STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2015007903 NEW BEGINNING ASSISTED LIVING, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration , (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, NEW BEGINNING ASSISTED LIVING, INC. (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2014), and states: NATURE OF THE ACTION This is an action to impose an administrative fine against an unlicensed facility in the sum of ONE THOUSAND DOLLARS ($1,000.00) based upon one (1) violation pursuant to Section 408.812(4), Florida Statutes (2014), to assess a survey fee in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(7), Florida Statutes (2014) and to REVOKE the license pursuant to Section 429.14(1)(e) 2 and 3, Florida Statutes (2014). JURISDICTION AND VENUE 1. The Court has jurisdiction over the matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2014). 2. The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, and Chapters 408 and 429, Florida Statutes (2014). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES . 4, The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable federal and state regulations, statutes and rules governing such facilities. Chapters 408, and 429, Florida Statutes (2014); Chapter 58A-5, Florida Administrative Code. | ; 5. The Respondent was operating a licensed 5-bed facility (License #12436) located at 418 N.W. 21st Terrace, Cape Coral, Florida 33993, and was at all times material required to comply with the applicable state regulations, statutes and rules governing assisted living facilities. . | COUNT I The Respondent Failed To Obtain A License For Operation In Violation Of Sections 429.08(1)(a) And 408.812, Florida Statutes (2014) 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, Section 429.08, Florida Statutes (2014), applies to the unlicensed operation of an assisted living facility in addition to the requirements of Part II of Chapter 408. Section 429.08(1)(a), Florida Statutes (2014). Pursuant to Florida law, a person or entity may not offer or advertise services that require licensure as defined by this part, authorizing statutes, or applicable rules to the public without obtaining a valid license from the agency. A licenseholder may not advertise or hold out to the public that he or she holds a license for other than that,for which he or she actually holds the license. (2) The operation or maintenance of an unlicensed provider or the performance of any services that require licensure without proper licensure is a violation of this part and authorizing statutes. Unlicensed activity constitutes harm that materially affects the health, safety, and welfare of clients. The agency or any state attorney may, in addition to other remedies provided in this part, bring an action for an injunction to restrain such violation, or to enjoin the future operation or maintenance of the unlicensed provider. or the performance of any services in violation of this part and authorizing statutes, until compliance with this part, authorizing statutes, and agency rules has been demonstrated to the satisfaction of the agency. (3) It is unlawful for any person or entity to own, operate, or maintain an unlicensed provider. If after receiving notification from the agency, such person or entity fails to cease operation and apply for a license under this part and authorizing statutes, the person or entity shall be subject to : penalties as prescribed by authorizing statutes and applicable rules. Each day of continued operation is a separate offense. (4) Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance. (5) When a controlling interest or licensee has an interest in more than one provider and fails to license a provider rendering services that require licensure, the agency may revoke all licenses and impose actions under Section 408.814, Florida Statutes (2014) and a fine of $1,000 per day, unless otherwise specified by authorizing statutes, against each licensee until such time as the appropriate license is obtained for the unlicensed operation.(6) In addition to granting injunctive relief pursuant to subsection (2), Florida Statutes (2014), if the agency determines that a person or entity is operating or maintaining a provider without obtaining a license and determines that a condition exists that poses a threat to the health, safety, or welfare of a client of the provider, the person or entity is subject to the same actions and fines imposed against a licensee as specified in this part, authorizing statutes, and agency rules. (7) Any person aware of the operation of an unlicensed = provider must report that provider to the agency. Section 408.812, Florida Statutes (2014). 8. On or about July 1, 2015, the Agency conducted a Complaint Survey (CCR# 2015007102) of the Respondent’s facility. 9. Based on observation, interview, and record review, the Respondent failed to appropriately discharge 2 of 4 sampled residents, specifically Resident #1 and Resident #2, to a licensed location. The licensed assisted living facility moved the residents to an unlicensed location called New Beginning II operated by the licensed ALF Administrator. Failure to maintain ALF residents in a licensed location can place the residents at risk of harm, including abuse and neglect. 10. During an unlicensed activity complaint (CCR# 2015005278) investigation conducted on 7/1/15 at New Beginning II located at 1637 N.W. 5" Place in Cape Coral, Florida, 2 residents, specifically Resident #1 and Resident #2, were observed in their rooms and in the common area of the home. 11. On 7/1/15 at 11:00 a.m. an interview was conducted with Staff A at New Beginning II, located at 1637 N.W. 5" Place in Cape Coral, Florida. Staff A said that the Administrator of the licensed facility, New Beginning Assisted Living Facility Inc., located at 418 N.W. 21st Terrace, Cape Coral, Florida was the operator of the unlicensed facility. Staff A said that 2 residents, specifically Resident #1 and Resident #2, resided at the unlicensed location that was not related to the Operator. Staff A said she kept the facility clean and provided breakfast, lunch and dinner and snacks to the residents. Staff A said Resident #1 needed help in the shower and both residents needed 24 hour care and assistance with medication. Staff A said the Operator did not live in the facility and the Operator lived down the road. Staff A said Staff B did the medications at the unlicensed location and the Operator's licensed facility located at 418 N.W, 21st Terrace, Cape Coral, Florida. Staff A said Staff B "Gets the medications ready for me for the day and I just give them out in the cups." Staff A said Staff B puts the medications in the cups and puts the cups inside the medication cart where it says "ready meds." Staff A said the medications are kept in the medication cart locked and staff A keeps the keys on her wrist. Staff A said medications are given in the morning around 8:00 a.m. and at night around 6:00 p.m. Staff A said Staff B will sometimes come and do the medications and sign the medication observation records for each resident. (Photographic evidence obtained). 12. On 7/1/15 at 11:13 a.m., an interview was conducted with the Operator of the unlicensed facility. The Operator said she did not live in the unlicensed home located at 1637 N.W. 5" Place Cape Coral, Florida and states the home is not licensed. She currently has 2 residents at the unlicensed location and she has another facility in the area, New Beginnings ALF, Inc. located at 418 N.W. 21st Terrace, Cape Coral, FL, licensed for 5 residents. She said Resident #1 needs assistance with bathing, dressing, medications, cooking, cleaning, and meals. Resident #2 needs assistance with medications and meals. 13. On 7/1/15 at 11:27 a.m. an interview was conducted with Resident #1. Resident #1 said he/she required assistance with bathing, dressing, meals, cleaning, medications and transportation. Resident #1 said he/she moved to the licensed facility at 418 N.W. 21st Terrace Cape Coral, Florida because of a stroke 2 years ago. Resident #1 said he/she was admitted to the facility located at 418 N.W. 21st Terrace Cape Coral originally and was later asked to move over to the "men's only" unlicensed facility located at 1637 N.W. 5" Place Cape Coral. 14, On 7/1/15 at 11:40 a.m., an interview was conducted with Resident #2. Resident #2 said he/she has lived at the unlicensed location since March 2015. Resident #2 said the name of the facility was New Beginning and said the facility was an ALF. Resident #2 received assistance with medication as "They make sure I get it in the night and morning.” Resident #2 said the medications are given in a cup. The medications are prepared the night before by the Certified Nursing Assistant and whoever is on duty gives the medications. Resident #2 said when he/she first moved to the facility he/she was told to meet the Operator at the licensed facility New Beginning Assisted Living, Inc. located on 418 N.W. 21st Terrace in Cape Coral. Resident #2 said when he/she arrived at the licensed facility he/she was told to go to the 1637 N.W. 5” Place Cape Coral location, the unlicensed facility. Resident #2 said ‘when he/she arrived at the licensed location Resident #1 was residing there with three residents. 15. A follow-up interview was conducted on 7/1/15 at 12:05 p.m. with the unlicensed facility Operator at the licensed facility New Beginning Assisted Living, Inc. located at 418 N.W. 21st Terrace in Cape Coral. The Operator identified herself as the Administrator of the licensed facility located at 418 N.W. 21st Terrace Cape Coral. The Administrator said she made a verbal agreement for services and payment between the residents or their families. The Operator said she and another employee (Staff B) who also works at the licensed location had taken the medication and class and gives out the medications to the residents at the unlicensed location located at 1637 N.W. 5™ Place Cape Coral. The Operator said that she goes over to the unlicensed location and does the medications by prefilling medication cups for the residents. — The Operator said she knew she could have 2 people and not be licensed that is why she started the second home prior to being licensed and admitted that Resident #1 was a resident at her licensed facility located at 418 N.W. 21st Terrace in Cape Coral. 16. On 7/1/15 at 1:13 p.m. an interview was conducted with Staff B. Staff B said he has worked at the unlicensed location located at 1637 N.W. 5” Place Cape Coral and licensed location located at 418 N.W. 21st Terrace in Cape Coral for 3 months and he is a Certified Nursing Assistant with medication technician training. Staff B said he assists the residents at the unlicensed location with Activities of Daily Living and occasionally a shower. Staff B said he takes vital signs and assists with blood sugar testing and watches the residents take their medication. Staff.said only Resident #1 and Resident #2 lived at the unlicensed location, StaffB - said Resident #1 needs care with bathing and assists while Resident #1 is in the shower in case he/she falls and helps Resident #1 wash his/her back. Staff B said Resident #2 needs hélp with food and medications. Staff B said he prefills the cups for the medications and places the prefilled cups of medication in the drawer on the medication cart that says 'ready meds' and "they are ready to go." 17. On 7/6/15 at 1:25 p.m., a telephone interview was conducted with the daughter of Resident #2. Resident #2's daughter said she was told the 1637 N.W. 5" Place Cape Coral facility was a licensed ALF. Resident #2's daughter said she was told the owner just bought the home and was getting things together. Resident #2's daughter said she writes a check to the Administrator monthly to pay for her parent's care. 18. On 7/6/15 at 2:33 p.m., a telephone interview was conducted with the son of Resident #1. Resident #1’s son said he was told the 1637 N.W. 5" Place facility was an ALF. Resident #1’s son said he writes a monthly check for $3,000, payable to New Beginning Assisted Living, Inc. 19. A record review of the admission discharge log revealed that Resident #1 was admitted to the licensed facility at 418 N.W. 21st Terrace in Cape Coral on 3/4/15. No documentation was noted on the record that identified that Resident #1 was discharged from the licensed facility. (Photographic evidence obtained) 20. A record review of Resident #1's chart revealed a Health Assessment Form (AHCA Form 1823) dated 3/3/15. The AHCA Form 1823 revealed the name of the facility was the licensed facility located at 418 N.W. 21st Terrace in Cape Coral. The AHCA Form 1823 also revealed that Resident #1 met ALF admission criteria and needed assistance and/or supervision with Activities of Daily Living and medication assistance. Upon further review of Resident #1's chart, an undated resident agreement for services to be provided by the licensed ALF to Resident #1 revealed Resident #1's signature was signed on the agreement. (Photographic evidence obtained) 21. A review of two participant demographic sheets obtained from the unlicensed location for Resident #1 and Resident #2 revealed the name "New Beginning Assisted Living, Inc." with an admission date for Resident #1 as 3/4/15 and an admission date for Resident #2 as 3/5/12. 22. A review of the dining menu provided at the unlicensed location dated 10/6/14 and the dining menu provided by the Administrator of the licensed facility located at 418 N.W. 21st Terrace in Cape Coral dated 10/6/14 revealed the Administrator was using the menu provided for her licensed facility for the unlicensed facility. (Photographic evidence obtained) 23. On 7/1/15 at 1:45 p.m., an interview was conducted with the Administrator who said she made a copy of the licensed facility menu and was using the menu at the unlicensed ~ location. . 24. The Respondent’s actions or inactions constituted a violation of Section 408.812, Florida Statutes (2014). The Agency may impose an administrative fine for a violation that is not designated as a class I, class I, class III, or class IV violation. 25. Any person or entity that fails to cease operation after agency notification may be fined $1,000 for each day of noncompliance as set forth in Section 408.812(4), Florida Statutes (2014). A fine shall be levied notwithstanding the correction of the violation. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 408.812(4) and (5) Florida Statutes (2014). COUNT H (Assessment of Survey Fee) 26. The Agency re-alleges and incorporates by reference paragraphs one (1) through 8 five (5) and the allegations in Count I. 27. The Agency, on or about July 1, 2015, conducted a Complaint Survey (CCR# 2015007102) of the Respondent’s facility. 28. As a result of the Agency’s Survey, the Respondent was cited with one (1) unclassified deficiency. 29. Pursuant to Section 429:19(7), Florida Statutes (2014), the Agency is authorized to, in addition to any administrative fines imposed, assess a survey fee equal to the lesser of one- half of the facility’s biennial license and bed fee or five hundred dollars ($500.00), to cover the cost of conducting initial complaint investigations that result in a finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statutes (2014), to verify the correction of the violations. 30. In this case, the Agency is authorized to seek a survey fee of FIVE HUNDRED DOLLARS ($500.00). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assess a survey fee against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00) pursuant to Section 429.19(7), Florida Statutes (2014). COUNT Revocation Of Licensure Pursuant to Sections 408.815(1)(c) and (d), and 429.14(1)(e) 2 and 3 and (k), Florida Statutes (2014) 31. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and the allegations in Count I. 32. Pursuant to Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license include any of the following actions by a controlling interest: A violation of Section 408, Part II, Florida Statutes (2014), authorizing statutes, or applicable rules, and a demonstrated pattern of deficient performance. Section 408.815(1)(c) and (d), Florida Statutes (2014). Pursuant to Florida law, in addition to the requirements of Part II of Chapter 408, Florida Statutes (2014), the Agency may deny, revoke, and suspend any license issued under Part I of Chapter 429, Florida Statutes (2014), and impose an administrative fine in the manner provided in Chapter 120, Florida Statutes (2014), against a licensee for a violation of any provision of Part I of Chapter 429 or Part II of Chapter 408, Florida Statutes (2014), or applicable rules, or for any of the following actions by a licensee: Any act constituting a ground upon which application for a license may be denied. Section 429.14(1)(e) 2 and 3 and (k), Florida Statutes (2014). 33. | The Respondent’s facility violated provisions of Chapter 429, Part I, Florida Statutes (2014) and Chapter 408, Part II, Florida Statutes (2014) and applicable rules as outlined in Count I above. 34. The Respondent’s facility was cited for an unclassified deficiency arising from circumstances from the July 1, 2015 Complaint Survey (CCR# 2015007102). WHEREFORE, the Agency respectfully requests the Court enter an order REVOKING the license of Respondent, an assisted living facility in the State of Florida, pursuant to Sections 408.815(1)(c) and (d) and 429.14(1)(e) 2 and 3 and (k), Florida Statutes (2014). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00). 3. Assess a survey fee against the Respondent in the amount of FIVE HUNDRED DOLLARS ($500.00). 4. Revoke the license of the Respondent. 5. Order any other relief that the Court deems just and appropriate. Respectfully submitted on this aus day of g egtene 2015. YY Oude oe th. remy Andrea M. Lang, Assistant General Counsel Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone: (239) 335-1253 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 412-3630. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form has been served to: Junia Osme, Administrator and Registered Agent, New Beginning Assisted Living, Inc., 418 N.W. 21% Terrace, Cape Coral, Florida 33993, by U.S. Certified Mail, Return Receipt No. 7007 1490 0003 3419 4299 on this “4~ day of Sgt ere? So15, Copies furnished to: Andrea M. Lang, Assistant General el Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 335-1253 Junia Osme Administrator and Registered Agent New Beginning Assisted Living, Inc. 418 N.W. 21" Terrace Cape Coral, Florida 33993 (U.S. Certified Mail) Andrea M. Lang, Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (interoffice Mail) Jon Seehawer Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Electronic Mail) 12 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: New Beginning Assisted Living, Inc. Case No. 2015007903 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be an Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. Your Election of Rights must be returned by mail or by fax within twenty-one (21) days of the date you receive the attached Administrative Complaint, Notice of Intent to Impose a Late Fee, or Notice of Intent to Impose a Late Fine. If your Election of Rights with your elected Option is not received by AHCA within twenty-one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed, action and a Final Order will be issued. Please use this form unless you, your attorney or your representative prefer to reply in accordance with Chapter 120, Florida Statutes (2015) and Rule 28, Florida Administrative Code. PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Phone: 850-412-3630 Fax: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) __—sI._ admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a Final Order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) _____ I admit the allegations of fact and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)__ I dispute the allegations of fact and law contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3) by itself is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4, A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes may be available in this matter if the Agency agrees, License Type: (Assisted Living Facility, Nursing Home, Medical Equipment, Other) Licensee Name: License Number: Contact Person: Name Title Address: Street and Number City State Zip Code Telephone No. Fax No. E-Mail (optional) hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the above licensee. Signature: Date: Print Name: Title: spss 25s 7OMPLETE: THIS’ SECTION. \COMPLETE THIS'S, ON OND,

Docket for Case No: 15-006765

Orders for Case No: 15-006765