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HomeMy WebLinkAbout05-2312IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, CIVIL ACTION - LAW CAUSE NUMBER: XO?;-23P V. DAVID WALKER 1700 Market Street Camp Hill, PA 17011 Defendant 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 (20) days after the 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 Plaintiffs. 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. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 Le had demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente dias de plazo al particular de la fecha de la demanda y l a notificication. Hace falta ascentar una comparencia escrita o en persona o con abogado y entregar a la corte en forma escrita sus defenses o sus objeciones a las demandas en contra de so persona. Se adviso que si usted no tiene defiende, la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso o notificacion. Ademas, la coorte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisiones de esta demanda. Usted puede perder dinero o sus propiedades y otros direchos importantes para usted. LLEVE ESTA DEMANDA A SU ABOGADO IMMEDIATAMENTE, SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 2 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, CIVIL ACTION - LAW CAUSE NUMBER: V, DAVID WALKER 1700 Market Street Camp Hill, PA 17011 Defendant COMPLAINT AND NOW, comes Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center, by and through their attorneys, Donald R. Reavey, Esquire and Michael B. Volk, Esquire, of the law firm Capozzi & Associates, P.C., and in support thereof, respectfully shows the Court as follows: 1. Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center (hereafter, "Plaintiff'), operates a long-term care nursing facility located at 745 Chiques Hill Road, Columbia, PA 17512. 2. Plaintiff is licensed to participate in the Medicaid and Medicare programs. 3. Defendant David Walker is an adult individual currently residing at the Susquehanna Nursing and Rehabilitation Center, 745 Chiques Hill Road, Columbia, PA 17512. Service of Process may be had upon him at that address. 4. On or about May 14, 2004, Defendant David Walker requested that Plaintiff admit him to Plaintiff s facility so he could receive nursing care and services. 3 On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the facility to receive nursing care and services. 6. At he time of the filing of this Complaint, Defendant continues to reside at Plaintiff s facility. At all times relevant to this action, the nursing care and services rendered have met all applicable federal, state and local standards of care. 8. On or about May 14, 2004, Plaintiff represented a promise to provide nursing care and services to Defendant David Walker. Simultaneously, David Walker, in requesting admission, represented a promise to pay Plaintiff for the nursing care and services. 9. A true and correct copy of the written contract by and between Plaintiff and Defendant David Walker is attached as Exhibit "1" and is hereby incorporated by reference. 10. Defendant David Walker's average monthly expenses incurred at Plaintiffs nursing facility exceed $3,000.00 (three thousand dollars). 11. Defendant David Walker's reasonable monthly living expenses incurred at Plaintiffs facility significantly exceed his monthly income and are insufficient to adequately provide for his care, maintenance, and support. 12. Due to the refusal of Defendant to remit payment in full each month for the nursing care and services rendered, his account is currently in arrears in the amount of $11,882.29. 13. Defendant David had a contractual, legal obligation to the facility to render payment for nursing service received by him. COUNT 1- BREACH OF CONTRACT 14. Plaintiff hereby incorporates paragraphs 1 through 13 of this Complaint as if set-forth at length herein. 15. As more fully described herein, on or about May 14, 2004, Defendant made application for his admission into Plaintiff's facility for the provision of nursing care and services. 16. Plaintiff is entitled to compensation for the health care services rendered to Defendant David Walker. 17. As such, Defendant David Walker is responsible for the outstanding balance owed to Plaintiff for nursing care services. 18. Plaintiff has demanded payment from Defendant David, but Defendant David Walker has refused and continues to refuse payment in breach of the Agreement. 19. Plaintiff has been damaged by the failure of Defendant David Walker to pay for the nursing care and services that Plaintiff rendered to Defendant David Walker. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff in the amount of at least $11,88299, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action as provided for in the Resident Agreement, and; C. Granting such other relief as the Court deems appropriate. COUNT 2-BREACH OF IMPLIED CONTRACT 20. Plaintiff hereby incorporates paragraphs 1 through 19 of this Complaint as if set forth at length herein. 21. Pursuant to Rule 1020(a) of the Pennsylvania Rules of Civil Procedure, Plaintiff hereby pleads the following alternative theory of recovery. 22. On or about May 14, 2004, Defendant David Walker agreed to pay Plaintiff in exchange for his admission into Plaintiffs nursing facility and the subsequent provision of nursing care and services to him. 23. On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the nursing facility and began rendering nursing care and services to him. 24. The facts, as set forth above, establish an implied-in-law and an implied-in- fact contract. 25. Due to the existence of the implied-in-law and implied-in-fact contract, the Plaintiff is entitled to compensation for the health care services rendered to Defendant David Walker. 26. Plaintiff has demanded payment from Defendant David Walker under the terms of the implied-in-fact and implied-in-law contract, but Defendant David Walker has refused to make payment. 27. The Plaintiff has been damaged by the refusal of Defendant David Walker to pay for the nursing care and services rendered, in breach of the implied-in-law and implied-in-fact contract. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff in the amount of at least $11,882.99 plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, as provided for in the Resident Agreement, and; C. Granting such other relief as the Court deems appropriate. COUNT 3-QUANTUM MERUIT 28. Plaintiff hereby incorporates paragraphs I through 27 of this Complaint as if set forth at length herein. 29. Pursuant to Rule 1020(a) of the Pennsylvania Rules of Civil Procedure, Plaintiff hereby pleads the following alternative theory of recovery. 30. As more fully described herein, Plaintiff's expectation of payment in exchange for rendering the nursing care and services to Defendant David Walker was reasonable. 31. Plaintiff, in rendering the nursing care and services to Defendant David Walker has conferred a substantial benefit upon him. 32. Defendant David Walker retained the benefit of the bargain with the Plaintiff for the provision of nursing care and services and has not conferred a similar benefit in return upon the Plaintiff; Defendant David Walker has been unjustly enriched at the expense of Plaintiff. 33. Due to the Defendant David Walker's unjust enrichment, Plaintiff is entitled to proper compensation for the services rendered to Defendant David Walker. 34. Defendant David Walker's unjust enrichment at Plaintiffs expense has damaged the Plaintiff. 7 35, Plaintiff has demanded payment from Defendant David but Defendant David Walker has refused payment. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff in the amount of at least $11,882.99, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees, as provided for in the Resident Agreement, and; C. Granting such other relief as the Court deems appropriate. Respectfully submitted, Date: 1 f 64 CAPOZZI AND ASSOCIATES, P.C. By .1 R. Reavey, Esquire Y I.D. # 82498 Michael B. Volk, Esquire Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, CIVIL ACTION - LAW CAUSE NUMBER: V. DAVID WALKER 1700 Market Street Camp Hill, PA 17011 Defendant VERIFICATION I, Michael B. Volk, Esquire, do hereby verify that the facts made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. This verification is being made as no and other representative of the Plaintiff is available and time is of the essence. Counsel will substitute a verification of an authorized representative of Plaintiff as soon as it becomes available. 1 understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unsworn falsification to auth i 'es B. Volk, Esquire I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff 04127/2005 07:35 410-529-4539 QUAIL RUN PAGE 12 SUMMARY OF ADVANCE DIRECTIVE Policy and Practice Facility: ' (Hereafter known as "FACILITYY") Resident: (Hereafter known as "RESIDENT") FACILITY will make note in RESIDENT's chart whether or not an Advance Directive has been executed concerning bare:' Also, a copy of the Advance Directive will be kept in the RESIDENT's chart. The RESIDENT is strongly urged to make the attending physician aware of the Advance Directive since all care provided while residing at the FACILITY is directed by the attending physician and the physician must incorporate the RESSIDENT's wishes into the care plan. RESIDENT will not be subject to any discriminatory treatment at the FACILITY based on whether or not an Advance Directive has been executed. An "Advance Directive" is any written document, including Living Wills or Durable Powers of Attorney, which deals with health care;treatment, or other written evidence of desires to accept or refuse certain medical treatment: Iri Pe4tnsylvania.there is a specific statute.which authorizes speck forms or creates specific responsibilities of physicians or health care providers in relation to Living Wills or Advance Directives.and Durable Powers of Attorney. Please remember that all cane given in a nursing home is provided under a physician approved Plan of Care. It is strongly advised that any Advance Directive be discussed with the attending physician. Residen Signature (Or Power of Attorney or Legal Guardian) Acknowledged by: lAiii?AgOfficey f 5 N-e Date BillinelAtlm Pk0SUMJn0rv of Adv Directive 10 At 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 13 RESPONSIBILITY FOR RETENTION OF CASH, JEWELRY AND VALUABLES Facility Resident Date 3-:V V- 6 7 I have been advised by the management not to keep cash, jewelry and other valuables in my possession while a Resident in this facility. Notwithstanding this advice, I wish to retain the :Following items in my possession- I agree to indemnify, defend, and hold harmless Facility, its successors, assigns, members, directors, officers, employees and agents from any and all losses, costs and expenses of any nature related to the above listed items and any items that maybe brought to me while residing in-this facility, Date Date Signature of Legal Representative Date eillvg,.adm PORelease ofResp Cnsh lewnlrv M.Dd 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 14 RESIDENT TRUST ACCOUNT AUTHORIZATION Resident: Resident Number- F] Authorize Do Not Authorize The facility is to place funds into the Resident Trust Account for safekeeping. I understand that I may use these funds at my discretion. If I am a Medical Assistance Resident, I may only take $30.00 per month unless additional personal deposits are made to my account. • 1 may withdraw funds during regular business office hours. Any request over $50.00 will be given by check. • For requests less than 550.00; the facility will use its best efforts to honor the request; however, it will depend on cash availability on the premises at the time the request is made. For check requests, funds will be provided by the next business day. • A quarterly statement will be issued to insure the accuracy of all transactions. • Accounts over $50.00 will be credited with interest monthly.' Le epresentative Date QillintlAdm PktlRcs Tmst A=t Aulh. 10.01 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 15 ACKNOWLEDGMENT Name of Resident: rl??-'{ (,t (_zlb.Cl pv -. SSN. ? I acknowledge receipt of The Wilmac Corporation's Notice of Privacy Practices, delivered to me this jy_ day of MU ? ^G- Date . Resident TFlame Date FOR INTERNAT. USE ONLY: T Name of.Responsible Person, if Resident unable to sign If unable to obtain a written Acknowledgement from (Name of Resident] or (Name of Responsible Person], please indicate the reason for the failure below- Resident or Responsible Petson refuses to sign this Acknowledgment Other (please discuss more fully below) 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 16 THE WILMAC CORPORATION OPPORTUNITY TO AGREE OR OBJECT FORM As outlined in The Wilmac Corporation's ("Wilmac") Notice of Privacy Practices, Wilmac may use or disclose my protected health information for the following purposes, absent my objections: Inclusion within the Facility Directory To Friends and Family Members upon their inquiry . To' Clergy Accordingly, to make my intentions clear regarding the above, I am executing this Form. r Facility Directory (check only one) I OBJECT to the use of my protected health mfortiration in the Facility Directory DO NOT OBJECT to the use of my protected health information in the Facility. Directory I DO NOT OBJECT to the use of some of my protected health information in the Facility Directory . However, ..I have checked below the information that.I DO NOT want included in the Facility Directory (check all that apply): My Name,. - My location in the facility - My health condition described in general terms that does not communicate any specific health information My religious affiliation I DO NOT OBJECT to the posting of the Facility Directory (containing some of my protected health information) in a publicly viewed area. 3, Family and Friends 1 OBJECT to the disclosure of my protected health information to my family and friends who make specific inquiries about me, (if checked, proceed to 93) 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 17 I DO NOT OBJECT to the disclosure of my protected health information to my family and friends who make specific inquiries about me. (if checked, proceed to #3) I DO NOT OBJECT to the disclosure of my protected health information to most of my family and friends who make specific inquiries about me. However, I DO NOT AGREE to the disclosure of my protected health information to the following individuals: (if checked, be sure to also read the following) I DO NOT OBJECT to the disclosure of some of my protected health information to my family and friends who make specific inquiries about me. However, I DO-NOT AGREE to the disclosure of the following protected heA th-information to those individual's.`` 3. Clergy I OBJECT to the disclosure ofmy protected health information to members of the clergy who make specific inquiries about.me. (if. checked, proceed to #4) I DO NOT OBJECT to the disclosure of any of my protected health information to members of the clergy who make "specific inquiries about me. (if checked, proceed to #4) I DO NOT OBJECT to the disclosure of my protected health information to most members of the clergy who make specific inquiries about me. However, I DO NOT AGRBIwto. the-disclosure of.my protected health information to the following individuals: (if checked, be sure to also read the ee:vt option) 76977 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 16 I DO NOT OBJECT to the disclosure of some of my protected health information to members of the clergy who make specific inquiries about me, However, I DO NOT AGREE to the disclosure of the following protected health information to those individuals: 4. Disaster Relief _ T OBJECT to the disclosure of my protected health information for purposes of assisting in disaster relief. (if checked, proceed to signature line) I DO NOT Oi JECT to the disclosure of my,protected health information for purposes of assisting in'disaster relief (if, c}?ecked; proceed to si?natnre lame) ^ I DO NOT OBJECT to the.disclosura of my protected health information for purposes of assisting in disaster relief However, I DO NOT AGREE . to the disclosure of my protected health information-to the following individuals: (if checke(= be sure to also read the next option). I DO. NOT OBJECT to the disclosure of some of my protected health information for purposes of assistingin disaster relief. However, I DO NOT AGREE to the disclosure of the following protected health information'tb those individuals: ig arure of Resident or Resident's Authorized Representative if signed by Resident's Authorized Representative, please print name and describe relationship: Name Relationship i ,esident 7 697% 3 04/2712005 07:35 410-529-4539 QUAIL RUN PATIENT NAMES PAGE 20 I acknowledge receipt of the Brockie Healthcare Incorporated HIPAA "Notice of Privacy Practices." I will authorize disclosure of Protected Health Information to only: NAME RELATION 1-' Vo 5 WL. km - U Use space below if you vdsh to add other names. Date: 'v d Authorization if other than patient and/or patient unable to sign: 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 24 I. RESIDENT AGREEMENT A. Name of Facility _ (Hereafter referred to in alladmission agreement documents.) B. Name of Resident --Q? (Hereafter referred to as Address in all admission agreement /i24'11 n d? c.( , Aq 1-7D l / C. Name of Legal Representative (Hereafter referred to as LEGAL REPRESENTATIVE in c I admission agreement documents. Legal Representative trust have legal standing to act on behalf of the resident.) Address / oe lvo INS/ V JTa Telephone Capacity of Representative I `gyp (Power ofAttorney, Guardian, Parent. of Minor) Copy of applicable'Power of Attorney or court order on which representative authority is based must be attached to this document. (1) 1 certify as the Legal Representative for Resident, I have legal access to Resident's income and resources available to pay_fot,care in Facility and I agree that I shall provide payment from Resident's income and resources for such care, I shall apply Resident's income and resources to the lawful and proper- costs and charges incurred during Resident's stay unless and until such costs are paid bypovate insurance or other benefits such as Medicare, Veterans' Health Insuraiice or Medical Assistance, When the Resident's financial resources warrantit, I shall take all actions necessary or appropriate to make application for Medical Assistance benefits on behalf of the Resident and shall exercise diligent efforts to provide all of the information required in the application process and thereafter to assure continued benefits. I understand that if I fulfill my obligations under this paragraph, I shall not be held personally.financially liable for the resident's care. I further understand, however, that if I do not fulfill my obligations underthis paragraph; or under the other paragraphs of this of this Agreement, I will be liable to the Facility-for whatever losses the Facility' sustains as a result of my breach of this Agreement. . • , . (3) The information provided is true and correct to the best of my knowledge, information and belief. 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 25 (3) 1 have received a copy of the Resident Agreement and agree to be bound by the terms and conditions contained therein. D. I desire admission to FACILITY E. The information set forth on the Admission record is true and correct to the best of my knowledge, information and belief. F. I have received a copy of the Resident Agreement and agree to be bound by the . terms and conditions contained therein. G. I have reviewed and indicated the optional contract services to be provided. H. I have reviewed the section of the Admissions Contract entitled "Other Information" and understand the information set forth therein. L Current daily rate: (NOTE: These are subject to change:) Daily rate`$ r/0' - J. MANDATORY ARBITRATION (1) Contractual and/or Property'Damage Disputes. ''Anycontroversy, dispute, Disagreement or claim df any kind or nature, arising from, or relating.to this Agreement,: or concerning any rights arising from or relating to an alleged breach of this Agr'eemetit,=with the excepti0n'of guardianship, proceedings resulting from the alleged incapacity of the Resident and with the further exception of amounts in controversy of less than Eight Thousand Dollars ($8,000), shall be settled exclusfvely by arbitration. This means that the Resident will not be able to file a lawsuit in any court to resolve any disputes or claims that the Resident may have against the Facility. It also means that the Resident is relinquishing or giving up all rights that the Resident may have to a jury trial to resolve any disputes or claims against the Facility. This provision is not inclusive of the facility's ability to file civil law suits in the appropriate county in which the Resident/Debtor resides, or to recover payment for outstanding billing which is not paid by the Resident and/or responsible party. The facility may elect not to utilize the American Arbitration Association in attempting to recover outstanding billing invoices for residential health care. The Arbitration shall be administered by the American Arbitration Association in accordance with the American Arbitration Association's Comimietciil Arbitration Rules and judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Responsible Person' acknowledge(s) and understand(s) that there will be no, jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible' Person relinquish and give up their tights to a jury trial on any matter submitted to arbitration under this Agreement. (2) Personal Injury or Medical Malpractice. Any claim that the Resident may have against the Facility for anypersonal injuries sustained'bythe Resident arising 2 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 26 from or relating to any alleged medical malpractice, inadequate care, or any other cause or reason while residing in the Facility, shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to bring any claims that the Resident may have against the Facility for personal injuries incurred while residing in the Facility. It also means that the Resident is relinquishipg or giving up all tights that the Resident may have to a jury trial to litigate any claims for damages or losses allegedly incurred as a result of personal injuries sustained while residing in the Facility. The Arbitration shall be administered by the American Arbitration Association in accordance with the American Arb,(tratiop Association's Health Care Claims Settlement Procedures, and Judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up the Resident's right to ajury trial on any claims for damages arising from personal injuries to the Resident which are submitted to arbitration under this Agreement. (3) Right to Legal Counsel. Resident has the right'to be represented by legal counsel in any proceedings initiated under this arbitration provision: Because this arbitration provisioiiaddresses important legal rights, Facility encourages and recommends that Resident obtain the advice and 9ssigtance of legal counsel to review the legal sigeificance of this'ma' ndatoryarbitratjon provision prior to signing-this Agreeffietit (4) Location ofArbittation. ' The Arbittation1will be conducted at a site selected by the Facility, which shall be at the Facility, or at a sitte.within a reasonable distance of the Facility.` (5) Time Limitation forArbitration.' Any request for arbitration of a dispute must be requested and submitted to the American Arbitration Association prior to the lapse of two (Z) years from the date on which the event giving rise to the dispute occurred. The failure to submit a request for Arbitration to the American Arbitration Association within the designated time shall operate as a bar to any subsequent reques@for Arbitration, or for any claim for relief or a remedy, or to any action or legal proceeding of any kind or nature;' and the parties will be forever barred from arbitrating or litigating a resolution to any such dispute. 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 27 K. This Resident Agreement, together with the Disclosures Requiting Signatures, Summary of Services, Contract Terms and Other Information contained in the admission agreement and which are incorporated by reference as part of this Resident Agreement, constitutes the entire agreement between the parties, with respect to the subject matter hereof and supersedes, merges and replaces aU prior negotiations, offers, representations, warranties and agreements with respect to such subject matter, I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS ADMITTANCE AGREEMENT, THAT I HAVE READ TIM PROVISIONS OF THIS AGREEMENT, AND THAT I HEREBY AGREE TO BE BOUND BY ALL OF ITS PROVISIONS. IN WITNESS WHEREOF , intending to be legally bound thereby we have set our hands and seal this L?day of 20 G Y Witness $ T Witness LEGAL REPRESENTATIVE Witness S Member If the RESIDENT is unable to sign, state the reason: If this Agreement is signed by a Power.of Attorney, attach a copy of the Power of Attorney. If this Agreement is signed by a Legal Guardian, attach a copy of the Court Order. 4 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 29 BED HOLD POLICY 1) Private Pay or Medicare Residents. If Resident leaves Facility for a period of hospitalization, therapeutic leave, or any other reason except death and is not receiving Medical Assistance, the Facility will hold the bed and contact the responsible person within 48 hours to determine if we are to continue to hold the bed. if we are to continue to hold the bed, the Resident will be charged the Current Room and board Rate while out of the Facility Or until the Facility is told to no longer hold the bed. If the Resident decides not to have the bed reserved and later desires to be readmitted to the Facility, that readmission will be dependent upon the availability of an appropriate bed. 2) Medical Assistance Residents. If Resident is eligible for, or is receiving Medical Assistance benefits, and Resident leaves Facility for a period of hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable maximum number of days, paid for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation period may be subject to change in accordance with any changes in the Pennsylvania Medical Assistance Program. If the period of hospitalization or therapeutic leave exceeds th'e'maxihium tithe for reservation of abed under the Pennsylvania Medical A'ssi., , , e,Proarram; l -1 stdenf will be.entitled to the . first available accommodation sui`fable for Re'sideri' at the time of readmission, if Resldent 'requires the services provided liy the Facility. Alternatively, fbllowing`the lapse of the'bed reservation period covered by the Medical Assistance Program. Resident may reserve ebed by. electing to. pay the Medical'Assistance per diem rate charged immediately prior to the leave, and by providing written notice and advancA'payment for the days included in the reservation period. 6 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 28 II. DISCLOSURES REQUIRING SIGNATURES A. MEDICARE CATASTROPHIC COVERAGE ACT Section 303(a) of the Medicare Catastrophic Coverage Act of 1988 (MCCA), known as the Spousal hnpoverishment Provisions, provides for the protection of a couple's income and resources within specified limits in the event one of them needs nursing facility care. FACILITY may direct RESIDENT or RESIDENT'S spouse to the appropriate agency for an assessment of RESIDENT'S total, income and resources. If the spouse in the community does not have income or resources up to the limits established by the state, the law permits the institutionalized spouse to transfer to the community spouse sufficient income and resources to assure protection up to the established limits. The intention of this portion of the law is to permit the spouse remaining in the community to retain a higher level of income and resources than is now permitted. Therefore, the community spouse does not have to live below the poverty level. These requirements are effective September 30, 1989, Witness RESIDENT, Legal Representative 5 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 30 Ill. SUMMARY OF SERVICES A. MEDICAL ASSISTANCE 1. Any resident who is a recipient of Medical Assistance is provided the following items or services as necessary: a. Room and Board b. Incontinent Supplies C, Over the Counter Medication d Nursing Care e. Personal Laundry f. Barber and Beauty care under Medicaid billing guidelines g. Items of Personal Hygiene h. Maintenance Therapy as deemed necessary by resident's physician 2. Resident may kbe charged for personal phone calls, television, personal laundry name tags and placement on clothing. Resident is also responsible for physician's charges. B. MEDICARE 1. Residents who come under Medicare guidelines will be provided the following services iupltisive under the Medicare per diem note. a: Nursing Care'" b. Room and Boar& c: Rehabilitation Therapy as deemed necessary by resident's physician d. Restoiative`Therapy' as deemed hecessary 'by resident's plan of care 2. Resident will ?be responsible for certain charges such as T.V., beauty & barber care, and. personal phone calls. 7 04/27/2005 07:35 410-529-4539 QUAIL RUN IV. CONTRACT TERMS A. MANDATORY CONTRACT PROVISIONS 1. ADMISSION PAGE 31 The FACILITY agrees to admit RESIDENT, an aged or infirm person, and to provide the appropriate level of nursing care. The level of care may change due to physician's orders and state of health of RESIDENT, and RESIDENT hereby recognizes that this level of care will be provided subject to the conditions set forth in paragraphs 7 and 8. 2. PAYMENT a- RESIDENT promises to pay to FACILITY the then current daily rate for the level of care set forth in this Agreement. A deposit equal to the amount of thirty (30) days charges is payable on admission. b. In the event the changes are to be paid by other sources or agencies (e.g., Medicare, Medical Assistance, etc.), RESIDENT agrees to make all riecessary remittance as required by the regulations of said agencies. c.- RESIDENT 'slrall pay promptly -when billed all extra charges including;' buf not limited to, cbarges for drugs, medicines, special nurses; clothing; dociors,Ahem' y and sach'ather supplies and services necessary'and proper for the-health and:comfort.of RESIDENT. d. `The daily rate specified in this Agreement for the level of care is subject to change by FACMITY upon, thirty (30) days written notice to RESIDENT. However, changes in the amount charged to RESIDENT : due to change in the level of care provided to RESIDENT is effective at the time level of came is changed. 1) Following' admission, all billings' shall be made for each calendar month; in`.advance; on the first- day of each month. Billings shall be paid no' later 4harl ten (10) days following transmittal of the billing. All billings unpaid after the last day of the calendar month shall bear interest at the rate of one and one-half percent (1,3%0) per month commencing on the fast day of the following month. 2) If admission occurs more than seven (7) days before the end of the calendar" month, the initial bill shall cover the period from the date of admission to the end of the month, plus the number of 'days in the succeeding calendar month. A credit shall be gNen"for admissions prepaymeiit. 8 .. r -., - 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 32 3) If admission occurs during the last seven (7) days of a calendar month, the initial bill shall include the number of days remaining in the month of admission, plus the number of days in the succeeding calendar month. This bill shall be due and payable by the tenth (10`s) day following transmittal of the bill. 4) RESIDENT agrees to apply for Medical Assistance benefits at such time as his or her income or assets warrant such application. RESIDENT agrees to make application in a timely fashion so the payments shall begin as soon as practical after RESIDENT qualifies for Medical Assistance. RESIDENT, as part of this agreement, further agrees to provide the Department of Public Welfare with all financial, medical and other information necessary or appropriate during the application process, and thereafter as may be required by the Department of Public Welfare for continued benefits. 3 e. All refunds due to a discharged RESIDENT will be remitted to RESIDENT within thirty (30) days of final billing. f. In admitting RESIDENT who intends to pay for his or her own costs of stay, FACILITY is relying on the financial information in the application. Any significant reduction in a RESIDENT'S ability to pay for his or her own care must `be immediately reported to FACILITY, CHANGE IN ACCOMMODATIONS a. The RESIDENT understands that the facility may find it necessary and/or appropriate to change the RESIDENT'S room or roommate during the RESIDENT'S stay at the facility, if this occurs, the facility will provide reasonable notice, to the"RESIDENT in advance of any room or roommate change, unless an emergency requires that an immediate change be made. b. If the-RESIDENT is being admitted to a Medicare area bed. RESIDENT hereby acknowledges that RESIDENT may be asked to be transferred to a different area and service that better meets the RESIDENT'S needs. C. FACILITY acknowledges that changes in accommodations are subject to applicable rules and regulations relating to RESIDENT'S rights, 9 04/27/2005 .07:35 410-529-4539 QUAIL RUN PAGE 33 a. MEDICATIONS AND FOOD RESTRICTIONS a. Medication as prescribed by the attending physician shall be administered only by persons authorized by FACILITY. RESIDENT and Legal Representative consent to any and all medical treatments prescribed by RESIDENT'S attending physician and administered by agents or employees of FACILITY. b. No foodstuffs, liquids, medicines or similar items shall be brought into FACILITY for RESIDENT'S use without permission first having been obtained from the Director of Nursing Services or his/her designee or charge nurse of FACILITY. 5. HOSPITALIZATION Should RESIDENT'S physician recommend hospitalization, FACILITY shall arrange for the trans: fer of RESIDENT to a hospital. Any hospital charges and/or transportation expenses incidental thereto shall be the responsibility of the RESIDENT: 6. LIMITATIONS ON LIABILITY FACILITY shall not be responsible for. RESIDENT while he or she is off premises with-or without its consent. 7. RULES AND REGULATIONS (Exhibit A) RESIDENT agrees to abide by all rules and regulations established in connection with the operation and maintenance of FACILITY as set forth in the Resident Responsibilities: ' FACILITY shall make available to RESIDENT any amendments to all applicable riles and regulations. S. RESIDENT ACCOUNTS Upon request; a, RESIDENT fund will be maintained for RESIDENT. Quarterly accounts are prepared and submitted to RESIDENT or personal representative. Any question regarding said account should be submitted within ten (10) days of receipt of the account. If no question is submitted, the account rendered shall be final within ten (10) days after receipt by RESIDENT (or personal representative). Any questionable account shall become final within ten (10) days after resolution of the question. 9. ATTORNEY FEES In the event it becomes 'necessary for the FACILITY to take legal action to recover any amount owed by RESIDENT under this Agreement. FACILITY shall recover from RESIDENT actual attorney's fees in addition to the 10 04/27/2005 07:35 41,0-529-4539 QUAIL RUN PAGE 34 amount due and payable under the Agreement, costs of collection and any other remedies to which FACILITY is entitled. 10. TERMINATION, TRANSFER OR DISCHARGE (a) Resident Initiated. Resident may terminate this Agreement upon fifteen- (15) days written notice to facility. if Resident leaves Facility for any reason other than a medical emergency or death, Resident must give written notice to Facility at least fifteen (15) days in advance of transfer, discharge or termination of this Agreement. If advance written notice is not given to Facility, there will be due to Facility the applicable Basic Daily Rate and other charges then in effect for Resident's stay and care for the required fifteen (15) day notice period. The charge applies whether or not the Resident remains at Facility during the fifteen- (15) day notice period. The harg'e specified in this section does not apply to a resident whose payor source is Medicare Part A or Medicaid. (b) Facility Initiated. Facility may te'rininate this Agreement and Resident's stay and transfer or discharge Resident if:.,,_ - 1. Transfer or discharge is necessary tofineet Resident's welfare, and Residen't's needs cannot be met in Facility; 2. Resident's" health has.iinproved sufficiently so that Resident no longer needs the services provided by facility 3: The s2fety orheilth of individuals im, facility 'is or otherwise would be endangered 4. Resident has failed, after notice, tc pay Yor (or to have paid or treated as paid under the Medicare or Medicaid Programs) charges for Resident's care and stay at Facility; and 5. Facility ceases to operate (c) Notice and Waiver of Notice. Facility will notify Resident and Responsible -Person (or if none, a family member or legal representative of Resident, if known to Facility) at least thirty (36)`days in advance of transfer or discharge. However, in any case described in Subparagraphs (1), (2) and (3) above Facility will give only such notice before transfer or discharge as a reasonable under the circumstances: 11. PAYMENT AUTHORIZATION (a) Assignment of Payments. Although it is the responsibility of Resident to secure payment from third-party resources, Resident also authorizes Facility to take such actions as it deems necessary to secure for the Facility receipt of third-party payments to reimburse Facility for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment of Facility's charges; Resident hereby assigns to Facility all of 11 04!27/2005 07:35 410-529-4539 QUAIL RUN PAGE 35 Resident's rights to any third-party payments now or subsequently payable to the extent of all charges due under this Agreement. Resident or responsible person promptly shall endorse and turn over to facility any payments received from third parties to the extent necessary to satisfy the charges under this Agreement. 12. RESIDENCY UNDER MEDICAL ASSISTANCE RESIDENT will remain as a resident of FACILITY under Pennsylvania Medical Assistance providing his or her level of care necessitates nursing home care as determined by Pennsylvania's medical evaluation upon application for Medical Assistance. 13. OBLIGATIONS OF RFSIDENT'S ESTATE & ASSIGNMENT OF PROPERTY Resident and itesponsible Person acknowledge the charges for services provided under this Agreement remains dud and payable until fully satisfied. In the event of Resident's discharge for any re"' A; including death, this Agreement shaff operate as'an assignment, transfer and conveyance to facility of so much of Resident's property as is equal in value to the amount of any unpaid obligations under this Agreement. This assignment shall be an obligation ofR.esident's.estite.and maybe enforced against Resident's estate, Resident's estate shall be liable to and shall pay,to Facility an amount equivalent to ,zany unpaid obligations of Resident tirider"this Agreement. 14. DEFAULT A default is' a failure to perform obligations" imposed by the admission agreement documents. If the RESIDENT defaults, in addition to any other rights which the FACILITY has under the admission agreement documents, the FACILITY?she have the right to discharge the RF81JDENT as permitted by -law. If a decision to discharge the RESIDENT is made because of a default under the admissions agreement, the FACILITY will give thirty (30) days written noticelto the RESIDENT and to either a family member or the RESIDENT'S legal representative, if either are known to the FACILITY. 12 0A/27/20e5 07:35 410-529-4539 QUAIL RUN PAGE 36 $, OPTIONAL CONTRACT PROVISIONS I. LAUNDRY FACILITY will provide personal laundry service for the RESIDENT. However, the service does not include ironing. If RESIDENT chooses not to have FACILITY provide laundry service, the legal representative or RESIDENT will be responsible for taking complete charge of the personal laundry of RESIDENT on at least a weekly basis. 10 do ? do not want FACILITY to provide daily laundry service. 2. DENTAL As part of a Wellness Program, FACILITY offers annual dental screening for RESIDENT. The purpose of the screening is to prevent any problems. Dental screenings are- dond' 1' the FACILITY. Should treatment be necessary, the family and attending physician will be contacted. RESIDENT will' be responsible for payment unless RESIDENT is covered by Medical Assistance, in which case the Department of Public Welfare will cover the cost of services: - ' Dental screenings are pbrfbrmed `a i ually by The'approximat6 cosi.fot an annual dental scietining is $ I El do ? do notwatrt to participate in the Dental Screening Prograrn. 3. PODIATRY Should podiatric medical seiices be required during the time I reside in FACILI'T'Y, I request that payment of authorized Medicare benefits be made on my behalf tdhe podiatrist i'ir physician named below for any services rendered. Podiatrist 10 do ? do not grant the above authorization for podiatric medical services. 4. 1 also understand that some services might not be considered necessary under Medicare guidelines, yet l still choose to accept these services since my Doctor is the one treating my condition, not Medicare. 1, also accept responsibility for payment of these services, even though Medicare may not. 5. I authorize the physician named to collect assignment on my behalf and also authorize the release of medical records and information to the Health Care Financing Administration, Medicare, and it's agent's. Any information needed to determine these benefits, or benefits payable for related services, may also be released. 13 Q4/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 37 6. I appoint the Legal Representative named in the Resident Agreement to act as my representative in the connection with my claim or Asserted right under Title 3VIII (Medicare Coverage). 7. I authorize the Legal Representative to make or give any request or notice, to present or elicit evidence to obtain information and to receive any notice in connection with my pending claim or asserted right wholly in my stead. 8. POWER OF ATTORNEY I ? have ? have not signed a Power of Attorney. (If so, a copy of the Power of Attorney should be attached to the Resident's Admission Contract). 9. TELEVISION 11:1 do ? do not wish to have television service in my room. 10. 'T'ELEPHONE' 1 0 do ? do not wish to have telephone service in.my room. 14 Q4/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 38 V_ OTHER INFORMATION A. B C. NON-DISCRIMINATION POLICY It is the policy of FACILITY to admit and treat all RESIDENTS without regard to race, color, national origin, sex, age, religious affiliation or handicap. All accommodations at FACILITY are available without distinction to all RESIDENTS and their visitors. There is no distinction in the eligibility for or in the manner of providing any patient service provided by FACILITY. In accordance with applicable Federal and State civil rights law and regulatory requirements, this FACILITY has agreed to comply with the provisions of the Federal Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, the Pennsylvania Human Relations Act, (43 P.S. & 951), and the Buildings and Facilities Accessibility Standards (7'1 P.S. 1455.1), and all requirements imposed pursuant thereto. No person shall, on the grounds of race, color, national origin, ancestry,- age, sex, religious creed or handicap or disability, be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination in, the provision of any cafe'orservice. If you feel' you have 'been discrimWated'against on the basis of your race, color, religious''nreed, `hanticap,° atlcestry, national origin, age'or sex, a complaint of discrirruinatim may be filed with any `of the:, following' ;Aepartment of Health, Bureau of, (Nality Aarsurahce, bivigitm"`of Ldng-Teint " Care, or Office of Civil Rights, U.S. Departmel t ofHeiilth and Human Services, Region III, PO Box 13716, Philadelphia, Pennsylvania 19101, or any other Human Rights agency having jurisdiction. RIGHTS OF RESIDENTS The patient shall be encouraged and assisted throughout the period of stay to exercise his rights as a patient and as a" citizen and may voice grievances and recommend changes in policies and services to the facility staff (toll free 1-888-710-3284) or to outside representatives -of his or her choice. The RESIDENT or RESIDENT'S responsible person shall be made aware of the Governor's Action line (toll free 1-800-932-0784) and the Department's Hot Line (1-800-692-7254) and the telephone number of the long Term Care Ombudsman Program located within the Local Area Agency on Aging, and the local Legal''Services Program to which the patient may address grievances. A facility is required to post the ombudsman poster in a prominent location. ACKNOWLEDGEMENTS 1) ROOM RATE SCHEDULE. Resident and Responsible Person acknowledge the receipt of a copy of the Room Rate Schedule and the opportunity to ask questions about Facility's charges: 15 Q4/27/2005 07:35 .. 410-529-4539 QUAIL RUN PAGE 39 2) RESIDENT RIGHTS. Resident and Responsible Person Acknowledge being informed orally and-in writing of Resident's Rights as specified in the current publication required by law and further acknowledge having an opportunity to ask questions about those rights. The Notice of Rights of Nursing Facility Residents (MA-401) is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on Facility or granting any contractual rights to Resident. 3) ADVANCE DIRECTIVES. Resident and Responsible Person acknowledge being informed, orally and in writing, of Facility's policy on advance directives and medical treatment decisions. 4) AGREEMENT. Resident and Responsible Person acknowledge that they have read- and understand the terms;.of;.;this Agreement, that the terms have be explained to them by a representative of Facility, and that they have an oppornnity to ask, questions about this Agreement. 5) RESIDENT HANDBOOK. Resident and'Respon$ible Person acknowledge the receipt of a copy' of the Resident handbook and the c?pportuzity to ask questions about. Facility's `policies contai led ih the Resident Haindbook. The Resident handbook is subject to change`from time-to-time and shall not be construed as imposing` any contractual obligations' on Facility- or'granting any contractual rights to Resident. 16 ? r v SHERIFF'S RETURN - NOT FOUND CASE NO: 2005-02312 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SUSQUEHANNA VALLEY NURSING AND VS WALKER DAVID R. Thomas Kline Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT WALKER DAVID but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , the within named DEFENDANT NOT FOUND , as to , WALKER DAVID 1700 MARKET STREET CAMP HILL, PA 17011 PER NURSING HOME, DEFENDANT MOVED OUT A YEAR AGO. THEY BELIEVE HE IS OUT OF STATE. Sheriff's Costs: Docketing 18.00 Service 11.10 Not Found 5.00 Surcharge 10.00 Postage .37 44.47 So answers: R. Thomas Kline Sheriff of Cumberland County CAPOZZI & ASSOCIATES 05/10/2005 Sworn and subscribed to before me this day of ?2tr , ?(L^S A.D. Prot otary '` SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-02312 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SUSQUEHANNA VALLEY NURSING AND VS WALKER DAVID Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: WALKER DAVID but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of LANCASTER serve the within COMPLAINT & NOTICE County, Pennsylvania, to On June 9th , 2005 , this office was in receipt of the attached return from LANCASTER Sheriff's Costs: So ans Docketing 6.00 Out of County 9.00 Surcharge 10.00 R. Thomas K4 6e Dep Lancaster Cc 45.41 Sheriff of Cumberland County Postage .37 70.78 06/09/2005 CAPOZZI & ASSOCIATES Sworn and subscribed to before me this day of l? dos A.D. u.H,u..- 4. XLC /lXa? -T' Prothonotary ' ` SHERIFF'S OFFICE 50 NORTH DUKE STREET, P.O. BOX 83480, LANCASTER, PENNSYLVANIA 17608-3480 e (717) 299-8200 n SHERIFF SERVICE PLEASE TYPE OR PRINT LEGIBLY. PROCESS RECEIPT, and AFFIDAVIT OF RETURN DO NOT DETACH ANY COPIES. I. PLAINTIFF/S/ Susquehanna Valley Nursing & Rehabilitation Center 2 COURT NUMBER 05-2312 civil en 3 DEFENDANT/S/ 4 TYPE OF WRIT OR COMPLAINT Notice and Complaint David Walker SERVE 5 NAME OF INDIVIDUAL. COMPANY. CORPORATION, ETC. TO BE SERVED David Walker 6 ADDRESS (Street or RFD. Apartment No., City, Boro, Twp_ Stale and ZIP Code) AT 745 Chiques Hill Road Colurnbia, PA 17512 (plaintiff's address) 7. INDICATE UNUSUAL SERVICE: 0 DEPUTIZE 0 OTHER C) 3mber 1 and Now, -may 20 I, SHERIFF OFD COUNTY, PA., do here,,py c?putlze the SW f Lancaster County to execute this Wnt afa#?94e(rS{ylr lryeceof Mpg pa This deputation being made at the request and risk of the plaintiff. to law ' E . n6F OF rakBebse COUNTY SR B. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: Cumberland Please mail return of service to Cumberland County Sheriff. Thank you. NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN -Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the pad of such deputy or the sheriff to any plaintiff herein for any loss, destruction or removal of any such property before sheriff's safe thereof S. SIGNATURE of ATTORNEY or other ORIGINATOR 10. TELEPHONE NUMBER I I. DATE DONALD R.REAVEY ESQ. 717-233-4101 5/5/05 _ 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed) CAPOZZI & ASSOCIASTES 2933 NORTH FRONT STREET. HARRISBURG PA 17110 SPACE BELOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS LINE 13. I acknowledge receipt of the writ t NAME of Authorized LCSO Deputy or Clerk 114. ? Date Received I 15 Expiration/Heanng date or complaint as indicated above ( 1wn11 .1111,N11 ^!T7 Inn oonn 110 Ina c/c 7nIX 16. 1 hereby CERTIFY and RETURN that I eve personally served, O have legal evidence of service as shown in "Remarks 0 have executed as shown in 'Remarks', the writ or complaint described on the individual, company, corporation, etc., at th a address sh own above or on the and ividual, company, cor. poralion, etc., at the address inserted below by handing a TRUE and ATTESTED COPY thereof. 17. 01 hereby certify and return a NOT FOUND because I am unable to locate the individual, company, corporation, etc.. named above. (See remarks below) 18 Name antl title of individual served (if not shown above) (Relationship to Defendant) 119. LINo Swwoe Soo Remarks Below (No. 30) 20 Address of where served (comp(ete only if different than shown above) (Street or RFD, Apartmentrio City, Boro. Twp 21. Date of Service 22 Time .*Wr State and Zip Code) . PU aEDDST s ar -os a:3s 23 . ATTEMPTS D••iite Miles Drip. hot. Data Miles Dori. Int. Date Milos Dep. Int. Date Miles Dep. Int. Date Miles Dep. Int. 24. Advance Costs 25 Service Costs 26. Notary Cert. 27 Miles elPosta e/N.F. 28 Total Cos 29 C ST DU? OR Of NO R/ 3 q?'? J 150.00 36.50 27 t ?. I 30. REMARKS: S.T.A.: 31 . AFFIRMED and subscribed to before me this 34 day 37 MY l? dull' - - -An . cnanifs Office 4. BLUE - Sheriff's Office IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 NOTICE OF INTENT TO ENTER DEFAULT JUDGMENT AGAINST DEFENDANT DAVID WALKER IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE :FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR 013JECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT GENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 USTED ESTA EN REBELDIA PRRQUE HA FALLADO DE TOMAR ACCION REQUERIDA EN ESTE CASO. A MENOS QUE USTED TOME ACCION DENTRO DE LOS PROXIMOS DIEZ (10) DIAS DE LA FECHA DE ESTE ADVISO, SE PUEDEDICTAR UN FALLO EN CONTRA SUYA SIN LLEVARSE A CABO UNA VISTA Y USTED PUEDE PEREDR SU PROPRIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO IMMEDEMENTE A SU ABOGADO. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGAR UNO, VAYA O LLAME LA OFICINA ABAJO INDICATA PARA QUE LE INFORMEN DONDE PUEDE CONQUIR AYUDA LEGAL. REGISTRAR COMPARECENCIA ESCRITA POR SI MISMO O ATRAVES DE UN ABOGADO SOMETER CON LA CORTE SUS DEFENSAS Y OBJECCIONES A LOS CARGOS QUE HAN PRESENTADO CONTRA USTED. A MENOS QUE USTED ACTUE DENTRO DE DIEZ DIAS DE HABER RECIBIDO ESTE ADVISO, LA CORTE PUEDE TOMAR UNA DECISION EN CONTRA SUYA SIN TENER DIRECHOS A UNA VISTA Y USTED PUEDE PERDER SU PROPIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEDERLE INFORMACION A CIRCA DE COMO CONSIGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA PUEDA PROVEDER INFORMACION SOBRE DE AGENCIAS QUE OFRESCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE QUALIFICAN. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 Date: t . ZGo j onald R. Reavey, Esq. Attorney I.D. # 82498 kMichael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above style and numbered cause of action , hereby certify that I did on this the 29 '? day of f 2005, serve a true and correct copy of the Notice of Intent to Enter fault Judgment against Defendant David Walker upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Wendy J.F. Grella, Esq. 3618 North 6 h Street P.O. Box 5292 Harrisburg, PA 17110 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Donald R. Reavey, Esq. A,Uomey I.D. # 82498 to ichael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff r..> '? /'v1? r) =f1 t,-_ -" C_: vi S -53 C??f_ , i r? ? r; a , `?t? . r : r?{ri 1, . r' Donald R. Reavey, Esq. Michael B. Volk, Esq. Attorney I.D.#88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 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 (20) days after the 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 and other claim or relief requested by the Plaintiffs. You may lose money or property or and 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. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT REDUCED FEE OR NO FEE. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 Le had demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente dias de plazo al particular de la fecha de la demanda y la notificication. Hace falta ascentar ana comparencia escrita o en persona o con abogado y entregar a la corte en forma escrita sus defenses o sus objeciones a las demandas en contra de su persona. Se adviso que si usted no tiene defiende, la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso o notificacion. Ademas, la coorte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisions de esta demanda. Usted puede perder dinero o sus propiedades y otros direchos importantes para usted. LLEVE ESTA DEMANDA A SU ABOGADO IMMEDIATAMENTE, SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 JOINDER COMPLAINT AND NOW, comes Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center, LLC, by and through their attorneys, Donald R. Reavey, Esquire and Michael B. Volk of the law firm Capozzi & Associates, P.C., and as set-forth in the following complaint, respectfully shows the Court as follows: 1. Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center, LLC, (hereafter referenced as "Susquehanna Valley Nursing and Rehabilitation Center, LLC" or "Plaintiff'), is long-term nursing care facility located at 745 Chiques Hill Road, Columbia, PA 17512. 2. Plaintiff is licensed to participate in the Medicaid and Medicare programs. 3. Defendant David Walker is an adult individual residing at 1700 Market Street, Camp Hill, PA 17011. Defendant David Walker has been served with a copy of the original complaint and service of this joinder complaint may be had upon him at this address. 4. Defendant Gregory E. Nickens is an adult individual residing at 2659 Waldo Street, Harrisburg, PA 17110. Service of Process may be had upon Defendant Gregory E. Nickens at that address. 5. On information and belief, Defendant Gregory E. Nickens is David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary. 6. Defendant David Walker has received nursing care and services at Susquehanna Valley Nursing and Rehabilitation Center, LLC, from May 14, 2004 until June 3, 2005. 7. On or about May 14, 2004, Defendant David Walker and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary, requested that Plaintiff admit Defendant David Walker to the Plaintiff's nursing facility so he could receive nursing care and services. 8. On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the facility to receive nursing care and services. 9. At all times relevant to this action, the nursing care and services rendered have met all applicable federal, state and local standards of care. 10. On or about May 14, 2004, Plaintiff represented a promise to provide nursing care and services to Defendant David Walker. Simultaneously, Defendant David Walker and Defendant Gregory E. Nickens, individually and as David Walker's requesting admission, (hereinafter collectively the "Defendants") represented a promise to pay Plaintiff for the nursing care and services. 11. A true and correct copy of the written contract by and between Plaintiff and Defendants (hereafter, the "Contract") is attached as Exhibit "1"and is hereby incorporated by reference. 12. In addition, Defendant made oral promises to Plaintiff for nursing care and services. 13. Defendant David Walker's average monthly expenses incurred at Plaintiff s nursing facility exceed $5,000.00 (five thousand dollars). 14. Defendant David Walker's reasonable monthly living expenses incurred at Plaintiff s facility significantly exceeded his monthly income and was insufficient to adequately provide for his care, maintenance, and support. 15. Due to the refusal of Defendants to make payment each month for the nursing care and services rendered to Defendant David Walker by the Plaintiff, the account for Defendant David Walker, is currently in arrears in the amount of $11,882.29. A true and correct copy of the invoice for services rendered is attached hereto as Exhibit "2" and is hereby incorporated by reference. 16. On information and belief, Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary has not made payments for the care of Defendant David Walker, as agreed to in the contract. 17. Defendant Gregory E. Nickens did at all times relevant and material hereto hold himself to the world at large and to the staff and administration of Susquehanna Valley Nursing and Rehabilitation Center, LLC as the attomey-in-fact for Defendant David Walker. 18. The income and assets of Defendant David Walker were, at all times relevant and material hereto, and currently are accessed and controlled by the Defendant Gregory E. Nickens. 19. Confidential personal financial information about Defendant David Walker, such as, but not limited to: life insurance policy numbers; bank account numbers, and real estate data were, at all times relevant and material hereto, accessed and controlled by the Defendant Gregory E. Nickens, and denied to the Plaintiff. 20. Defendant Gregory E. Nickens, has substantially refused all communication from the facility related to the past due balance. 21. Defendant David Walker, and Defendant Gregory E. Nickens had a contractual, legal and fiduciary obligation to the facility to pay for the medical and nursing services rendered. COUNT I- BREACH OF CONTRACT David Walker, Individually and Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 22. Plaintiff hereby incorporates paragraphs 1 through 21 of this Complaint as if set- forth at length herein. 23. As more fully described herein, on or about May 14, 2004, Plaintiff and Defendants made application for the admission of Defendant David Walker into Plaintiffs facility and the subsequent provision of nursing care and services. 24. Defendants have not made payments for the medical and nursing services rendered to Defendant David Walker, as agreed to in the contract by and between the parties. 25. Plaintiff is entitled to compensation for nursing care and services rendered to Defendant David Walker. 26. As such, Defendants are responsible for the outstanding balance owed to Plaintiff for nursing care and services. 27. It is an implied term of the agreement, both oral and written, between Plaintiff and Defendant Gregory E. Nickens that he would responsibly use and safeguard the assets of Defendant David Walker, for his care. To the extent that he has failed to do this, he should be held personally responsible. 28. Plaintiff has demanded payment from the Defendants, but the Defendants have refused and continue to refuse payment in breach of the Contract. See, Exhibit {L1 )> 29. Plaintiff has been damaged by the failure of the Defendants to pay for the nursing care and services that Plaintiff rendered to Defendant David Walker. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. 7 COUNT 2-BREACH OF IMPLIED CONTRACT David Walker, Individually and Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 30. Plaintiff hereby incorporates paragraphs 1 through 29 of this Complaint as if set forth at length herein. 31. On or about October 15, 2003, Defendants agreed to pay Plaintiff in exchange for the admission of Defendant David Walker, into Plaintiff's nursing facility and the subsequent provision of nursing care and services to her 32. On or about October 15, 2003, Plaintiff admitted Defendant David Walker to the nursing facility and began rendering nursing care and services. 33. The facts, as set forth above, establish an implied-in-law and an implied-in-fact contract. 34. Due to the existence of the implied-in-law and implied-in-fact contract, Plaintiff is entitled to compensation for the health care services rendered to Defendant David Walker. 35. It is an implied term of the agreement between Plaintiff and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary that he would responsibly use and safeguard Defendant David Walker's assets for his care. To the extent that he has failed to do this, he should be held personally responsible. 36. Plaintiff has been damaged by the refusal of Defendants to pay for the nursing care and services rendered, in breach of the implied-in-law and implied-in-fact contract. WHEREFORE, Plaintiff respectfully requests that this ]honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. COUNT 3-QUANTUM MERUIT David Walker, Individually and Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 37. Plaintiff hereby incorporates paragraphs 1 through 43 of this Complaint as if set forth at length herein. 38. As more fully described herein, Plaintiff's expectation of payment in exchange for rendering the nursing care and services to Defendant David Walker was reasonable. 39. Plaintiff, in rendering nursing care and services to Defendant David Walker, has conferred a substantial benefit upon his and Defendant Gregory E. Nickens. 40. It is an implied term of the agreement between Plaintiff and Defendant Gregory E. Nickens that he would responsibly use and safeguard Defendant David Walker's assets for his care. To the extent that Defendant Gregory E. Nickens has failed to do this, he should be held personally responsible. 41. It is an implied term of the agreement between Plaintiff and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary that he would assist with, including, but not limited to, providing the necessary documentation and signatures for an application for medical assistance on behalf of Defendant David Walker. 42. Defendants retained the benefit of the bargain with Plaintiff for the provision of nursing care and services and have not conferred a similar benefit in return upon the Plaintiff. Defendants have been unjustly enriched at the expense of Plaintiff. 43. Due to Defendants' unjust enrichment, Plaintiff is entitled to proper compensation for the services rendered to Defendant David Walker. 44. Defendants' unjust enrichment at Plaintiff's expense has damaged the Plaintiff. 45. Plaintiff has demanded payment from Defendants, but Defendants have refused payment. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; Granting such other relief as the Court deems appropriate. COUNT 4 - BREACH OF FIDUCIARY DUTY Rodkey, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 46. Plaintiff hereby incorporates paragraphs 1 through 52 of this Complaint as if set forth at length herein. 47. On information and belief and as described more fullly herein, the income and assets of Defendant David Walker were, at all times relevant and material hereto, 10 accessed and controlled by Defendant Gregory E. Nickens. 48. As the Power of Attorney, Attorney-in-Fact, Responsible Party and Fiduciary for David Walker, Defendant Gregory E. Nickens had a fiduciary duty to act in Defendant David Walker's best interest. 49. On information and belief, Defendant Gregory E. Nickens refused to make the income and assets of Defendant David Walker available to Plaintiff to pay for his nursing care and services. 50. Plaintiff, by virtue of the contract with Defendant Gregory E. Nickens, is an intended third party beneficiary of the agency relationship that existed between Defendant David Walker and Defendant Gregory E. Nickens, as Defendant David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary. 51. On information and belief, Defendant Gregory E. Nickens owes a fiduciary obligation to Plaintiff to use the assets of Defendant David Walker, to pay for his nursing care and services when invoiced, to inform the facility when such assets became depleted, if applicable, and to disclose the available income and assets to the facility. 52. Due to the existence of the fiduciary duty between Defendant Gregory E. Nickens, and Plaintiff, Plaintiff is entitled to compensation for the health care services rendered to Defendant David Walker. 53. On information and belief, Defendant Gregory E. Nickens, violated his fiduciary duty to Defendant David Walker and to Plaintiff by refusing to use Defendant David Walker's, income and assets to pay for his nursing care and services and thus damaged Plaintiff. 11 54. On information and belief, Defendant Gregory E. Nickens violated his fiduciary duty to Plaintiff by refusing to be available to the facility to act in his role as fiduciary for Defendant David Walker and thus damaged Plaintiff. 55. On information and belief, Plaintiff has been damaged by Defendant Gregory E. Nickens's violation of his fiduciary duty to Defendant David Walker. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. COUNT 5 - NEGLIGENT MISREPRESENTATION Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 56. Plaintiff hereby incorporates paragraphs 1 through 5:5 of this Complaint as if set forth at length herein. 57. On information and belief and as described more fully herein, Defendant Gregory E. Nickens, did at all times relevant and material hereto hold himself out to the world at large and to the staff and administration of Plaintiffs facility as the Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary for Defendant David Walker. 58. On information and belief, the income and assets of Defendant David Walker were, at all times relevant and material hereto, accessed and controlled by 12 Defendant Gregory E. Nickens. 59. 60. Due to the existence of Defendant David Walker's written Power of Attorney, it is an implied term that Defendant Gregory E. Nickens would responsibly use and safeguard Defendant David Walker's assets for his care. To the extent that Defendant Gregory E. Nickens has failed to do this, he should be personally liable for any misapplication of funds or failure to act. 61. On information and belief, Defendant Gregory E. Nickens specifically represented to the staff and administration of Plaintiffs facility that they were entirely justified in relying upon him to act as the Attorney-in-Fact, Responsible Party and Fiduciary for Defendant David Walker. 62. Plaintiff reasonably relied on all of Defendant Gregory E. Nickens's representations including, but not limited to, that he would: a. Make the income and assets of Defendant David Walker, available to the Plaintiff to pay for his nursing care and services; b. Be available to make decisions on behalf of Defendant David Walker, with respect to relevant aspects of the care and services rendered to her; c. Provide timely all information required executing a Medical Assistance application on behalf of Defendant David Walker; d. Safeguard and use Defendant David Walker's, assets responsibly to pay for his care. 63. Plaintiff, in reasonably relying on the Defendant Gregory E. Nickens's promises has been damaged in the amount of at least $11,882.29. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: 13 a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. COUNT 6 - MISREPRESENTATION Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 64. Plaintiff hereby incorporates paragraphs 1 through 63 of this Complaint as if set forth at length herein. 65. On information and belief and as described more fully herein, Defendant Gregory E. Nickens at all times relevant and material hereto, held himself out to the world at large and to the staff and administration of Plaintiff's facility as the Power of Attorney, Attorney-in-Fact, Responsible Party and Fiduciary for David Walker. 66. On information and belief, the income and assets of Defendant David Walker, were, at all times relevant and material hereto, accessed and controlled by Defendant Gregory E. Nickens. 67. Due to the existence of Defendant David Walker's written Power of Attorney, it is an implied term that Defendant Gregory E. Nickens would responsibly use and safeguard Defendant David Walker's assets for his care. To the extent that Defendant Gregory E. Nickens has failed to do this, he should be personally liable for any misapplication of funds or failure to act. 68. 69. On information and belief, Defendant Gregory E. Nickens specifically and 14 intentionally represented to the staff and administration of Plaintiff s facility that they were entirely justified in relying upon him to act as the Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary for Defendant David Walker and that he would safeguard Defendant David Walker's assets to pay for his care. To the extent that Defendant Gregory E. Nickens has breached this promise, he should be held personally liable. 70. Plaintiff reasonably relied on all of Defendant Gregory E. Nickens's representations including, but not limited to, that he would: a. Make the income and assets of Defendant David Walker available to the Plaintiff to pay for his nursing care and services; b. Be available to make decisions on behalf of Defendant David Walker, with respect to relevant aspects of the care and services rendered to her. C. Safeguard and use Defendant David Walker's assets responsibly to pay for his care. 71. Due to the existence of the Contract, the Plaintiff is entitled to compensation for the health care services rendered to Defendant David. Walker. 72. Plaintiff, in reasonably relying on the representations of the Defendant Gregory E. Nickens, has been damaged in the amount of at least $11,882.29. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and. as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; 15 C. Granting such other relief as the Court deems appropriate. COUNT 7 - NEGLIGENCE Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 73. Plaintiff hereby incorporates paragraphs 1 through 72 of this Complaint as if set forth at length herein. 74. Defendant Gregory E. Nickens had a duty to act in Defendant David Walker's best interest. 75. Defendant Gregory E. Nickens, had a duty to use Defendant David Walker's income and assets to serve Defendant David Walker's best interests, which would be to pay for his nursing care and services. 76. Defendant Gregory E. Nickens breached his duty to use Defendant David Walker's income and assets to serve Defendant David Walker's best interests by refusing to make the income and assets of Defendant. David Walker available to Susquehanna Valley Nursing and Rehabilitation Center, LLC to pay for his nursing care and services. 77. On information and belief, Defendant Gregory E. Nickens breached his duties to Susquehanna Valley Nursing and Rehabilitation Center, LLC by refusing to be available to the facility to act in his role as power of attorney for the Defendant David Walker and thus damaged Susquehanna Valley Nursing and Rehabilitation Center, LLC. 78. Plaintiff has been damaged by the Defendant Gregory E. Nickens's violation of his duty to Defendant David Walker in the amount of at least $11,882.29. 16 WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against David Walker, individually and Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at least $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. COUNTS-CONVERSION Gregory E. Nickens,m Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 79. Plaintiff hereby incorporates by reference paragraphs 1 through 78 of this Complaint as if set forth at length. 80. Defendant Gregory E. Nickens had a duty to act in Defendant David Walker's best interest. 81. Defendant Gregory E. Nickens had a duty to use Defendant David Walker's income and assets to serve Defendant David Walker"s best interest, which would be to safeguard his assets and to pay for his nursing care and services. 82. On information and belief, Defendant Gregory E. Nickens was aware that due to the contractual relationship between Defendant David Walker and Plaintiff, Defendant David Walker's, assets properly belonged to Defendant David Walker and the Plaintiff. Defendant Gregory E. Nickens, despite this knowledge converted the assets of the Defendant David Walker and the assets of Plaintiff to his own use. 83. Plaintiff has been damaged by Defendant Gregory E. Nickens's conversion of 17 Defendant David Walker's assets in the amount of at least $11,882.29. WHEREFORE, Plaintiff respectfully requests that this honorable Court enter an Order as follows: a. Granting judgment for Plaintiff and against Defendant Gregory E. Nickens, individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary in the amount of at ]east $11,882.29, plus 6% prejudgment and post judgment interest per annum, or as determined by the Court, inclusive of interest and costs; b. Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action, and; C. Granting such other relief as the Court deems appropriate. COUNT 9 - PETITION FOR ACCOUNTING Gregory E. Nickens, Individually and as David Walker's Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary 84. Plaintiff hereby incorporates paragraphs I through 83 of this Complaint as if set- forth at length. 85. Due to Defendant Gregory E. Nickens's conduct described herein, Plaintiff is entitled to an accounting of: a. All transactions and dealings with relation to his duties as Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary for Defendant David Walker; b. All profits and losses gained or lost as a result of any investments or businesses run during his tenure as Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary on behalf of'Defendant David Walker; C. A listing of all of Defendant David Walker's assets and liabilities during the entire time that Defendant Gregory E. Nickens acted as Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary for Defendant David Walker and had control of the Defendant David Walker's assets and any actions taken by Defendant Gregory E. Nickens with regard to the assets and property of Defendant David Walker or held in for the benefit of David Walker; d. Defendant Gregory E. Nickens is a constructive trustee of the funds and assets of Defendant David Walker and should account for any 18 and all of Defendant David Walker's funds and funds held for his benefit, spent for his personal use. C. Moreover, Defendant Gregory E. Nickens should account for any wrongful conversion; dissipation and sale of Defendant David Walker's property or the property held for the benefit of Defendant David Walker and return the items or their value to pay for Defendant David Walker's obligations. 86. As a party to the power of attorney between Defendant Gregory E. Nickens and Defendant David Walker, Plaintiff is also entitled to a full and complete inspection of any books or records in the possession of the Defendant Gregory E. Nickens pertaining to his action as a power of attorney, attorney in fact, responsible party and fiduciary for Defendant David Walker. 87. WHEREFORE, Plaintiff demands judgment in its favor and against Defendant Gregory E. Nickens, and for an Order directing Defendant Gregory E. Nickens to produce all books and records for inspection relating to his actions as Power of Attorney, Attorney in Fact, Responsible Party and Fiduciary for David Walker and account for all of the transactions, dealings, assets and liabilities and such other relief that the Court may deem just and proper. Respectfully submitted, CAPOZZI AN,p ATES, P.C. Date: 28 z, ads- By: Donald R. Reavey, Esquire Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff 19 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above styled and numbered cause of action, hereby certify that I did on this the ?6?'k_ day of -Nur, e 2005, serve a true and correct copy of the Joinder Complaint upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Wendy J.F. Grella, Esq. 3618 North 6"' Street P.O. Box 5292 Harrisburg, PA 17110 20 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 /j l Donald R. Reavey, Esq. Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff 21 VERIFICATION I, Michael B. Volk, Esquire, do hereby verify that the facts made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. This verification is being made as Defendant is unavailable and time is of the essence. Counsel will substitute a verification of Defendant as soon as available. I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unworn falsification to authorities. By. v` v Michael B. Volk, Esquire Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 12 SUNIM"Y OF ADVANCE DIRECTIVE Policy and Practice Facility: (Hereafter known as "FACILITY') Resident: C? ?-L RUC 2?.Qti? (Hereafter known as "RESIDENT') FACILITY will make note in RESIDENT's chart whether or not an Advance Directive has been executed. concerning oaie:' Also, a copy of the Advance Directive will be kept in the RESIDENT's chart. The RESIDENT is strongly urged to make the attending physician aware of the Advance Directive since all care provided while residing at the FACILITY is directed by the attending physician and the physician must incorporate the RESIDENT's wishes into the care plan. RESIDENT will not be subject to any discriminatory treatment at the FACILI'T'Y based on whether or not an Advance Directive has been executed. An "Advance Directive" is any written document, including Living Wills or Durable Powers of Attorney, which deals with health care treatment, or other written evidence of desires to accept or refuse certain medical. treatment. In Peimsylvania there is it specific statute.which authorizes speck forms or creates specific responsibilities of physicians or healthcare providers in relation to Living Wills or Advance Directives.and Durable Powers of Attorney. Please remember that all care given in a nursing home is provided under a physician approved Plan of Care. It is strongly advised that any Advance Directive be discussed with the attending physician. _h 1 V-4 Residen Signature Date (Or Power of Attorney or Legal Guardian) - Acknowledged by: 2 f Adm ing Officer OillinglAdm PkMUM111arv of Adv Directive (0.01 04/27/2005 07;35 410-529-4539 QUAIL RUN PAGE 13 RESPONSIBILITY FOR RETENTION OF CASH, JEWELRY AND VALLUABLES Facility r Resident -e?- /y'Q y Date I have been advised by the management not to keep cash, jewelry and other valuables in my possession while a Resident in this facility. Notwithstanding this advice, I wish to retain the following items in my possession. 1 agree to indemnify, defend, and hold harmless Facility, its successors, assigns, members, directors, officers, employees and agents from any and all losses, costs and expenses of any nature related to the above listed items and any items that maybe brought to me while residing in this facility, ignature of Resident Witness Signature of Legal Representative Date Jy. Date Date B!IIing'Adin PWR:laaw Of Rop Cash Je,oehv N Od 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 14 RESIDENT TRUST ACCOUNT AUTHORIZATION Resident: ?J( /??. ?/' Resident Number: Authorize M Do Not Authorize The facility is to place funds into the Resident Trust Account for safekeeping. I understand that I may use these funds at my discretion. If I am a Medical Assistance Resident, I may only take $30.00 per month unless additional personal deposits are made to my account. I may withdraw funds during regular business office hours. Any request over $50.00 will be given by check. • For requests less than $50.00; the facility will use its best efforts to honor the request; however, it will depend on cash availability on the premises at the time the request is made. For check requests, funds will be provided by the next business day. A quarterly statement will be issued to insure the accuracy of all transactions. . Accounts over $50.00 will be credited with interest,monthly. Le epresentative -/V-oy Date DillintlAdm Pkt%Rcs Tnist A=t Auth. 10.01 QUAIL RUN PAGE 15 04/27(2005 07:35 410-529-4539 ACKNOWLEDGMENT Name of Resident: SSN: ?(fJ 7 qV 3 99? I acknowledge receipt of The Wilmac Corporation's Notice of Privacy Practices, delivered to me this day of J?YJU , Date . Resident ame Date Name of Responsible Person, if Resident unable to sign FOR INTERNAL USE ONLY: If unable to obtain a written Acknowledgement from Resident] or [Name of Responsible Person], reason for the failure below [Name of please indicate the Resident or Responsible Pelson refuses to sign this Acknowledgment Other (please discuss more fully below) QUAIL RUN PAGE 16 04/2712005 07:35 410-529-4539 THE WILMAC CORPORATION OPPORTUNITY TO AGREE OR. OB3ECT FORM As outlined in The Wilmac Corporation's ("Wilma c") Notice of Privacy Practices, Wilmac may use or disclose my protected health information for the following purposes, absent my objections: Inclusion within the Facility Directory To Friends and Family Members upon 'their inquiry To Clergy Accordingly, to make my intentions clear regarding the above, I am executing this Form. r , 1. Facility Directory (check only one) _ I OBJECT to the use of my protected health information in the Facility Directory DO NOT OBJECT to the use of my protected health information in the Facility. Directory I DO NOT OBJECT to the use of some of my protected health information in the Facility Directory . However, ,.I have checked below the information that.I DO NOT want included in the Facility Directory. (check all that apply): My Name My location in the facility My health condition described in general terms that does not communicate any specific health information My religious affiliation I DO NOT OBJECT to the posting of the Facility Directory (containing some of my protected health information) in a publicly viewed area. 3, Family and Friends 1 OBJECT to the disclosure of my protected health information to my tainily and friends who make specific inquiries about Me. (if checked, proceed to #3) 04/27/2005 07:35 410-529-4539 GUAIL RUN PAGE 17 I DO NOT OBJECT to the disclosure of my protected health information to my family and friends who make specific inquiries about me. (if checked, proceed to #3) I DO NOT OBJECT to the disclosure of my protected health information to most of my family and friends who make specific inquiries about me. However, I DO NOT AGREE to the disclosure of my protected health' information to the following individuals: (if checked, be sun to also read the following) 3 I DO NOT OBJECT to the disclosure of some of my protected health information to my family and friends who make specific inquiries about me. However, I DO-NOT AGREE to the disclosure of the following protected health-information16those individual's:' clergy .. I OBJECT to the disclosure of.my protected health information to members of the clergy who make specific inquiries about.me. (if. checked, proceed to #4) I DO NOT OBJECT to the disclosure of any of my protected health information to members of the clergy who make'specific inquiries about me. (if checked, proceed to #4) I DO NOT OBJECT to the disclosure of my protected health information to most members of the clergy who make specific inquiries about me. However, 1 DO NOT AGREE to- the-disclosure of -my protected health information to the following individuals: (if checked, be sure to also read the next option) 76977 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 18 _ I DO NOT OBJECT to the disclosure of some of my protected health information to members of the clergy who make specific inquiries about me, However, I DO NOT AGREE to the disclosure of the following protected health information to those individuals: 4. Disaster Relief I OBJECT to the disclosure of my protected health information for purposes of assisting in disaster relief. (if checked, proceed to signature lline) I DO NOT O1 JECT to the disclosure of my protected health information for purposes of assisting in disaster relief (if checked, proceed to signature fine) I DO NOT OBJECT to the disclosure of my protected health information for purposes of assisting in disaster relief. However, I DO NOT AGREE . to the disclosure of retry protected health infomtation4o the following individuals: (if checke(4 be sure to also read the next option). I DO. NOT OBJECT to the disclosure of some of my protected health information forpurposes of assisting-in disaster relief. However, I DO NOT AGREE to the disclosure of the following protected health information to those individuals: Qfigzamre of Resident or Resident's Date Authorized Representative if signed by Resident's Authorized Representative, please print Tram! and describe relationship: Name Relationship [ esident 76977 3 QUAIL RUN PAGE 20 04/27/2005 07:35 410-529-4539 PATIENT NAME ' I acknowledge receipt of the Brockie Healthcare Incorporated HIPAA "Notice of Privacy Practices. " I will authorize disclosure of Protected Health Information to only: NAME U Use space below if you wish to add other names. C,A"j _ Signed: RELATION Date: Authorization if other than patient and/or patient unable to sign: 04/27/2005 07:35 410-529-4539 I. RESIDENT AGREEMEN'T' QUAIL RUN PAGE 24 A. Name of Facility (Hereafter referred to FACILITY in all;admission agreement documents.) B. Name of Resident (Hereafter referred to as RESIDENT in all admission agreement documents.) Address /7101) 1124 A"u n . X?? l ?d l l C. Name of Legal Representative u r t " (Hereafter referred to as LEGAL REPRESENI:9TIVE in l admission agreement documents. Legal Representative must have legal standing to act on behalf of the resident.) Address iJ -7 Telephone Capacity of Representative (Power ofAttorney, Guardian, Parent -of Minor) Copy of applicable-Power ofAttorney or court order on which representative authority is based must be .attached to This document. (1) 1 certify as the Legal Representative for Resident, I have legal access to Resident's income and resources available to pay.for,care in Facility and I agree that I shall provide payment from Resident's income and resources for such care. I shall apply Resident's income and resources to the lawful and proper costs and charges incurred during Resident's stay unless and until such costs are paid by ppvate insurance or other benefits such as Medicare, Veterans' Health Insurance or Medical Assistance. When the Resident's financial resources warrantit, I shall hike all actions necessary or appropriate to make application fob Medical Assistance benefits on behalf of the Resident and shall exercise diligent efforts to provide all of the information required in the application process and thereafter to-assure continued benefits. I understand that if I fulfill my obligations under this paragraph, I shall not be. held personally.fanancially liable for the Resident's care. I further understand, however, that if I do not fulfill my obligations under this paragraph, or under the other paragraphs of this of this Agreement, I will be liable to the Facility for whatever losses the Facility sustains as a result of my breach of this Agreement. (2) The information provided is true and correct to the best of my knowledge, information and belief. t 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 25 (3) 1 have received a copy of the Resident Agreement and agree to be bound by the terms and conditions contained therein. D. I desire admission to FACILITY. E. The information set forth on the Admission record is true and correct to the best of my knowledge, information and belief. F. I have received a copy of the Resident Agreement and agree to be bound by the terms and conditions contained therein. G. I have reviewed and indicated the optional contract services to be provided. H. I have reviewed the section of the Admissions, Contract entitled "Other Information" and understand the information set forth therein. Current daily rate: (NOTE: These are subject to chadge.) Daily rate $ -/O' ' J. MANDATORY ARBITRATION (1) Contractual and/or Property'DamageDisputes. 'Any controversy, dispute, Disagreement or claim''of any kind or nature, arising from, or relating to this Agreement,: or concerning any rights arising from or relating to an alleged breach of this Agteem'erit,•with the exception' ofguardianship- proceedings resulting from the alleged incapacity of the Resident and with the further exception of amounts in controversy of less than Eight Thousand Dollars ($8,000), shall be settled exclusively by arbitration. This means that the Resident will not be able to file a lawsuit in any court to resolve any disputes or claims that the Resident may have against the Facility. It also means that the Resident is relinquishing or giving up all tights that the Resident may have to a jury trial to resolve any disputes or claims against the Facility. This provision is not inclusive of the facility's ability to file civil law suits in the appropriate county in which the Resident/Debtor resides, or to recover payment for outstanding billing which is not paid by the Resident and/or responsible party. The facility may elect not to utilize the American Arbitration Association in attempting to recover outstanding billing invoices for residential health care. The Arbitration shall be administered by the American Arbitration Association in accordance with the American Arbitration Association's Cominaerciil Arbitration Rules, and judgrnenron any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up their tights to a jury trial on any matter submitted to arbitration under this Agreement. (2) Personal Injury or MedicalMalpractice. Any claim that the Resident may have against the Facility for anypersonal injuries sustained by the Resident arising 2 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 26 from or relating to any alleged medical malpractice, inadequate care, or any other cause or reason while residing in the Facility, shall be settled exclusively by arbitration. This means that the Resident -will not be able to file a lawsuit in any court to bring any claims that the Resident may have against the Facility for personal injuries incurred while residing in. the Facility. It also means that the Resident is relinquishing or giving up all tights that the Resident may have to a jury trial to litigate any claims for damages or losses allegedly incurred as a result of personal injuries sustained while residing in the Facility, The Arbitration shall be administered by the American Arbitration Association in accordance with the American Arbiitratiop Association's Health Care Clairns Settlement Procedures, and Judgment on any award rendered by the arbitrator(s) may be entered in any court having appropriate jurisdiction. Resident and/or Responsible Person acknowledge(s) and understand(s) that there will be no jury trial on, any claim or dispute submitted to arbitration, and Resident and/or Responsible Person relinquish and give up the Resident's right to ajury trial on any claims for damages arising from personal injuries to the Resident which are submitted to arbitration under this Agreerent. (3) Right to Legal Counsel. Resident has the right'to be represented by legal counsel in any proceedings initiated under this arbitration provision: Because this arbitration provisioiiaddresses important legal rights, Facility encourages and recommends that Resident obtain the advice and Assistance of legal counsel to review the legal significance of this knand,atory arbitration provision prior to sigw mg this A greement: (4) Location of Arbitration. The Arbittation'will be conducted at a site selected by the Facility, which shall be at the Facility, or at a site within a reasonable distance of the Facility.` (5) Time Limitation forArbitration. Any request for arbitration of a dispute must be requested and submitted to the American Arbitration Association prior to the lapse of two (2) years from the date on which the event giving rise to the dispute occurred. The failure to submit a request for Arbitration to the American Arbitration Association within the designated time shall operate as a bar to any subsequent requestfor Arbitration, or for any claim for relief or a remedy, or to any action or legal proceeding of any kind or nature, and the parties will be forever batted from "arbitrating or litigating a resolution to any such dispute. 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 27 K. This Resident Agreement, together with the Disclosures Requiring Signatures, Summary of Services, Contract Terms and Other Information contained in the admission agreement and which are incorporated by reference as part of this Resident Agreement, constitutes the entire agreement between the parties, with respect to the subject matter hereof and supersedes, merges and replaces an prior negotiations, offers, representations, warranties and agreements with respect to such subject matter. I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS ADMITTANCE AGREEMENT, THAT I HAVE READ THE PROVISIONS OF THIS AGREEMENT, AND THAT I HEREBY AGREE TO BE BOUND BY ALL OF ITS PROVISIONS. IN WITNESWHEREOF, intending to be legally bound thereby we have set our hands and seal l ?Y day of 20 f this Witness Witness LECr',AL REPRESENTATIVE Witness S Member If the RESIDENT is unable to sign, state the reason: If this Agreement is signed by a Power.of Attorney, attach a copy of the Power of Attorney. If this Agreement is signed by a Legal Guardian, attach a copy of the Court Order. 4 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 29 BED HOLD POLICY 1) Private Pay or Medicare Residents. If Resident leaves Facility for a period of hospitalization, therapeutic leave, or any other reason except death and is not receiving Medical Assistance, the Facility will hold the bed and contact the responsible person within 48 hours to determine if we are to continue to hold the bed. If we are to continue to hold the bed, the Resident will be charged the Current Room and board Rate while out of the Facility or until the Facility is told to no longer hold the bed. If the Resident decides not to have the bed reserved and later desires to be readmitted to the Facility, that readmission will be dependent upon the availability of an appropriate bed. 2) Medical Assistance Residents. If Resident is eligible for, or is receiving Medical Assistance benefits, and Resident leaves Facility for a period of hospitalization or therapeutic leave, Resident's bed will be reserved for the applicable maximum number of days, paid for a reserved bed under the Pennsylvania Medical Assistance Program. The bed reservation period may be subject to change in accordance with any changes in the Pennsylvania medical Assistanbe Pfogram. If the period of hospitalization or therapeutic leave exceeds thle'makimum time for r6iervatioh of abed under the Pennsylvania 11ledical Assistance Progrzm Resident will be entitled to the first available accommodation suifable forResidei t at the time of readmission, if Resident iequires the service 'sIpiovtded by the Facility. Alternatively, fhllowing,the lapse ofthi bed reder`vatioit. period covered by the Medical Assistance Program; Resident may reserve abed by-electing to. pay the Medical 'Assistance per them rate charged'immedlately prior to the leave, and by providing written notice and advance-'payment for the days included in the reservation period. 6 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 28 11. DISCLOSURES REQUIRING SIGNATURES A. MEDICARE CATASTROPHIC COVERAGE ACT Section 303(a) of the Medicare Catastrophic Coverage Act of 1988 (MCCA), known as the Spousal Impoverishment Provisions, provides for the protection of a couple's income and resources within specified limits in the event one of them needs nursing facility care. FACILITY may direct RESIDENT or RESIDENT'S spouse to the appropriate agency for an assessment of RESIDEN'T'S total income and resources. If the spouse in the community does not have income or resources up to the limits established by the state, the law permits the institutionalized spouse to transfer to the community spouse sufficient income and resources to assure protection up to the established limits. The intention of this portion of the law is to permit the spouse remaining in the community to retain a higher level of income and resources than is now permitted. Therefore, the community spouse does not have to live below the poverty level. These requirements are effective September 30, 1989. Witness l ?. Legal Representative 5 04/27/2005 07:35 410-529-4539 QUAT'_ RUN PAGE 30 W. SUMMARY OF SERVICES A. MEDICAL ASSISTANCE I. Any resident who is a recipient of Medical Assistance is provided the following items or services as necessary: a. Room and Board b. incontinent Supplies C, Over the Counter Medication d Nursing Care e. Personal Laundry f. Barber and Beauty care under Medicaid billing guidelines g. Items of Personal Hygiene h. Maintenance Therapy as deemed necessary by resident's physician 2. Resident maybe charged for personal phone calls, television, personal laundry name tags and placement on clothing. Resident' is also responsible " for physician's charges. B. MEDICARE 1. Residents who come under Medicare guidelines will be provided the following services inchlsive under the Medicare per diem note, a: Nursing Care" b. Room and Board c: Rdbabilitati,bdTherapy as deemed necessary by resident's physician d. RestofagveTherapy as deemed necessary'by resident's plan of care 2. Resident will,be responsible for cen:ain charges such as T.V„ beauty & barber care, and personal phone calls. 7 QUAIL RUN PAGE 31 04/27/2005 07:35 410-529-4539 IV. CONTRACT TERMS A. MANDATORY CONTRACT PROVISIONS ADMISSION The FACILITY agrees to admit RESIDENT, an aged or infirm person, and to provide the appropriate level of nursing care. The level of care may change due to physician's orders and state of health of RESIDENT, and RESIDENT hereby recognizes that this level of care will be provided subject to the conditions set forth in paragraphs 7 and 8. 2. PAYMENT a. RESIDENT promises to pay to FACILITY the then current daily rate for the level of care set forth in this Agreement. A deposit equal to the amount of thirty (30) days charges is payable on admission. b. In the event the charges are to be paid by other sources or agencies (e.g., Medicare, Medical Assistance, etc.), RESIDENT agrees to make all decessary remittance as required by the regulations of said agencies, c. RESIDENT 'shall pay promptly when, billed all extra charges including;' buf uat limited to, charges`for drugs, medicines, special nurses,iolothing, doctors,' therapy and siubh, ther supplies and services necessary-and proper forthe?health andxomfort.of RESIDENT. d. The daily rate specified in this Agreement for the level of care is subject to change by FACILITY upon thirty (30) days written notice to RESIDENT. However, changes in the amount charged to RESIDENT ; due to change in the level of care provided to RESIDENT is effective at the time level of cage is changed. 1) Following admission, all billings" shall be made for each calendar month, in`advance, on the f"irst" day of each month. Billings shall be paid no later than ten (10) days following transmittal of the billing. All billings unpaid after the last day of the calendar month shall bear interest at the rate of one and one-half percent (1:5%) per month commencing on the first day of the following month. 2) If admission occurs more than seven {7) days before the end of the calendar month, the initial bill shall cover the period from the date of admission to the end of the month, plus the number of days in the succeeding calendar month, A credit shall be giden for admissions prepayment. s 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 32 3) if admission occur during the last seven (7) days of a calendar month, the initial bill shall include the number of days remaining in the month of admission, plus the number of days in the succeeding calendar month. This bill shall be due and payable by the tenth (I 0`a) day following transmittal of the bill. 4) RESIDENT agrees to apply for Medical. Assistance benefits at such time as his or her income or assets warrant such application. RESIDENT agrees to make application in a timely fashion so the payments shall begin as soon as practical after RESIDENT qualifies for Medical Assistance. RESIDENT, as part of this agreement, further agrees to provide the Department of Public Welfare with all financial, medical and other information necessary or appropriate during the application process, and thereafter as may be required by the Department of Public Welfare for continued benefits. e. All refunds due to a discharged RESIDENT will be remitted to RESIDENT within thirty (30) days of final billing. f. In admitting RESIDENT who intends to pay for his or her own costs of stay, FACILITY is relying on the financial information in the application. Any significant reduction' in a RESIDENTS ability to pay for his or her own care must' bb immediately reported to FACILI'T'Y. 3. CHANGE IN ACCOMMODATIONS a. The RESIDENT understands that the facility may find it necessary and/or appropriate to change the RESIDENT'S room or roommate during the RESIDENT'S stay at the facility, If this occurs, the facility will provide reasonable: notice to the RESIDENT in advance of any room or roommate change, unless an emergency requires that an immediate change be made. b. If the RESIDENT is being admitted to a Medicare area bed. RESIDENT hereby acknowledges that RESIDENT may be asked to be transferred to a different area and service that better meets the RESIDENT'S needs. C. FACILITY acknowledges that changes in accommodations are subject to applicable rules and regulations relating to RESIDENT'S rights. 9 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 33 4. MEDICATIONS AND FOOD RESTRICTIONS a. Medication as prescribed by the attending physician shall be administered only by persons authorized by FACILITY. RESIDENT and Legal Representative consent to any and all medical treatments prescribed by RESIDENT'S attending physician and administered by agents or employees of FACD-ITY. b. No foodstuffs, liquids, medicines or similar items shall be brought into FACILITY for RESIDEN'T'S use without permission first having been obtained from the Director of Nursing Services or his/her 5. HOSPITALIZATION Should RESIDENT'S physician recommend hospitalization, FACILITY shall arrange for the transfer of RESIDENT to a hospital. Any hospital charges and/or transportation expenses incidental thereto shall be the responsibility of the RESIDENT: 6. LIMITATIONS ON LIABILITY FACILITY shall not be responsible for. RESIDENT while he or she is off premises with or without its consent. 7. RULES AND REGULATIONS (Exhibit A) RESIDENT agrees to abide by all rules and regulations established in connection with the operation and maintenance of FACILITY as set forth in the Resident Responsibilities: R'NCILITY shall make available to RESIDENT any amendments to all applicable rules and regulations. 8. RESIDENT ACCOUNTS Upon requesi, a, RESIDENT fund will be maintained for RESIDENT. Quarterly accounts are prepared and submitted to RESIDENT or personal representative. Any question regarding said account should be submitted within ten (10) days of receipt of the account. If no question is submitted, the account rendered shall be final within ten (10) days after receipt by RESIDENT (or personal representative), Any questionable account shall become final within ten (10) days after resolution of the question. 9. ATTORNEY FEES In the event it becomes necessary for die FACILITY to take legal action to recover any amount owed by RESIDENT under this Agreement. FACILITY shall recover from RESIDENT actual attomey's fees in addition to the 10 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 34 amount due and payable under the Agreement, costs of collection and any other remedies to which FACILITY is entitled. 10. TERMINATION, TRANSFER OR DISCHARGE (a) Resident Initiated, Resident may terminate this Agreement upon fifteen- (15) days written notice to facility. If Resident leaves Facility for any reason other than a medical emergency or death, Resident must give written notice to Facility at least fifteen (15) days in advance of transfer, discharge or termination of this Agreement. If advance written notice is not given to Facility, there will be due to Facility the applicable Basic Daily Rate and other charges then in effect for Resident's stay and care for the required fifteen (15) day notice period. The charge applies whether or not the Resident remains at Facility during the fifteen- (15) day notice period The Charge specified in this section does not apply to a resident whosepayor source is Medicare PartA or Medicaid. (b) Facility lititiated. Facility may terminate this Agreement and Resident's „- stay and transfer or discharge Resident if 1. Transfer or discharge is necessary to meet Resident's welfare, and Resident's needs cannot be met in Fadiltty; 2. Resident's, health has.-improved sufficiently so that Resident no longer needs the services provided by facility; 3. The safety ahealth:of individuals im, facility is or otherwise: would be endangered 4. Resident has failed, after notice, to pay `for (or to have paid or treated as paid under the Medicare or Medicaid Programs) charges for Resident's care and stay at Facility; and S. Facility ceases to operate. (c) Notice and Waiver of Notice. Facility will notify Resident and Responsible-Person (or if none, a firaily member' br legal representative of Resident, if known to Facility) at least: thirty (30)'days in advance of transfer or discharge. However, in any case described in Subparagraphs (1), (2) and (3) above. Facility will give only such notice before transfer or discharge as a reasonable under the circumstances. 11. PAYMENT AUTHORIZATION (a) Assignment of Payments. Although it is the responsibility of Resident to secure payment from third-party resources,, Resident also authorizes Facility to take such actions as it deems necessary to secure for the Facility receipt of third-party payments to 'reimburse Facility for its charges for the stay and care of Resident. To the fullest extent permitted by law, as security for payment of Facility's charges, Resident hereby assigns to Facility aJl of 1t 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 35 Resident's rights to any third-parry payments now or subsequently payable to the extent of all charges due under this Agreement. Resident or responsible Person promptly shall endorse and turn over to Facility any payments received from third parties to the extent necessary to satisfy the charges under this Agreement. 12. RESIDENCY UNDER MEDICAL ASSISTANCE RESIDENT will remain as a resident of FACILITY under Pennsylvania Medical Assistance providing his or her level of care necessitates nursing home care as determined by Pennsylvania's medical evaluation upon application for Medical Assistance. 13. OBLIGATIONS OF RESID)NT'$ ESTATE & ASSIGNMENT OF PROPERTY Resident and Responsible Person acknowledge the charges for services provided under this Agreement remains dud and payable until fully satisfied. In the event of Resident's discharge for any reason}, including death, this Agreement shaft operate as'an assignment, trausfei and conveyance to facility of so much of Resident's property as is equal in value to the amount of any unpaid obligations under this Agreement. This assignment shall be an obligation of Resident's estate. and maybe enforced against Resident's estate. Resident's estate shall be liable; to and shall pay,to Facility an amount equivalent io any unpaid obligations of Resident under1his Agreement. 14. DEFAULT ' A default is' a 'failure to perform obligations imposed by the admission agreement documents. If the RESIDEFNT defaults, in addition to any other rights which the FACILITY has under the admission agreement documents, the FACILITY shall have the right to discharge the RESIDENT as permitted by-law. If a decision to discharge the RESIDENT is made because of a default under the admissions agreement, the FACILITY will give thing (30) days written noticetto the RESIDENT and to either a family member or the RESIDENT'S legal representative, if either are known to the FACILITY. 12 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 36 B. OPTIONAL CONTRACT PROVISIONS I. LAUNDRY FACILITY will provide personal laundry service for the RESIDENT. However, the service does not include ironing. If RESIDENT chooses not to have FACILITY provide laundry service, the legal representative or RESIDENT will be responsible for taking complete charge of the personal laundry of RESIDENT on at least a weekly basis. 113 do ? do not want FACILITY to provide daily laundry service. 2. DENTAL As part of a Wellness Program, FACILITY offers annual dental screening for RESIDENT. T}xe purpose of the screening is to prevent any problems. Dental screeninigs are- done' 1i the FACILITY. Should treatment be necessary, the family and attending physician will be contacted. RESIDENT will, be responsible for payment unless RESIDENT is covered by Medical Assistance, in which case the Department of Public Welfare will cover the cost of services: Dental scieeriitgs are pErformed aiiriually,by The appraximatd cost for an annual dental sciet'ning is S I Cl do ? do not want to participate in -the Dental Screening Program. 3. PODIATRY Should podiatric medical services be required during the time I reside in FACILITY, I request that payment of authorized Medicare benefits be made on my behalf "talre podiatrist or physician named below for any services rendered. Podiatrist 111 do ? do not grant the above authorization for podiatric medical services. 4. 1 also understand that some services might not be considered necessary under Medicare guidelines, yet I still choose to accept these services since my Doctor is the one treating my condition, not Medicare. I also accept responsibility for payment of these services, even though Medicare may not. S. I authorize the physician named to collect assignment on my behalf and also authorize the release of medical records and information to the Health Care Financing Administration, Medicare, and it's agents. Any information needed to determine these benefits, or benefits payable for related services, may also be released. 13 04/27/2005 07:35 410-529-4539 QUAIL RUN PAGE 37 6. I appoint the Legal Representative named in the Resident Agreement to act as my representative in the connection with my claim or Asserted right under Title XVIII (Medicare Coverage). 7. I authorize the Legal Representative to make or give any request or notice, to present or elicit evidence to obtain information and to receive any notice in connection with my pending claim or asserted right wholly in my stead. g. POWER OF ATTORNEY 10 have ? have not signed a Power of Attorney. (If so, a copy of the Power of Attorney should be attached to the Resident's Admission Contract). 9. TELEVISION 11:1 do ? do not wish to have television service in my room. T_ 10. TELF-PHONE` 1 0 do ? do not wish to have telephone service in.my room. 14 04427/2005 07:35 410-529-4539 QUAIL RUN PAGE 38 V. OTHER INFORMATION A. NON-DISCRIMINATION POLICY It is the policy of FACILITY to admit and ti,-eat all RESIDENTS without regard to race, color, national origin, sex, age, religious affiliation or handicap. All accommodations at FACILITY are available without distinction to all RESIDENTS and their visitors. There is no distinction in. the eligibility for or in the manner of providing any patient service provided by FACILITY. In accordance with applicable Federal and State civil rights law and regulatory requirements, this FACILITY has agreed to comply with the provisions of the Federal Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, the Pennsylvania Human Relations Act, (43 P.S. & 951), and the Buildings and Facilities Accessibility Standards (71 P.S. 1455.1), and all requirements imposed pursuant thereto. No person shall, on the grounds of race, color, national origin, ancestry, age, sex, religious creed or handicap or disability, be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination in, the provision of any cate or service. If you feel you have been disciinvinated'against on the basis of your race, color, religious` creed, hantficap, agcestry nation;Weinpin, age or sex, a complaint of discrimination may :be filed with ti y. of th6, following Department of Health, Bureau of' Quality AesuraYrce; Divisiim of" I ongJeim'Care, or Office of Civil Rights, U.S. Department of Health and Human Services, Region III, PO Box 13716, Philadelphia, Pennsylvania 19101, or any other Human Rights agency having jurisdiction. , B. RIGHTS OF RESIDENTS The patient shall be encouraged and assisted throughout the period of stay to exercise his rights as a patient and as a citizen and may voice grievances and recorrrrrtend changes in policies and services to the facility staff ('toll free 1-888-710-3284) or to outside representatives of his or her choice. The RESIDENT or RESIDENT'S responsible person shall be made aware of the Governor's Action line (toll free 1-800-932-0784) and the Department's Hot Line (1-800-692-7254) and the telephone number of the long Teri Care Ombudsman !P'rogram located within the Local Area Agency on Aging, and the local Legal''Services Program to which the patient may address grievances. A facility is required to post the ombudsman poster in a prominent location. C. ACKNOWLEDGEMENTS 1) ROOM RATE SCHEDULE. Resident and Responsible Person acknowledge the receipt of a copy of the Room Rate Schedule and the opportunity to ask questions about Facility's charges. 15 __ min-b29-4539 QUAIL RUN PAGE 39 2) RESIDENT RIGHTS. Resident and Responsible Person Acknowledge being informed orally and?m writing of Resident's Rights as specified in the current publication required by law and further acknowledge having an opportunity to ask questions about those rights. The Notice of Rights of Nursing Facility Residents (MA-401) is subject to change from time-to-time and shall not be construed as imposing any contractual obligations on Facility or granting any contractual rights to Resident. 3) ADVANCE DIRECTIVES. Resident and Responsible Person acknowledge being informed, orally and in writing, of Facility's policy on advance directives and medical treatment decisions. 4) AGREEMENT. Resident and Responsible Person acknowledge that they have read and understand the terms_.of,.,_this Agreement, that the terms have be explained to them by a representative of Facility, and that they have an oppormnity.to asl; questions about this Agreern;zIt. 5) RESIDENT HANDBOOK. Resident aud'Resp&41ble Person acknowledge the receipt of a copy of the Resident Hdi ndbook and the gppoitimity to ask questions about'Facility's `policies contained ih the Resident haidbook. The Resident handbook is subject to ehange`from timi-to-time arid shall not be construed as imposing` atry co>itiactual obligdtibns an Facility or granting any contractual rights'to Resident. ,r 16 Heatherbank Nursing and Rehabilitation Center 745 Chiques 1'-171 Road - Colnmbiey PA 17512 (717) 684-7555 Billing Qucations : (877) 945-6220 (Toll Free) DAVID WALRU 1700 MARimT ST CAMP HILL. PA 17044 .2101/04 DAUMCS FORWARD ?AYMM LIDaMMENTa 17117/04 1 LAS- CSC 1712.2/04 1 LAB- WRSR 17/11/04 1 LAS- Drswi.ng FCC 17/12/04 1 LAB - CMTUAS 17/12/04 1 LAS- SENSITIVITY DAVID WALRER RBCORD 4 1705605 11,027.64 ?--_ D-- __-,...---------------- 11,882-- B---------------------- P n `- r t t C ? n y N F 7pI r^ l T ?" c. ra PRAECIPE FOR LISTING CASE FOR ARGUMENT (Must be typewritten and submitted in duplicate) TO THE PROTHONOTARYIOF CUMBERLAND COUNTY: Please list the within matter for the next: ? Pre-Trial Argument Court ® Argument Court ----------------------------------------------------------------------- CAMON OF CASE (entire caption must be stated in full) KIMBERLY DUNHAM and TIMOTHY IN THE COURT OF COMMON PLEAS DUNHAM, her husband, CUMBERLAND COUNTY, Plaintiffs PENNSYLVANIA V. CIVIL ACTION - LAW SAMBHU N. KUNDU, M.D., and MEDICAL MALPRACTICE ACTION CENTRAL PENNSYLVANIA OBSTETRICS -GYNECOLOGY, INC. NO: 05-2412 CIVIL TERM Defendants JURY TRIAL. DEMANDED 1. State matter to be argued (i.e., plaintiff's motion for new trial, defendant's demurrer to compliant, etc.): Defendants' Preliminary Objections 2. Identify counsel who will argue case: (a) for plaintiffs: Neil J. Rovner, Esquire (b) for defendants: Michael D. Pipa, Esquire 3. I will notify all parties in writing within two days that this case has been listed for argument. Date: 6-3Q - 0-1- 211o v ! Michael D. (Attorney for Defendants) \OS_A\L1ABTNC\LLPG\190506VMF\01012\00144 KIMBERLY DUNHAM and TIMOTHY DUNHAM, her husband, Plaintiffs V. SAMBHU N. KUNDU, M.D., and CENTRAL PENNSYLVANIA OBSTETRICS -GYNECOLOGY, INC. Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA, CIVIL ACTION - LAW MEDICAL MALPRACTICE ACTION NO: 05-2412 CIVIL TERM JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, Joanne M. Parr, an employee of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this-: V day of June 2005, served a copy of the foregoing Praecipe for Listing Case for Argument via First Class United States mail, postage prepaid as follows: Neil J. Rovner, Esquire Angino & Romer, P.C. 4503 North Front Street Harrisburg, PA 17110-1708 R, l anne M. Parr n ?- _N Q 'T7 711' G II C.. f r =gig C_} f i t an ul ul -< SHERIFF'S RETURN - NOT FOUND CASE NO: 2005-02312 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SUSQUEHANNA VALLEY NURSING AND VS WALKER DAVID R. Thomas Kline Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT WALKER DAVID but was unable to locate Him in his bailiwick. He therefore returns the JOINDER COMPLAINT & NOTIC, NOT FOUND , as to the within named DEFENDANT , WALKER DAVID 1700 MARKET STREET CAMP HILL, PA 17011 PER MANOR CARE, DEFENDANT HAS NEVER BEEN THERE. Sheriff's Costs: So answers: Docketing 18.00 Service 12.00 Not Found 5.00 R. Thomas Kline Surcharge 10.00 Sheriff of Cumberland County Postage 1.74 46.74 CAPOZZI & ASSOCIATES 07/18/2005 Sworn and subscribed to before me this J?2n,.c day of A. D. n ?_ . , PYoYhonotary SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-02312 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SUSQUEHANNA VALLEY NURSING AND VS WALKER DAVID R. Thomas , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: NICKENS GREGORY but was unable to locate Him deputized the sheriff of DAUPHIN in his bailiwick. He therefore serve the within COMPLAINT & NOTICE County, Pennsylvania, to On July 18th , 2005 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: So ans % ?- Docketing 6.00 Out of County 9.00 Surcharge 10.00 R. Thomas Kline Dep Dauphin County 36.00 Sheriff of Cumberland County .00 61.00 07/18/2005 CAPOZZI & ASSOCIATES Sworn and subscribed to before me this LZ2A ?k day of oZW ?? A. D. Clou, (2 I /?- Prothonotary SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-02312 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SUSQUEHANNA VALLEY NURSING AND VS WALKER DAVID R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: NICKENS GREGORY E POA, AIF, RP FIDUCUARY FOR DAVID WALKER but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On July 18th , 2005 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: So answers: - / Docketing 6.00 Out of County .00 Surcharge 10.00 R. Thomas Kline .00 Sheriff of Cumberland County .00 16.00 07/18/2005 CAPOZZI & ASSOCIATES Sworn and subscribed to before me this ,2d. xk day of Q _ Y'",s A.D. -emu 0- -)" 44 Prothonotary T In The Court of Common Pleas of Cumberland County, Pennsylvania Susquehanna valley Nursing and Rehabilitation Center LLC vs. SERVE: David Walker et al Gregory E. Nickens as FOA, attorney in fact,No.` Responsible Party and/or Fiduciary for David Walker NOW, July 1, 2005 I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Affidavit of Service Now, within upon at by handing to _ a 20 , at o'clock copy of the original and made known to So answers, M. served the the contents thereof. Sheriff of Sworn and subscribed before me this day of 20 COSTS SERVICE _ MILEAGE _ AFFIDAVIT 05-2312 civil County, PA In The Court of Common Pleas of Cumberland County, Pennsylvadia Susquehanna Valley Nursing and Rehabilitation Center LLC Vs. David Walker et al SERVE: Gregory E. Nickens No. 05-2312 civil Now, July 1, ;2005 , I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Affidavit of Service Now, within upon at by handing to a and made known to So answers, Sheriff of Sworn and subscribed before me this _ day of 20 20, at o'clock M. served the copy of the original COSTS SERVICE MILEAGE _ AFFIDAVIT the contents thereof. County, PA of f-Tre of 14-C Mary Jane Snyder Real Estate Deputy William T. Tully Solicitor J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy Dauphin County Harrisburg, Pennsylvania 17101 ph:(717)255-2660 fax:(717)255-2889 Jack Lotwick Sheriff ConLnonwealth of Pennsylvania SUSQUEHANNA VALLEY NURSING AND vs County of Dauphin NICKENS GREGORY E AS POA ATTORNEY INFA Sheriff's Return No. 1192-T - - -2005 OTHER COUNTY NO. 05-2312 CIVIL NOW:July S, 2005 at 1:OOPM served the within NOTICE & JOINDER COMPLAINT upon NICKENS GREGORY E AS POA ATTORNEY INFACT by personally handing RESPONSIBLE PARTY FOR DAVID WALKER to GREGORY NICKENS DEFT 1 true attested copy(ies) of the original NOTICE & JOINDER COMPLAINT and making known to him/her the contents thereof at 2659 WALDO ST HARRISBURG, PA 17110-0000 Sworn and subscribed to before me this 11TH day of JULY, 2005 "It - !-- NOTARIAL SEAL MARY JANE SNYDER, Notary Public Highspire, Dauphin County My Commission Expires Sept. 1, 2006 So Answers, y /,i? Sheriff's COSts:$36.a9--P15 07/06/2005 RCPT NO 206505 SP (office of e rS4,vxrff Mary Jane Snyder Real Estate Deputy William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255-2660 fax: (717) 255-2889 Jack Lotwick Sheriff J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy Con nlonwealth of Pennsylvania SUSQUEHANNA VALLEY NURSING AND Vs County of Dauphin NICKENS GREGORY E AS POA ATTORNEY INFA Sheriff's Return No. 1192-T - - -2005 OTHER COUNTY NO. 05-2312 CIVIL AND NOW:July 8, 2005 at 1:OOPM served the within NOTICE & JOINDER COMPLAINT upon NICKENS GREGORY E. by personally handing to GREGORY E NICKENS DEFT 1 true attested copy(ies) of the original NOTICE & JOINDER COMPLAINT and making known to him/her the contents thereof at 2659 WALDO ST HARRISBURG, PA 17110-0000 Sworn and subscribed to before me this 11TH day of JULY, 2005 11 - A- NOTARIAL SEAL MARY JANE SNYDER, Notary Public Highspire, Dauphin County My Commission Expires Sept. 1, 2006 So Answers, yx ?Sheriff of Dau n Count By Detutf/sAjol ff Sheriff's Costs:$36.00 PD 07/06/2005 RCPT NO 208505 SP Donald R. Reavey, Esq. Attorney I.D.#82498 Michael B. Volk, Esq. Attorney I.D.#88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 PRAECIPE FOR ENTRY OF DEFAULT JUDGMENT AGAINST DEFENDANT DAVID WALKER To the Prothonotary: Please enter judgment for Plaintiff and against Defendant David Walker, and assess damages certified to be calculable as a sum certain from the Complaint. Principal due: $11,882.29 Attorney Fees: $2,335.00 Costs: $579.88 Current amount due : $14,797.17 Total Due: $14,797.17 I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unworn falsification to authorities. I verify that: 1. Defendant David Walker resides at 1700 Market Street, Camp Hill, PA 17011. 2. It is certified that a written notice of intention to file this praecipe was mailed to the Defendant against whom judgment is to be entered, and his Co-Defendants after the default occurred and at least 10 days prior to the date of the filing of this praecipe. A copy of the Notice of Intent to Enter Default Against Defendant David Walker is attached as Exhibit "A" and is hereby incorporated by reference. THIS DAY OF , JUDGMENT IS ENTERED IN FAVOR OF PLAINTIFF AND AGAINST DEFENDANT DAVID WALKER BY ORDER OF COURT AND DAMAGES ASSESSED AT THE SUM OF $14,797.17. 7;0? 2 C--? Prothonotary Date:. By. Do ]d R. Reavey, Esq. Attorney I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 NOTICE OF THE ENTRY OF DEFAULT JUDGMENT TO: David Walker 1700 Market Street Camp Hill, PA 17011 Pursuant to Pa. R.C.P. No. 236, you are hereby notified that a Judgment has been entered against you in the above proceeding as indicated below: X JUDGMENT BY DEFAULT - in the amount of $14,797.17; Money Judgment; Amount on Award of Arbitrators; Judgment on Verdict; Money Judgment Transferred from Other Jurisdiction; Other. IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE PLEASE CALL ATTORNEY MICHAEL VOLK, TELEPHONE NUMBER: (717) 233-4101 By: Donald R. Reavey, Esq. Attorney I.D.#82498 Michael B. Volk, Esq. Attorney I.D.#88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § AFFIDAVIT OF NON-MILITARY SERVICE The undersigned, being duly sworn, according to law, deposes and says that the Defendant(s) is not in the Military or Naval Service of the United States or its Allies, or otherwise within the provisions of the Solders' and Sailors' Civil Relief Act of Congress of 1940 as amended: 1. That Defendant, David Walker, is over 18 years of age, resides at 1700 Market Street, Camp Hill, PA 17011. Sworn to and subscribed before me this Aeday of(4Akj% 2005 COWAOMNEALTN OF PENNSYLVMgA NDWW Sed KrentalesFWW,NoblyRtk Oiy Of N*ftbLn, t)s 4" Owity WOMWA"m EK*esJune 7,20M Member, Penns*vnis Ass=1* bn Of Nowt" /,/ Z Donald R. Reavey, Esquire Attorney ID # 82498 Michael B. Volk, Esquire Attorney ID #88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Pla' tiff Date: ZC ??<' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 V. DAVID WALKER, Individually 1700 Market Street Camp Hill, PA 17011 § CIVIL ACTION - LAW § § § Plaintiff. § CAUSE NUMBER: § , § Defendant. § c ? -n 05-2312 NIT CD LJ E a IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT GENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 LISTED ESTA EN REBELDIA PRRQUE HA FALLADO DE TOMAR ACCION REQUERIDA EN ESTE CASO. A kIENOS QUE USTED TOME ACCION DENTRO DE LOS PROXIMOS DIEZ (10) DIAS DE LA FECHA DE ESTE ADVISO, SE PUEDEDICTAR UN FALLO EN CONTRA SUYA SIN LLEVARSE A CABO UNA VISTA Y USTED PUEDE PEREDR SU PROPRIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO IMMEDEMENTE A SU ABOGADO. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGAR UNO, VAYA 0 LLAME LA OFICINA ABAJO INDICATA PARA QUE LE INFORMEN DONDE PUEDE CONQUIR AYUDA LEGAL. REGISTRAR COMPARECENCIA ESCRITA POR SI MISMO O ATRAVES DE UN ABOGADO SOMETER CON LA CORTE SUS DEFENSAS Y OBJECCIONES A LOS CARGOS QUE HAN PRESENTADO CONTRA USTED. A MENDS QUE USTED ACTUE DENTRO DE DIEZ DIAS DE HABER RECIBIDO ESTE ADVISO, LA CORTE PUEDE TOMAR UNA DECISION EN CONTRA SUYA SIN TENER DIRECHOS A UNA VISTA Y USTED PUEDE PERDER SU PROPIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEDERLE INFORMACION A CIRCA DE COMO CONSIGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA PUEDA PROVEDER INFORMACION SOBRE DE AGENCIAS QUE OFRESCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE QUALIFICAN. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 Date: <. t 7-C,o? onald R. Reavey, Esq. Attorney I.D. # 82498 vMichael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above style and numbered cause of action, hereby certify that I did on this the 2 ? 'r-- day of 2005, serve a true and correct copy of the Notice of Intent to Enter fault Judgment against Defendant David Walker upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Wendy J.F. Grella, Esq. 3618 North 6a` Street P.O. Box 5292 Harrisburg, PA 17110 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 V Donald R. Reavey, Esq. Z orney I.D. # 82498 chael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff CERTIFICATE OF SERVICE I, Michael Volk, hereby certify that I am serving this / ?day of July, 2005, a copy of the A/\ Affidavit OfNon-Military Service, upon the persons and in the manner indicated: Service by Regular First Class U.S. Mail, postage paid, addressed as follows: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 1701 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Respectfully Submitted, ??v { .- By: Donald R. Reavey, Esq. Attorney I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE Ze'L?7 I, Michael Volk, hereby certify that I am serving thisday of 2005, a copy of the Praecipe for Entry of Default Judgment against Defers ant Dupon the persons and in the manner indicated: Service by Regular First Class U.S. Mail, postage paid, addressed as follows: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 V14 FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Respectfully submitted: r By. Don d R. Reavey, Esq. Atto ey I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 ? ? Il C'J Y 4) { Donald R. Reavey, Esq. Michael B. Volk, Esq. Attorney I.D.#88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 NOTICE OF INTENT TO ENTER DEFAULT JUDGMENT AGAINST DEFENDANT GREGORY E. NICKENS IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT GENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 USTED ESTA EN REBELDIA PRRQUE HA FALLADO DE TOMAR ACCION REQUERIDA EN ESTE CASO. A MENOS QUE USTED TOME ACCION DENTRO DE LOS PROXIMOS DIEZ (10) DIAS DE LA FECHA DE ESTE ADVISO, SE PUEDEDICTAR UN FALLO EN CONTRA SUYA SIN LLEVARSE A CABO UNA VISTA Y USTED PUEDE PEREDR SU PROPRIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO IMMEDEMENTE A SU ABOGADO. SI USTED NO TIENE UN ABOGADO 0 NO PUEDE PAGAR UNO, VAYA 0 LLAME LA OFICINA ABAJO INDICATA PARA QUE LE INFORMEN DONDE PUEDE CONQUIR AYUDA LEGAL. REGISTRAR COMPARECENCIA ESCRITA POR SI MISMO O ATRAVES DE UN ABOGADO SOMETER CON LA CORTE SUS DEFENSAS Y OBJECCIONES A LOS CARGOS QUE HAN PRESENTADO CONTRA USTED. A MENOS QUE USTED ACTUE DENTRO DE DIEZ DIAS DE HABER RECIBIDO ESTE ADVISO, LA CORTE PUEDE TOMAR UNA DECISION EN CONTRA SUYA SIN TENER DIRECHOS A UNA VISTA Y USTED PUEDE PERDER SU PROPIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGA.DO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEDERLE INFORMACION A CIRCA DE COMO CONSIGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA PUEDA PROVEDER INFORMACION SOBRE DE AGENCIAS QUE OFRESCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE QUALIFICAN. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 Date: ?;170Q Donald R. Reavey, Esq. Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in bove style and numb red cause of action, hereby certify that I did on this the 3V day of G e, e 2005, serve a true and correct copy of the Notice of Intent to Enter Defau t Judgment against Defendant Gregory Nickens upon the person(s), and/or their counsel, in the manner indicated below: V14 FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 / VIA FIRST CLASS MAIL: David Walker 1700 Market Street / Camp Hill, PA 17011 Donald R. Reavey, Esq. Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff Donald R. Reavey, Esq. Michael B. Volk, Esq. Attorney I.D.988553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 PRAECIPE FOR ENTRY OF DEFAULT JUDGMENT AGAINST DEFENDANT GREGORY E. NICKENS To the Prothonotary: Please enter judgment for Plaintiff and against Defendant Gregory E. Nickens and assess damages certified to be calculable as a sum certain from the Complaint. Principal due: $11,882.29 Attorney Fees: $2,335.00 Costs: $579.88 Current amount due : $14,797.17 Total Due: $14,797.17 I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unworn falsification to authorities. I verify that: 1. Defendant Gregory Nickens resides at 2659 Waldo Street, Harrisburg, PA 17110. 2. It is certified that a written notice of intention to file this praecipe was mailed to the Defendant against whom judgment is to be entered, and his Co-Defendant after the default occurred and at least 10 days prior to the date of the filing of this praecipe. A copy of the Notice of Intent to Enter Default Against Defendant Gregory Nickens is attached as Exhibit "A" and is hereby incorporated by reference. THIS DAY OF , JUDGMENT IS ENTERED IN FAVOR OF PLAINTIFF AND AGAINST DEFENDANT GREGORY NICKENS BY ORDER OF COURT AND DAMAGES ASSESSED AT THE SUM OF $14,797.17. Date: -31 ?? O? By: Don lTRReavey, Esq. Attorney I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Prothonotary IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael Volk, hereby certify that I am serving this-? ?day of 2005, a copy of the Praecipe for Entry of Default Judgment against Defendant Gregory Nickens upon the persons and in the manner indicated: Service by Regular First Class U.S. Mail, postage paid, addressed as follows: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Respectfully submitted: By: Do Id R. Reavey, Esq. Attorney I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Donald R. Reavey, Esq. Michael B. Volk, Esq. Attorney I.D.#88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § NOTICE OF INTENT TO ENTER DEFAULT JUDGMENT AGAINST DEFENDANT GREGORY E. NICKENS IMPORTANT NOTICE - c YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. Am? 1 YOU SHOULD TAKE THIS NOTICE TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT GENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 USTED ESTA EN REBELDIA PRRQUE HA FALLADO DE TOMAR ACCION REQUERIDA EN ESTE CASO. A MENOS QUE USTED TOME ACCION DENTRO DE LOS PROXIMOS DIEZ (10) DIAS DE LA FECHA DE ESTE ADVISO, SE PUEDEDICTAR UN FALLO EN CONTRA SUYA SIN LLEVARSE A CABO UNA VISTA Y USTED PUEDE PEREDR SU PROPRIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO IMMEDEMENTE A SU ABOGADO. SI USTED NO TIENE UN ABOGADO 0 NO PUEDE PAGAR UNO, VAYA 0 LLAME LA OFICNA ABAJO NDICATA PARA QUE LE NFORMEN DONDE PUEDE CONQUIR AYUDA LEGAL. REGISTRAR COMPARECENCIA ESCRITA POR SI MISMO 0 ATRAVES DE UN ABOGADO SOMETER CON LA CORTE SUS DEFENSAS Y OBJECCIONES A LOS CARGOS QUE RAN PRESENTADO CONTRA USTED. A MENDS QUE USTED ACTUE DENTRO DE DIEZ DIAS DE HABER RECIBIDO ESTE ADVISO, LA CORTE PUEDE TOMAR UNA DECISION EN CONTRA SUYA SIN TENER DIRECHOS A UNA VISTA Y USTED PUEDE PERDER SU PROPIEDAD Y OTROS DIRECHOS IMPORTANTES. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICNA. ESTA OFICNA PUEDE PROVEDERLE NFORMACION A CIRCA DE COMO CONSIGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICNA PUEDA PROVEDER NFORMACION SOBRE DE AGENCIAS QUE OFRESCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE QUALIFICAN. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 Date: Donald R. Reavey, Esq. Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, v. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 Defendant. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in th?bove style and numb red cause of action , hereby certify that I did on this the 3=- day of 2005, serve a true and correct copy of the Notice of Intent to Enter Defau t Judgment against Defendant Gregory Nickens upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 VIA FIRST CLASS MAIL: David Walker i 1700 Market Street Camp Hill, PA 17011 Donald R. Reavey, Esq. Attorney I.D. # 82498 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff CERTIFICATE OF SERVICE 0K I, Michael Volk, hereby certify that I am serving this 7/ day of August, 2005, a copy of the Affidavit OfNon-Military Service, upon the persons and in the manner indicated: Service by Regular First Class U.S. Mail, postage paid, addressed as follows: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Respectfully By: -4Donald R. Reavey, Esq. Attorney I.D. No. 88553 Michael B. Volk, Esq. Attorney I.D. No.: 88553 Capozzi and Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Donald R. Reavey, Esq. Attorney I.D.482498 Michael B. Volk, Esq. Attorney I.D.488553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 AFFIDAVIT OF NON-MILITARY SERVICE The undersigned, being duly sworn, according to law, deposes and says that the Defendant(s) is not in the Military or Naval Service of the United States or its Allies, or otherwise within the provisions of the Solders' and Sailors' Civil Relief Act of Congress of 1940 as amended: 1. That Defendant, Gregory Nickens, is over 18 years of age, resides at 2659 Waldo Street, Harrisburg, PA 17110. Sworn to and subscribed before me this I-W day of. , 2005 otary Oubc C,pMMONWEALTH OF PENNSYLVANIA NoW W Seed Karen W As Fisher, Notary Public county W June 7, Zoos Member, PenneNvenis Aesafenon Of Wt*"s i Donald R. Reavey, Esquire Attorney ID # 82498 Michael B. Volk, Esquire Attorney ID #88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff YLV? Date: O C V? f fa b. T }S ' l f `, ?\ ? ? J ? w ? ?, v h r.'; ?? p ?0 1l T`- rn I ? i'iT , `, 1 ? .5 ?. ? .?? rn ? r.a { ,- ? qq Ci '-? ?; ? ? =? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § Principal: $14,797.17 § Clerk's costs: $15.50 § Sheriff s costs: $150.00 § Attorney fees: $350.00 § TOTAL: $15,312.67 PRAECIPE TO ISSUE WRIT OF EXECUTION FOR ATTACHMENT AND GARNISHMENT OF BANK ACCOUNT To the Prothonotary: Issue a Writ of Execution in the above matter, (1) directed to the Sheriff of Dauphin County, Pennsylvania. (2) against Defendant David Walker, 1700 Market Street, Camp Hill, PA 17512; (3) against Gregory E. Nickens, 2659 Waldo Street, Harrisburg, PA 17110; and (4) against Fulton Bank Branch, as garnishee, located at Third and Locust Streets, Harrisburg, PA 17101; and (5) Exemption has (not) been waived. Date: Z 1147'?°'` ' 2ae s By. 11,11,41 - Michael B. Volk, Esquire Attorney ID No. 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 3 c: L-7 0 o r a? PA cy? :S7 Michael B. Volk, Esq. Attorney I.D.#88553 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: § Principal: § Clerk's costs: § Sheriffs costs: § Attorney fees: § TOTAL: 05-2312 $14,797.17 $15.50 $150.00 $350.00 $15,312.67 NOTICE OF WRIT OF EXECUTION FOR ATTACHMENT AND GARNISHMENT OF BANK ACCOUNT TO: David Walker This paper is a Writ of Execution. It has been issued because there is a judgment against you. It may cause your property to be held or taken to pay the judgment. You may have legal rights to prevent your property from being taken. A lawyer can advise you more specifically of these rights. If you wish to exercise your rights, you must act promptly. The law provides that certain property cannot be taken. Such property is said to be exempt. There is a debtor's exemption of $300.00. There are other exemptions which may be applicable to you. Attached is a summary of some of the major exemptions. You may have other exemptions or other rights. If you have an exemption, you should do the following promptly: (1) Fill out the attached claim form and demand for a prompt hearing. (2) Deliver the form or mail it to the Sheriff s Office at the address noted. You should come to court ready to explain your exemption. If you do not come and prove your exemptions, you may lose some of your property. 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 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § Principal: $14,797.17 § Clerk's costs: $15.50 § Sheriff's costs: $150.00 § Attorney fees: $350.00 § TOTAL: $15,312.67 WRIT OF EXECUTION FOR ATTACHMENT AND GARNISHMENT OF BANK ACCOUNT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN: To the Sheriff of Dauphin County: To satisfy the judgment, interest and costs against David Walker, Defendant, (1) You are directed to attach the property of the Defendant, David Walker not levied upon, being held in the IOLTA Account of Capozzi & Associates at the Fulton Bank, to wit: Specifically, the IOLTA Account under the name of Capozzi & Associates, located at the Fulton Bank, Third and Locust Streets, Harrisburg, PA 17101, account numbered 54166136, in which the Defendant, David Walker may hold a partial property right to funds segregated in the name of the Plaintiff, in the amount of $14,556.00, are being held: And to notify Garnishee that; (a) an attachment has been issued; 4 (b) the Garnishee is enjoined from paying any debt to or for the account of Capozzi & Associates and from delivering any property of Capozzi & Associates or otherwise disposing thereof. (2) If the property of the Defendant not levied upon and subject to attachment is found in the possession of anyone other than named garnishee, you are directed to notify him that he has been added as a Garnishee and is enjoined as above stated. Amount Due: Principal: Clerk's costs: Sheriff's Cost Attorney Costs: TOTAL: 14,797.17 15.50 150.00 350.00 $ 15,312.67 (Name of the Prothonotary) (Clerk) Seal of the Court By: 5 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § Principal: $14,797.17 § Clerk's costs: $15.50 § Sheriffs costs: $150.00 § Attorney fees: $350.00 § TOTAL: $15,312.67 CLAIM FOR EXEMPTION To the Sheriff: I, David Walker, Defendant, claim exemption of property from levy or attachment: (1) From my personal property in my possession which has been levied upon, (a) I desire that my $300.00 statutory exemption be (i) set aside in kind (specify property and basis of exemption: _ (ii) paid in cash following the sale of the property levied upon; or (2) From my property which is in the possession of a third party, I claim the following exemptions: (a) my $300 statutory exemption: _ in cash; _ in kind (specify property): (b) Social Security benefits on deposit in the amount of $ ; (c) other (specify amount and basis of exemption): 6 I request a prompt court hearing to determine the exemption. Notice of the hearing should be given to me at (Address) (Telephone Number) I verify that the statements made in this claim for Exemption are true and correct. I understand that false statements herein are made subsequent to the penalties of 18 Pa. C.S. 4904 relating to unworn falsification to authorities. Date: (Defendant) THIS CLAIM TO BE FILED WITH THE OFFICE OF THE SHERIFF OF DAUPHIN COUNTY Dauphin County Courthouse Front and Market Streets Harrisburg, PA 17101 MAJOR EXEMPTIONS UNDER PENNSYLVANIA AND FEDERAL LAW $300.00 statutory exemption 2. Bibles, school books, sewing machines, uniforms and equipment Most wages and unemployment benefits 4. Social Security benefits Certain retirement funds and accounts Certain veteran and armed forces benefits Certain insurance proceeds 8. Such other exemptions as may be provided by law IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Parry and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: § Principal: § Clerk's costs: § Sheriff's costs: § Attorney fees: § TOTAL: CERTIFICATE OF SERVICE 05-2312 $14,797.17 $15.50 $150.00 $350.00 $15,312.67 I, Michael B. Volk, an attorney for Plaintigin the above ? styled and numbered cause of action , hereby certify that I did on this the / sue- day of q ?--- 2005, serve a true and correct copy of the Praecipe to Issue a Writ of Execution for Attachment and Garnishment of Bank Account upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 VIA EIRST CLASS MAIL: I Walker Market Street Hill, PA 17011 Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Plaintiff WRIT OF EXECUTION and/or ATTACHMENT COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND) NO 05-2312 Civil CIVIL ACTION - LAW TO THE SHERIFF OF DAUPHIN COUNTY: To satisfy the debt, interest and costs due SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC., Plaintiff (s) From DAVID WALKER, INDIVIDUALLY, 1700 MARKET STREET, CAMP HILL, PA 17011 AND GREGORY E. NICKENS, INDIVIDUALLY AND AS POWER OF ATTORNEY, ATTORNEY IN FACT, RESPONSIBLE PARTY AND/OR FIDUCIARY FOR DAVID WALKER, 2659 WALDO STREET, HARRISBURG, PA 17110 (1) You are directed to levy upon the property of the defendant (s)and to sell (2) You are also directed to attach the property of the defendant(s) not levied upon in the possession of FULTON BANK BRANCH AS GARNISHEE LOCATED AT THIRD AND LOCUST STREETS, HARRISBURG, PA 17101 GARNISHEE(S) as follows: and to notify the gamishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant (s) or otherwise disposing thereof; (3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a garnishee and is enjoined as above stated. Amount Due $14,797.17 Interest L.L. $.50 Arty's Comm % Arty Paid $330.49 Plaintiff Paid Date: SEPTEMBER 26, 2005 (Seal) REQUESTING PARTY: Name MICHAEL B. VOLK, ESQUIRE Address: 2933 NORTH FRONT STREET HARRISBURG, PA 17110 Attorney for: PLAINTIFF Telephone: 717-233-4101 Due Prothy $1.00 Other Costs - ATTORNEY FEES - $350.00 irothonotary. By: Deputy Supreme Court ID No. 88553 4 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, v. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § § CAUSE NUMBER: 05-2312 RULE DEC 1 3 2005 ." )f AND NOW, this I r; - day of D/ ee, d , , 2005, upon consideration of Plaintiff's Motion, Rule is hereby issued upon Defendants to show cause why the relief requested should not be granted. Rule returnable feeteet -H* days from the date of service via regulanmail. In the event that Defendants fail to respond to this rule, Plaintiff shall file a Petition to Make Rule Absolute, at which point an Order granting Plaintiff s Motion will be issued. A4 13 V\ ?. ?1-9 ?, ? I Michael B. Volk, Esq. Attorney I.D. #88553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 MOTION TO RELEASE FUNDS AND NOW, comes Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center, by and through their attorney, Michael B. Volk, Esquire, of the law firm Capozzi & Associates, P.C., and in support thereof, respectfully shows the Court as follows: Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center (hereafter, "Plaintiff'), operates a long-term care nursing facility located at 745 Chiques Hill Road, Columbia, PA 17512. 2. Defendant David Walker is an adult individual who previously resided at the Susquehanna Nursing and Rehabilitation Center, 745 Chiques Hill Road, Columbia, PA 17512. On or about May 14, 2004, Defendant David Walker requested that Plaintiff admit him to Plaintiff's facility so he could receive nursing care and services. 4. On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the facility to receive nursing care and services. On or about May 14, 2004, Plaintiff represented a promise to provide nursing care and services to Defendant David Walker. Simultaneously, David Walker, in requesting admission, represented a promise to pay Plaintiff for the nursing care and services. 6. Due to the refusal of Defendant to remit payment in full each month for the nursing care and services rendered, this action was instituted against Defendants. A Judgment in the amount o5 11,882.20 for the amount owed, attorney fees of $2,335.00 and costs of $579.88, totaling $14,797.17 was entered against David Walker on July 25, 2005 and against Defendant Gregory Nickens on September 1, 2005. 8. Giving rise to this matter was a check in the amount of $14,556.00 made payable to Defendant David Walker and Plaintiff, tendered by the Social Security Administration for payment of Defendant David Walker's recovery. A copy of the check is attached to this Motion as Exhibit "I". 9. Defendant David Walker wanted the check returned to him, indorsed, for his own use. 10. Plaintiff maintains that the funds should be used for their intended purpose, namely, to pay for the recovery and rehabilitation services provided by Plaintiff to Defendant David Walker and to pay for the judgment entered against the Defendants. 11. Plaintiff respectfully requests that this Honorable Court issue a rule upon Defendants to show cause why Plaintiff should the authority to endorse the check and use the proceeds to satisfy the judgment against Defendants. 12. Plaintiff respectfully requests that this Honorable Court issue a rule upon Defendants to show cause why these funds should not be released to Plaintiff and used to satisfy Defendants' debt for services rendered and to satisfy the judgment. WHEREFORE, Plaintiff respectfully requests that a rule be issued upon Defendant to show cause why the funds currently being held in trust by Attorney for Plaintiff should not be released in satisfaction of Defendant's debt. Date: 6 OA Q, fin" -Zoas- Respectfully submitted, CYAP D SOCIATES, P.C. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above styled and numbered W- cause of action , hereby certify that I did on this the (o day of 0"-" r 2005, serve a true and correct copy of the Motion for Rule to Release Funds upon the person(s), and/or their counsel, in the manner indicated below: VIA FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA FIRST CLASS MAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 4 /Michael/B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff L ?.? J r._. '. '_ ?. ?.? C'J !_ .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW a? § § CAUSE NUMBER: 05-2312 § § § i PETITITON TO MAKE RULE ABSOLUTE FOR RELEASE OF FUNDS AND NOW, comes Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center, by and through its attorney, Michael B. Volk, Esq. and in support thereof, respectfully shows the Court as follows: 1. Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center (hereafter, "Plaintiff'), operates a long-term care nursing facility located at 745 Chiques Hill Road, Columbia, PA 17512. 2. Defendant David Walker is an adult individual who previously resided at the Susquehanna Nursing and Rehabilitation Center, 745 Chiques Hill Road, Columbia, PA 17512. 3. On or about May 14, 2004, Defendant David Walker requested that Plaintiff admit him to Plaintiffs facility so he could receive nursing care and services. 4. On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the facility to receive nursing care and services. 5. On or about May 14, 2004, Plaintiff represented a promise to provide nursing care and services to Defendant David Walker. Simultaneously, David Walker, in requesting admission, represented a promise to pay Plaintiff for the nursing care and services. 6. Due to the refusal of Defendant to remit payment in full each month for the nursing care and services rendered, this action was instituted against Defendants. 7. A Judgment in the amount of$1 1,882.20 for the amount owed, attorney fees of $2,335.00 and costs of $579.88, totaling $14,797.17 was entered against David Walker on July 25, 2005 and against Defendant Gregory Nickens on September 1, 2005. 8. Giving rise to this matter was a check in the amount of $14,556.00 made payable to Defendant David Walker and Plaintiff, tendered by the Social Security Administration for payment of Defendant David Walker's recovery. 9. Defendant David Walker wanted the check returned to him, indorsed, for his own use. 10. Plaintiff maintains that the funds should be used for their intended purpose, namely, to pay for the recovery and rehabilitation services provided by Plaintiff to Defendant David Walker and to pay for the judgment entered against the Defendants. 11. This Motion to release funds was filed on or about December 8, 2005. A copy of the Motion is attached as Exhibit "1" and is hereby incorporated by reference. 12. A Rule was issued upon Defendants on or about December 16a', 2005 to show cause why Plaintiffs Motion to Release funds should no be granted and was served upon Defendants on or about December 27th, 2005. A copy of the rule is attached as Exhibit "2" and is incorporated by reference. Copies of the outgoing envelopes as well as the certified mail receipts showing transmittal of the rule are attached as Exhibit "3" and are hereby incorporated by reference. 13. As of the date of this Petition, no answer or response has been received. 14. In accordance with the terms of the Rule, Defendant has failed to respond to the Rule, Plaintiff has filed this Petition to Make Rule Absolute. WHEREFORE, Plaintiff respectfully requests this Honorable Court make the Rule of December 16th, 2005 absolute and issue the proposed order granting Plaintiff's Motion to Release Funds. Dated: r 9(4- 0 ;-60 6 Respectfully submitt d: n Michael B. Volk Attorney ID # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff ,vlichael B. Volk, Esq. Attorney I.D. 988553 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17055 Tel: (717) 233-4101 DEC 1 3 2005 cop Attorneys for: Susquehanna Valley Nursing and Rehabilitation Center, LLC N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attomey in Fact, Responsible Party andior fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § § § § § MOTION TO RELEASE FUNDS T_ C i ? - i ^ c: W AND NOW, comes Plaintiff. Susquehanna Valley Nursing and Rehabilitation Center, by and through their attorney, Michael B. Volk, Esquire, of the law firm Capozzi & Associates, P.C., and in support thereof, respectfully shows the Court as follows: Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center (hereafter, "Plaintiff'), operates a long-term care nursing facility located at 745 Chiques Hill Road, Columbia, PA 17512. EXHIBIT 8 Defendant David Walker is an adult individual who previously resided at the Susquehanna Nursing and Rehabilitation Center, 745 Chiques Hill Road, Columbia, PA 17512. On or about May 14, 2004, Defendant David Walker requested that Plaintiff admit him to Plaintiffs facility so he could receive nursing care and services. 4. On or about May 14, 2004, Plaintiff admitted Defendant David Walker to the facility to receive nursing care and services. 5. On or about May 14, 2004, Plaintiff represented a promise to provide nursing care and services to Defendant David Walker. Simultaneously, David Walker, in requesting admission, represented a promise to pay Plaintiff for the nursing care and services. 6. Due to the refusal of Defendant to remit payment in full each month for the nursing care and services rendered, this action was instituted against Defendants. A Judgment in the amount of$11,982.20 for the amount owed, attorney fees of $2,335.00 and costs of $579.88, totaling $14,797.17 was entered against David Walker on July 25, 2005 and against Defendant Gregory Nickens on September 1, 2005. 8. Giving rise to this matter was a check in the amount of S 14,556.00 made payable to Defendant David Walker and Plaintiff, tendered by the Social Security Administration for payment of Defendant David Walker's recovery. A copy of the check is attached to this Motion as Exhibit "1 ". 9. Defendant David Walker wanted the check returned to him, indorsed, for his own use. to. Plaintiff maintains that the funds should be used for their intended purpose, namely, to pay for the recovery and rehabilitation sen ices provided by Plaintiff to Defendant David Walker and to pay for the judgment entered against the Defendants. 11. Plaintiff respectfully requests that this Honorable Court issue a rule upon Defendants to show cause why Plaintiff should the authority to endorse the check and use the proceeds to satisfy the judgment against Defendants. 12. Plaintiff respectfully requests that this Honorable Court issue a rule upon Defendants to show cause why these funds should not be released to Plaintiff and used to satisfy Defendants' debt for services rendered and to satisfy the judgment. WHEREFORE, Plaintiff respectfully requests that a rule be issued upon Defendant to show cause why the funds currently being held in trust by Attorney for Plaintiff should not be released in satisfaction of Defendant's debt. fo { 1R1a,& ?.tied' Date: Respectfully submitted, CAP ZZI SOCIATES, P.C. By Michael B. Folk, Esq. Attorney I.D. = 53553 2933 North Front Street Harrisburs. PA 171 10 (717)233-4101 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above styled and numbered v? cause of action , hereby certify that I did on this the (v ` day of 0? 2005, serve a true and correct copy of the Motion for Rule to Release Funds upon the person(s), and/or their counsel, in the manner indicated below: GId FIRST CLASS MAIL: David Walker 1700 Market Street Camp Hill, PA 17011 PIA FIRST CLASS tVAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 4 ? Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § § § CAUSE N-LMBER: DEC 1 3 2005 05-2312 RULE AND NOW, this rL day of n 2005, upon consideration of Plaintiff's Motion, Rule is hereby issued upon Defendants to show cause why the relief requested should not be granted. -J' Rule returnable €emrteem (i65 days from the date of service via regularrail. In the event that Defendants fail to respond to this rule, Plaintiff shall file a Petition to Make Rule Absolute, at which point an Order granting Plaintiff's Motion will be issued,, i J. 11 EXHIBIT 2 N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYLVANIA SUSQUEHANNA VALLEY NURSENG AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attomey, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § 3 § CAUSE NUMBER: 05-2312 § § § § CERTIFICATE OF SERVICE I, Michael B. Volk, an attorney for Plaintiff in the above styled ltd num ered cause of action , hereby certify that I did on this the /9 4^ day of 2005, serve a true and correct copy of the Rule on Plaintiff s Motion to Release Funds upon the person(s), and/or their counsel, in the manner indicated below: VIA CERTIFIED AIAIL:7003-2260-0000-2421-4490 VIA FIRST CLASS AlAIL: David Walker 1700 Market Street Camp Hill, PA 17011 VIA CERTIFIED V1.4IL:7005-0390-0001-4509-5354 VIA FIRST CLASS NAIL: Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 ?LI Michael B. Volk, Esq. Attorney I.D. # 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff -L'ln' , CERTIFIED M AIL,. RECEIPT m (Vomestic Mail Only; No Insurance Coverage Provided) Ln a ° J IL ui 7 Postage ap Cerlifled Fee R l F R "-` O9.!P'f75ef.K ' p eturn ece pt ee (Endcrsement Required) ; Uxe .1 Er Reatn'cted Oelly y Fee (Entlorsement Required) m m Total Postage & Fees lA M p o/-? _..???yyy Gy fe, +4 Jun. 2002 PS F.. 3800 ? [ t See Reverse for (nstructions , 3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, V. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 CERTIFICATE OF SERVICE I, Karen Fisher, an employee for Capozzi and Associates, PC, hereby certify that I did on this the t?' day of d /{ 2006, serve a true and correct copy of the Petition to ?Iake Rule Absolute for Release of Funds, upon the person(s), and/or their counsel, in the manner indicated below: David Walker Gregory E. Nickens 1700 Market Street 2659 Waldo Street Camp Hill, PA 17011 Harrisburg, PA 17110 aren Fi aralegal 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff ;, -r ,_ ?. J rt_iVED mAR D 3 ?C IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC 745 Chiques Hill Road Columbia, PA 17512 Plaintiff, v. DAVID WALKER, Individually, 1700 Market Street Camp Hill, PA 17011 and GREGORY E. NICKENS, Individually and as Power of Attorney Attorney in Fact, Responsible Party and/or Fiduciary for David Walker, 2659 Waldo Street Harrisburg, PA 17110 Defendants. § CIVIL ACTION - LAW § CAUSE NUMBER: 05-2312 § ti § ORDER In consideration of Plaintiff's duty filed and served Motion to Release funds and seeing that no response to the same has been made by Defendants, it is hereby ORDERED that the check in question be released to Plaintiff to satisify the judgment taken against Defendants. 0 '041f CX Signed this t4e-? 3 day of Sam , 2006. ?v l?`0 0? •?? f i COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Susquehanna Valley Nursing and Rehabilitation Center, LLC, CIVIL ACTION - LAW Plaintiff CAUSE NUMBER: 05-2312 V. David Walker and Gregory E. Nickens, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker Defendant PRAECIPE TO WITHDRAW APPEARANCE Please withdraw my appearance as counsel on behalf of Plaintiff, Susque a Valley Nursing and Rehabilitation Center, LLC, in the above-referenced matt . New counsel is concurrently entering his appearance. Michael B. Volk, Esquire Attorney I.D. No. 88553 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 PRAECIPE TO ENTER APPEARANCE Please enter my appearance as new counsel on behalf of Plaintiff, Susquehanna Valley Nursing and Rehabilitation Center., LI,C, in the above-referenced matter. 'ATidf w R(?mann, Esquire Attorney I.D. No. 87441 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Dated: 1 a7 e .t COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Susquehanna Valley Nursing and Rehabilitation Center, LLC, CIVIL ACTION - LAW Plaintiff CAUSE NUMBER: 05-2312 vi. David Walker and Gregory E. Nickens, Individually and as Power of Attorney, Attorney in Fact, Responsible Party and/or Fiduciary for David Walker Defendant CERTIFICATE OF SERVICE I hereby certify that I have, this date, mailed a true and correct copy of the foregoing document by United States mail, first-class, postage prepaid, addressed to the following individual: David Walker 1700 Market Street Camp Hill, PA 17011 Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 J fifer K A, Paralegal Dated: I AIV r-> 77x - 5 Y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC, Plaintiff p?- 01310' V. Cumberland CCP No.: 85 23 i g DAVID WALKER, Individually, and GREGORY E. NICKENS, Defendants PRAECIPE TO SATISFY JUDGMENT AND DISCONTINUE ACTION TO THE PROTHONOTARY: Kindly mark the Judgment in the above-captioned matter as satisfied and discontinued. Respectfully submitted, Date: October 6, 2008 By: CAPOZZI & ASSOrI kTES, P.C. w R ise , Esquire Attorney 74 1 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff AND NOW, this day of , 2008, the judgment in the above-captioned action against the Defendants is hereby marked SATISFIED and DISCONTINUED of record. Prothonotary W` IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Cumberland CCP No.: 05-2313 SUSQUEHANNA VALLEY NURSING AND REHABILITATION CENTER, LLC, Plaintiff V. DAVID WALKER, Individually, and GREGORY E. NICKENS, Defendants CERTIFICATE OF SERVICE I hereby certify that I caused a copy of the foregoing Praecipe to Satisfy and Discontinue to be served by regular first class United States mail, postage prepaid addressed as follows: David Walker 2422 N. 0 Street Harrisburg, PA 17110-1905 Gregory E. Nickens 2659 Waldo Street Harrisburg, PA 17110 Date: October 6, 2008 By: Esquire Capozzi soda s, P.C. Attorney I.D. # 87441 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff c`? ? ? ? ? ?:rt? °s? . . ?,, ` ` ? " ' =`r- ?.? ?? ??.._ s ? ?w ?. _ , -. _ ? ?? -?; c...a ?? ::? --?.