p.m. PA PERSONAL CARE HOME COMPLAINT HOTLINE 1-877401-8835 PA PCH admission agreement Rev, 8/10 "EXHIBIT C" [Insert Schedule of Rates and Charges] PA PCH admission agreement - Rev. IO/D9 "EXHIBIT D" NOTICE OF RIGHT TO RESCIND You may rescind Your Personal Care Home Admission Agreement, without penalty or forfeiture, within seventy-two (72) hours of the date You signed the Agreement. No other agreement or statement you sign shall constitute a waiver of your right to rescind your Personal Care Home Admission Agreement within the seventy-two (72) hour period. If You rescind Your Agreement, You will owe Cumberland Crossings for any services You received from Cumberland Crossings prior to rescission. To rescind your Personal Care Home Admission Agreement, mail or deliver a signed and dated copy of this notice, or any other written notice, letter or telegram, stating your desire to rescind to: Director of Residential Services, Cumberland Crossings, 1 Longsdorf Way, Carlisle PA 17013. Pursuant to this notice, I hereby cancel my Personal Care Home Admission Agreement. DATE RESIDENT'S SIGNATURE RF_SIDENTS NAME (PRINTED) PA PCH admission agreement - Rev. 10/09 VERIFICATION I, �i\.����\�ari'r��c hereby state that I am the authorized representative of the Plaintiff in this action and that the statements of fact made in the foregoing Complaint are true and correct to the best of my information and belief. The undersigned understands that the statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. § 4904 relating to unsworn falsification to authorities. Date: -tvq\�y Printed Name: Title: Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor SHERIFF'S OFFICE OF CUMBERLAND COUNTY ILEO- i# H C . CF THE FROTHOHO iAR 20I JUL 31 Ali +6; 38 CUMBERLAND COUNTY PENNSYLVANIA OFFICE OFTNF SHERIFF Diakon Lutheran Social Ministries d/b/a Cumberland Crossings vs. Winnifred B Beam Case Number 2014-1938 SHERIFF'S RETURN OF SERVICE 07/18/2014 04:25 PM - Deputy Dawn Kell, being duly sworn according to law, served the requested Complaint & Summons by "personally" handing a true copy to a person representing themselves to be the Defendant, to wit: Winnifred B Beam at 1 Longsdorf Way, South Middleton, Carlisle, PA 17015. SHERIFF COST: $34.78 July 21, 2014 (c) CountySuito Sheriff. Teleosoti. Inc. �v..,.. . leo_n_ DAWN KELL, DEPUTY SO ANSWERS, RONKS' R ANDERSON, SHERIFF