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IN THE COURT OF COMMON PLEAS .-� �`? , �_� �
OF CUMBERLAND COUNTY, PENNSYLVANIA `�`� t�`' �.� '� ��� `�
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ORPHANS' COURT DIVISION °.:� <-= F,_,,, •.�� s:,
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IN THE MATTER OF : �-' � U' -°�
SARAH QUIMBY, :
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An Alleged Incapacitated Person : No.
PETITION FOR ADJUDICATION OF INCAPACITY
AND APPOINTMENT OF GUARDIAN
AND NOW COMES, Petitioner, Messiah Lifeways, by and through its attorneys, Latsha
Davis & McKenna, P.C., and hereby petitions for an adjudication of incapacity and appointment
of a guardian under 20 Pa.C.S. § 5511, and in support thereof represents as follows:
1. The name of the alleged incapacitated person is Sarah Quimby, hereinafter
referred to as "Mrs. Quimby."
2. Petitioner is Messiah Lifeways, a continuing care retirement community located
at 100 Mt. Allen Drive, Mechanicsburg, Cumberland County, Pennsylvania, 17055.
3. Mrs. Quimby is widowed, 90 years of age, and has resided at Messiah Lifeways'
skilled nursing facility since June 22, 2007.
4. There are no individuals who are sui juris and entitled to inherit from Mrs.
Quimby's estate if she dies intestate.
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5. Mrs. Quimby's attending physician is Michael Sams, D.O., the medical director at
Messiah Lifeways' skilled nursing unit, located at 100 Mt. Allen Drive, Mechanicsburg,
Pennsylvania, 17055.
6. On December 16, 2013, a Brief Interview for Mental Status (`BIMS") was
administered by Messiah Village's staff to Mrs. Quimby, on which she scored a 5, which is
indicative of severe cognitive impairment.
7. Mrs. Quimby suffers from severe dementia.
8. Due to her mental condition, Mrs. Quimby is:
a. Unable to manage her financial affairs;
b. Unable to make and communicate responsible decisions relating to her
financial affairs;
c. Unable to make responsible decisions concerning her person, health,
welfare, and safety;
d. Unable to communicate her needs concerning her health, welfare, and
safety;
e. Unable to reside alone;
f. Unable to provide for her personal safety;
g. Unable to keep herself properly nourished and hydrated;
h. Unable to tend to her personal hygiene;
j. Unable to medicate herself; and
k. Unable to make responsible decisions with regard to her medical care,
including, but not limited to, obtaining health care services and entering
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herself into a hospital, convalescent home, skilled care facility, residential
care facility or similar institution.
9. Given Mrs. Quimby's condition, her capacity will not improve, but rather
deteriorate over time.
10. Dr. Sam's medical deposition will be submitted in advance of the hearing
scheduled in this matter.
11. Mrs. Quimby executed a Durable Power of Attorney designating her daughter,
Mary E. Orse, or in the alternative, Patricia D. Shelton, her agents. A true and correct copy of
the Durable Power of Attorney is attached hereto as Exhibit "A" and is incorporated by
reference.
12. Mary E. Orse died on October 31, 2011.
13. Patricia D. Shelton does not wish to serve as Mrs. Quimby's agent.
14. Mrs. Quimby has executed a living will.
15. Mrs. Quimby has executed a Last Will and Testament.
16. Mrs. Quimby has a pre-paid burial account with Smith and Williams in Norfolk
Virginia and a burial plot at Rosewood-Kellum Memorial Park in Virginia Beach, Virginia.
17. Mrs. Quimby is entitled to benefits from the United States Veteran's
Administration.
18. Mrs. Quimby receives the following income: ,
a. Social Security $733.00 monthly
b. Pension $1,010.36 monthly
c. Veterans Benefit $816.08 monthly
19. Mrs. Quimby is eligible for and is receiving Medical Assistance benefits.
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20. Keystone Guardianship Services, located at PO Box 804, Elizabethville,
Pennsyvlania, 17023, (717) 674-5757, consents to serve as the plenary guardian of Mrs.
Quimby's person and estate. An executed Consent is attached hereto as Exhibit "B" and is
incorporated by reference.
21. Keystone Guardianship Services is qualified to act as the guardian of the person
and estate of Mrs. Quimby by virtue of familiarity and experience and acting as the guardian of
the person and estate for individuals such as Mrs. Quimby.
22. Keystone Guardianship Services charges a one-time start-up fee of$ $500.00.
23. As Mrs. Quimby is a recipient of Medical Assistance benefits, Keystone
Guardianship Services will serve as guardian of Mrs. Quimby's person and estate for a fee of
$100.00 per month. Otherwise, Keystone Guardianship Services will charge its regular rate for
services.
24. This proposed guardianship is in the best interests of Mrs. Quimby for the
management of her financial resources and healthcare decisions.
25. A Power of Attorney instrument has been considered as an alternative to the
appointment of a guardian.
26. However, this alternative is ineffective because the alleged incapacitated person's
incapacity precludes her from executing a Power of Attorney instrument designating a new
agent.
27. The severity of the alleged incapacitated person's mental and/or physical
condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of
her estate be appointed to manage and handle all aspects of Mrs. Quimby's estate, specifically
including, but not limited to: all issues regarding her cash, checks, and any bank or saving
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accounts held in her name; her stocks and bonds; her personal property; her life and/or long term
care insurance of which she is a beneficiary; her entitlement to any governmental and non-
governmental benefit plans; federal, state and local taxes; claims made or to be made on behalf
of her or against her; the execution of documents; entry into contracts affecting her and the
payment of reasonable compensation or costs provided to provide services for her.
28. The severity of the alleged incapacitated person's mental and/or physical
condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of
her person be appointed to handle all issues relating to the person of the alleged incapacitated
person, specifically including, but not limited to: her living arrangements, her medical and
psychiatric care, the administration of inedication to her, and the employment of discharge of
physicians, psychiatrists, dentists, nurses, therapists and other professionals for her physical and
mental treatment and care.
29. It is believed, and therefore averred, that neither the alleged incapacitated person
nor any interested party will contest the medical determination that the alleged incapacitated
person is completely incapacitated.
30. It is believed, and therefore averred, that neither the alleged incapacitated person
nor any interested party will contest this Petition.
31. Mrs. Quimby is alert and able to communicate. However, she is not oriented,
suffers from severe dementia, and is unable to make and communicate responsible decisions
regarding her health or financial affairs.
32. No other court within this Commonwealth has appointed a guardian of the person
or estate of Mrs. Quimby.
33. The type of guardianship sought is plenary of Mrs. Quimby's person and estate.
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WHEREFORE, Petitioner, Messiah Lifeways respectfully requests that this Honorable
Court issue a Citation directed to Sarah Quimby or her counsel, if sa appointed, to show cause
why she should not be adjudicated an incapacitated person and should not have a plenary
guardian of her person and estate appointed on her behalf.
Respectfully submitted,
LATSHA DAVIS & MCKENNA, P.C.
Date: �� � By:
Steven M. Montresor
Attorney I.D. No.: PA 74244
1700 Bent Creek Boulevard, Suite 140
Mechanicsburg, PA 17050
Tele: (717) 620-2424
Fax: (717) 620-2444
smontresor@ldylaw.com
Attorneys for Petitioner,
Messiah Lifeways
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VERIFICATION
I, Ken Beiler,hereby verif�that I am the administrator of the skilled nursing facility at
Messiah Lifeways, and that I am duly authorized on behalf of Messiah Lifeways,the Petitioner
named in the fore�oin�Petition for Adludication of Incapacity and Appointment of Guardian,to
verify that the sta.tements made therein are true and correct to the best of my knowledge,
information and belief and that these statements are made subject to the penalties of 18 Pa.C.S. �
4904 relatin�to unsworn falsification to authorities.
Date: %' 3 '�G By: �-
Ken Beiler,Administrator
44 t_47(hr l_
' _ � ATTORNEY AT LAW V'
' � , 54 FAST MAW STRCET
MECH.4NICSBURG,PA 17055
' . (717)697-4650 FA7{(717)697-9395
DURABLE POWER OF ATTORNEY
SARAH S.QUIMBY
TO
MARY E.ORSE
� OR
PATRICIA D.SHELTON
NOTICE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DFSIGNATE
(YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO SELL OR OTf�RWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WTTHOUT
ADVANCE NOTICE TO YOU OR APPROVAL BY YOU.
TH75 POWER OF ATTORNEY DOES NOT IMI'OSE A DVTY ON YOUR AGENT TO EXERCISE
GRANTED POWERS,BUT WI�N POWERS ARE EXERCLSED,YOUR AGENT MUST USE DUE CARE TO
ACT FOR YOUR BENEFIT AND IN ACCORDANCE W1TH THIS ppWER OF ATTORNEY.
YOUR AGENT MAY EXERCISE T'F�POWERS GIVEN HERE THROUGHOUT YOUR LIFETIIvIE,
EVEN AN"TER YOU BECOME INCAPACTI'ATED,UNLESS YOU EXPRBSSLY LINIIT THE DURATION OF
Tf�SE POWERS OR YOU REVOKE THFSE POWERS OR A COURT ACTING ON YOUR BEHALF
TERMINATES YOUR AGENT'S AU'1'�iORTTY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGF.NT'S FUNDS.
A COURT CAN TAI�AWAY THE POWEIi�S OF YOUR AGENT IF TI'FINDS YOUR AGENT IS
NOT ACI'ING PROPERLY.
THE 1'OWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXI'LAINED MORE FULLY IN 20 PA.G.S.CH.56.
IF TI�RE LS ANYTHIIVG ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU
SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN TI'TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.
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Date SARAH S.QLJIIvIBY (PrincipaI)
I, SARAH S.QUIMBY,of Cumberiand County,Pennsylvania,do hereby appoint
my daughter, MARY E. ORSE, or she is unable or unwilling to act in that capacity, I
appoint PATRICIA D. SHELTON as my agent ("my agent") with full power of
substitution,for me and in my name, to transact all my business and to manage all my
property and affairs as I might do if personally present, including but not limited to
exercising the following powers:
Durable Power of Attorney
This power of attorney shall not be affected by my subsequent disability or
incapacity. All acts done by my agent pursuant to this power during any period of my
disability or incapacity shall have the same effect and enure to my benefit and bind me
and my successors in interest as if I were competent and not disabled.
_ _ _ _
Management of Assets
1. Cash Accounts:
To collect and receive any money and assets to which I may be entitled;to
deposit cash and checks in any of my accounts; to endorse for deposit, transfer or
collection,in my name and for my account any checks payable to my order;and to draw
and sign checks for me and in my name,including any accounts opened by my agent in
my name at any bank or banks,savings society or elsewhere;and to receive and apply the
proceeds of such checks as my agent deems best; and to act as my representative payee
for all Social Security,Medicare,and other federal and state benefits.
2. Stocks and Bonds:
To take custody of my stocks,bonds and other investments of all kinds,to
give orders for the sale,surrender or exchange of any such investments and to receive the
proceeds therefrom; to sign and deliver assignments, stock and bond powers and other
documents required for any such sale,assignment,surrender or exchange;to give orders
for the purchase of stocks,bonds and other investments of any kind and to settle for same;
to give instructions as to the registration thereof and the mailing of dividends and
interest;to clip and deposit coupons attached to any coupon bonds,whether now owned
by me or hereafter acquired;to represent me at shareholders' meetings and vote proxies
on my behalf;and generally to handle and manage my investments.
3. Personal Property:
To buy or sell at public or private sale for cash or credit or by any other means
whatsoever;to acquire,dispose of,repair,alter or manage my tangible personal property
or any interests therein.
4. Real Estate:
To lease,sell,release,convey,extinguish or mortgage any interest in any real estate
I own on such terms as my agent deems advisable,and to purchase or otherwise acquire
any interest in and acquire possession of real property and to accept all deeds for such
property; and to manage, repair, improve, maintain, restore, build, or develop any real
property in which I now have or may later acquire an interest.
5. Safe Deposit Boxes:
To have access to any and all safe deposit boxes now or hereafter standing in my
name;and add to and to remove all or any part of the contents thereof;and to enter into
leases for such safe deposit boxes or surrender same.
6. Insurance:
To procure,change,carry or cancel insurance of such kind in such amounts against
any and all risks affecting property or persons against liability, damage or claim of any
sort.
7. Benefit Plans:
To apply for and receive any government, insurance and retirement benefits to
which I may be entitled and to exercise any right to elect benefits or payment option
8. Taxes:
To prepare,execute and file in my name and on my behalf any taac returns such as
Internal Revenue Service forms numbered 1 through 10,000, including return, report,
� protest,application for correction of assessed valuation of real or other property or claim
for refund in any connection with any tax imposed by any government and to obtain an
extension of time for any of the foregoing or to execute waivers of restrictions on the
assessment of deficiency on any tax.
9. Employment of Others:
To employ lawyers, investment counsel, accountants, custodians, physicians,
dentists,nurses,therapists,and other persons to render services for,or to me,or my estate
and to pay the usual and reasonable fees and compensation of such persons for their
services.
10. Claims:
To institute,prosecute,defend,compromise or otherwise dispose of and to appear
for me in any proceedings at law or in equity.
11. Medical Procedures:
To arrange for and consent to or to withhold medical, therapeutical and surgical
procedures for me,including the administration of drugs.
12. Admission Into Facilities:
To apply for my admission into medical, nursing, residential, rehabilitation,
convalescent or other similar facilities on my behalf,and to sign any consent or admission
forms required by such facilities which are consistent with this power, and to enter into
agreements for my care by such facilities or elsewhere during my lifetime or for lesser
periods of time as my agent may designate,including the retention of nurses for my care.
13. General Authority:
To do all other things which my agent shall deem necessary and proper in order to
cany out the foregoing powers which shall be construed as broadly as possible.
14. Reliance on Power:
This power may be accepted and relied upon by anyone to whom it is presented
until such person either receives written notice of revocation by me or a guardian or
similar fiduciary of my estate or has actual knowledge of my death.
15. Hold Harmless:
All actions of my agent shall bind me and my heirs, distributees, legal
representatives,successors and assigns,and for the purpose of inducing anyone to act in
accordance with the powers I have granted herein,I hereby represent,warrant and agree
that if this power of attorney is terminated or amended for any reason, I and my heirs,
distributees,legal representatives, successors and assigns will hold such party or parties
harmless from any loss suffered or liability incurred by such party or parties while acting
in accordance with this power prior to that party's receipt of written notice of any such
ternunation or amendment.
16. Pennsylvania Law Governs:
Questions pertaining to the validity, construction and powers created under this
instrument shall be detexmined in accordance with the laws of the Commonwealth of
Pennsylvania.
' I have signed this power of attorney this 1�� '�' day of - � , 2006.
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SARAH S.QUIMBY (Principal)
COMMONWEALTH OF PENNSYLVANIA .
ss.
COUNTY OF CUMBERLAND
On this ��r��-- day of -_✓���'�• ,2006,personally appeared before
me, a Notary Public in and for the said county and state, the above-named SARAH S.
QUIMBY,who acknowledged the foregoing power of attorney to be her act and deed and
desires the power of attorney might be recorded according to law.
I have signed my name and affixed my seal.
�� � J ,,�` ,�'�� .�
Notary Public Common ealth of Penns Ivani
NOTARIAL SEAL
DEBOR,4H L.RYAN,Notary Public
Mechanicsburg Boro.,County of Cumberland
My Commission Expires June 11,2010
AGENT'S ACKNOWLEDGEMENT
I, MARY E.ORSE and PATRICIA D.SHELTON,have read the attached power of
attorney and am the person identified as the agent for the principal. I hereby
acknowledge that in the absence of a specific provision to the contrary in the power of
attorney or in 20 Pa.C.S.when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions,receipts and disbursements on
behalf of the principal.
Date MARY E.ORSE (Agent)
Date PATRICIA D.SHELTON (Agent)
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN THE MATTER OF .
SARAH QUIMBY, :
An Alleged Incapacitated Person . No.
CONSENT OF THE PROPOSED GUARDIAN OF THE PERSON AND ESTATE
I, Constance Stoneroad, on behalf of Keystone Guardianship Services ("Keystone"), do
hereby consent to the appointment of Keystone Guardianship Services as the Plenary Guardian
of the Person and Estate of Sarah Quimby, an alleged incapacitated person, if so appointed by the
Court.
I understand that if Keystone is appointed as guardian, Keystone will be serving for the
benefit of Sarah Quimby, an alleged incapacitated person, and I affirm that Keystone will act in
her best interests at all times.
I further understand that if Keystone is appointed as Guardian of the Estate, it is
accepting fiduciary responsibility for the financial affairs of Sarah Quimby, an alleged
incapacitated person, and will be required to report to the Orphans' Court Division with regard to
these financial affairs and personal affairs on an annual basis.
I certify that neither I nor Keystone is a fiduciary of any estate in which Sarah Quimby
has an interest. I certify that neither I nor Keystone has an interest which is adverse to Sarah
Quimby.
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Date eystone Guardianship Services
Constance E. Stoneroad, President