STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. Case No. 2018006813 WG HERITAGE LF, LLC d/b/a Facility Type: Assisted Living ATRIA PARK OF LAKE FOREST, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent WG Heritage LF, LLC d/b/a Atria Park of Lake Forest (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2017), and alleges: NATURE OF THE ACTION This is an action against an assisted living facility to impose an administrative fine in the amount of five thousand dollars ($5,000.00) and survey fees of five hundred dollars ($500.00), for a total sum of five thousand five hundred dollars ($5,500.00) based upon one (1) Class II deficient practice. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Florida Statutes (2017). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 4. Respondent operates a two hundred twenty (220) bed assisted living facility located at 5433 West State Road 46, Sanford, Florida 32771, and is licensed as an assisted living facility, license number 10233. 5; Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That Florida law provides: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or 2 other changes which resulted in the provision of additional services. Rule 58A-5.0182(1), Florida Administrative Code. 8. That on June 2, 2017, the Agency completed a complaint (CCR# 2017005471) survey of Respondent’s facility. 9. That based upon the review of records, observation, and interview, Respondent failed to provide care and services, including personal supervision, appropriate to the needs of residents, the failure to maintain an awareness of the general health and safety of a resident, relating to, inter alia, the failure to respond to a known infection risk in a timely manner, the same being contrary to the requirements of law. 10. That on May 10, 2017, Respondent reported to Florida’s Department of Health nineteen (19) symptomatic respiratory infection cases in the facility, with the first case onset of May 4, 2017. 11. That this report to Florida’s Department of Health was six (6) days delinquent according to Respondent’s policy and procedure covering such matters. 12. That on May 16, 2017, Florida’s Department of Health conducted an on-site investigation of Respondent and its operations pursuant to the provisions of Chapter 381, Florida Statutes and Chapter 64D-3, Florida Administrative Code, and issued the following recommendations on or about May 19, 2017: a. Increase the cleaning and sanitation of all items such as pool sticks, poker chips, keyboards, water dispensers, tables, chairs, high touch surfaces, wheelchairs, and walkers. b. Suspension of group activities, including meals, in affected areas, with meals served in rooms. c. Suspension of admissions to the affected units. d. Follow manufacturer instructions on contact times for cleaning and if surface dries before time, reapply chemical. e. Encourage visitors, through signage, to use hand sanitizer or wash hands before and after visits. f. Environmental cleanings to be done after group activities and meals in unaffected unit. g. Sanitizing the dish room and juice machine. h. Require therapy equipment be cleaned after each patient with appropriate chemicals and contact time. i, Reinforce isolation of ill residents until twenty-four (24) hours after the resolution of symptoms. j. Monitor staff absenteeism and exclude ill staff until twenty-four (24) hours after resolution of symptoms. k. Conduct in-service trainings for staff on hand washing and respiratory hygiene. iP Strongly suggested were the check of air conditioners in all residential units especially the air conditioner unit located in the Manor Memory Care Unit, which did not seem to be operating at full capacity. m. Strongly suggested was to consider increasing the hot water temperatures and, if the temperatures checked were in the 100 to 102 degree Fahrenheit range, this is considered at the low end of the recommended range and increases chances of the risk for Legionella harborage in the water system. 13. That on May 17, 2017, Florida’s Department of Health conducted an on-site investigation and observed that Respondent had not cancelled all group activities as recommend the prior day. 14. On May 19, 2017, three (3) new symptomatic cases were reported by Respondent to Florida’s Department of Health, and the Department of Health directed Respondent, via electronic mail, to shut down all activities and the dining room for the weekend. 15. On May 22, 2017, Respondent reported at total of forty-three (43) cases and the Department of Health recommended that Respondent continue to cancel all group activities and keep the dining room closed. 16. On May 23, 3017, a representative of Florida’s Department of Health met with Respondent’s administrator and requested that consents be obtained to collect specimens from residents. 17. On May 24, 2017, Respondent finally posted signage throughout the community which read, “Starting tomorrow and for the next six days all dining rooms in assisted living and life guidance will be closed ... All activities and bus trips are cancelled, except trips to doctors...,” such signage posted five (5) days after the recommendations of the Department of Health. 18. That Petitioner’s representative interviewed Respondent’s administrator on June 2, 2017 regarding these infection control events and the administrator indicated: a. He confirmed that Respondent failed to shut down activities and the dining room timely as recommended by the Department of Health. b. He failed to follow the facility’s policy and procedure when he failed to report to the Department of Health the first sign of infection onset on May 4, 2017, and did not report to the Department until May 10, 2017. 19. That Petitioner’s representative interviewed Respondent’s maintenance director on June 2, 2017 regarding these infection control events and the director confirmed that Respondent had no documentation reflecting that the air conditioners had been checked or water temperatures checked during the infection control outbreak as recommended by the Department of Health. 20. That Petitioner’s representative interviewed a representative of the Department of Health on June 2, 2017 regarding these infection control events and representative concluded that Respondent failed to follow the Department’s recommendations in a timely manner and a correct manner to help prevent the development of new cases in residents. 21. That Petitioner’s representative reviewed Respondent’s records related to resident number three (3) during the survey and noted as follows: a. The resident’s health assessment, form 1823, dated March 4, 2017, documented diagnoses including Alzheimer’s disease, chronic obstructive pulmonary disease without exacerbation, and gait instability. b. A Hospice admission and certification for Alzheimer’s disease and chronic obstructive pulmonary disease was dated May 15, 2017, five days after the reported onset of symptoms having been reported to the Department of Health. C. On May 16, 2017, a family member was informed of the resident’s congestion and a high fever of one hundred two (102) degrees. d. The family member requested antibiotics be discontinued and the resident passed away on May 19, 2017. 22. That Petitioner’s representative interviewed the hospice nurse for resident number three (3) on May 25, 2017, who confirmed the resident’s lungs were congested, the resident was on five (5) liters of oxygen, and had a fever of one hundred two (102) degrees for several days, with a family member requesting antibiotics be discontinued. 23. That Petitioner’s representative reviewed Respondent’s records related to resident number seven (7) during the survey and noted as follows: The resident’s health assessment, form 1823, dated December 12, 2016, documented diagnoses including Alzheimer’s disease, hypertension, gait instability, frequent falls, and protein calorie malnutrition. The resident received hospice services for cerebral atherosclerosis. On March 14, 2017, the health care provider ordered Ciprofloxin ophthalmic 0.3% solution, two drops twice daily to both eyes for ten days for an eye infection. On March 22, 2017, and order was obtained for Mucinex 400 milligrams daily for ten days for cough and congestion. On March 23, 2017, and order was obtained for Duoneb via nebulizer one vial twice daily for ten days for congestion. On April 7, 2017, an order was obtained for a chest x-ray and Duoneb one vial via nebulizer three times daily for ten days. On April 8, 2017, the chest x-ray results indicated a cardiomegaly and a large left mid and lower lung field infiltrate/ atelectasis and effusion (“Atelectasis” is the collapse or closure of a lung resulting in reduced or absent gas exchange. It may affect part or all of a lung. [Wikipedia,org] A “plural effusion” is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess can impair breathing by limiting the expansion of the lungs. [Wikipedia.com].) On April 13, 2017, an order was obtained for Doxycycline 100 milligrams twice daily for ten days for a lung infiltrate, Singulair 10 milligrams daily for allergies, and Gentamycin ophthalmic solution two drops in both eyes four times a day for seven days for an eye infection. (A “pulmonary infiltrate” is a substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs. Pulmonary infiltrates are associated with pneumonia... [Wikipedia.com]). On May 4, 2017, the resident was coughing and had a fever of one hundred one point four (101.4) degrees and an order was obtained for Duoneb one amp via nebulizer every four hours while awake, 8:00 a.m., noon, 4:00 p.m., and 8:00 p-m., Mucinex 400 milligrams daily for ten days for congestion, Prednisone 20 milligrams for five days for cough and congestion, and Tylenol 650 milligrams by mouth every six hours as needed for a fever greater than one hundred (100) degrees. On May 5, 2017, an order was obtained for Tylenol 650 milligrams by mouth every six hours around the clock for a fever for three days then resume the as needed dose On May 5, 2017, the resident had a temperature of one hundred two (102) degrees and the lungs were congested. On May 8, 2017, the resident’s temperature was one hundred one point two (102.2) degrees. On May 10, 2017, the resident had a productive cough and a temperature of ninety-nine point five (99.5) degrees. On May 12, 2017, the resident was isolated to the room due to a cough and a temperature of ninety-nine point eight (99.8) degrees. On May 15, 2017 the resident had a temperature of one hundred point four (100.04) degrees and coughed up green sputum and remained isolated in the room for meals. On May 16, 2017, an order was obtained for Mucinex six hundred milligrams daily for congestion, and Ciloxan point three percent Instill two drops each eye twice daily for an eye infection for ten days with symptoms of cough, chronic congestion, eye crusting, and irritation. On May 19, 2017, an order was obtained for Roxanol point twenty-five milliliters every four hours as needed for shortness of breath or pain with a new symptom of lung congestion. On May 19, 2017, the resident did not feel well with a temperature of one hundred point two (100.2) degrees and a pulse of one hundred twelve (112). On May 23, 2017, the resident did not have a fever but was still coughing and had increased lethargy. On May 24, 2017, an order was obtained for Mucinex four hundred milligrams one tablet by mouth twice daily for congestion. On May 25, 2017, the resident’s temperature was ninety-nine point four (99.4) degrees, did not have a cough, and the lungs were minimally congested. On May 29, 2017, on order was obtained for Atavan one milligram every four hours as needed for agitation and restlessness; Atropine Opthalmic Solution, two drops sublingually every six hours as needed for secretions; Tylenol suppository six hundred fifty milligrams rectally every six hours for fever greater than one hundred (100) degrees; to start crisis care with hospice for pain and agitation; and to administer Duoneb one vial via nebulizer every four hours around the clock. On May 30, 2017, an order was obtained for Morphine liquid ten milligrams every six hours around the clock and five milligrams every two hours as needed for pain, shortness of breath or agitation. On May 31, 2017, an order was obtained to discontinue all routine medications as the resident was unable to swallow. The resident’s temperature was one hundred point four (100.4) degrees, the resident was short of breath with little air exchange due to congestion. The resident did not take anything by mouth, the mouth was dry, the resident was restless, and did not want to be touched. The resident expired at approximately 6:00 p.m. 24, That Petitioner’s representative reviewed Respondent’s records related to resident number eight (8) during the survey and noted as follows: a. The resident’s health assessment, form 1823, dated November 15, 2016, documented diagnoses including history of chest pain, pneumonia, hypertension, atrial fibrillation, and dementia. The resident received hospice services for Cerebral Atherosclerosis. On April 19, 2017, the resident had a fever of ninety-nine point four (99.4) degrees and a cough without lung congestion. On April 28, 2017, the resident had a cough and congestion with the health care provider ordering Mucinex four hundred milligrams by mouth twice daily for seven days for congestion. On May 1, 2017, the resident had a temperature of one hundred point four (100.4) degrees. On May 2, 2017, the resident’s temperature was ninety-nine point four (99.4) degrees and had rhonchi in the lungs and an order was obtained for oxygen two liters per minute as needed for shortness of breath. (“Rhonchi” are coarse rattling respiratory sounds somewhat like snoring, usually caused by secretions in bronchial airways. [Wikipedia.com]). 10 g. On May 4, 2017, the resident had a cough and was congested. h. On May 5, 2017, the congestion in the lungs had improved but the resident still had a cough. i, On May 8, 2017, an order was obtained for Erythromycin ophthalmic ointment, an antibiotic, apply a ribbon of salve to the lower right eyelid pocket four times daily for ten days for an eye infection. Js On May 9, 2017, the resident’s lungs were mildly congested, had a temperature of one hundred (100) degrees, and a decrease in level of consciousness. k. On May 10, 2017, an order was obtained for Mucinex four hundred milligrams twice daily for congestion and Duoneb one vial via nebulizer four times daily for congestion. 1. On May 12, 2017, the resident’s lungs were congested bilaterally, respirations were shallow, and blood pressure was low. 25. That the above reflects the failure of Respondent to provide care and services, including personal supervision, appropriate to resident needs, the failure to maintain an awareness of the general health and safety of a resident, including Respondent’s failure to timely respond to a known risk of infection and take prompt preventative actions to reduce risk to residents. 26. The Agency determined that this deficient practice was a condition or occurrence related to the operation and maintenance of a provider or to the care of clients which directly threatens the physical or emotional health, safety, or security of the clients, other than class I violations. 27. That the same constitutes a Class II offense as defined in Florida Statute 429.19(2)(b) (2013). WHEREFORE, the Agency intends to impose an administrative fine in the amount of five thousand dollars ($5,000.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(2)(c), Florida Statutes (2016). COUNT II 28. The Agency re-alleges and incorporates paragraphs (1) through (5) and Count 1 as if fully set forth herein. 29. That pursuant to Section 429.19(7), Florida Statutes (2016), in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of a facility’s biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statues (2016), to verify the correction of the violations. 30. That Respondent was subject to the citation of one or more Class II deficient practices or the citation of a violation that was subject of the complaint which requires the imposition of a survey pursuant to law. See, Section 429.28(3)(c), Florida Statues (2016). 31. That Respondent is therefore subject to a survey fee of five hundred dollars ($500.00), pursuant to Section 429.19(7), Florida Statutes (2016). WHEREFORE, the Agency intends to impose a survey fee of five hundred dollars ($500.00) against Respondent, an assisted living facility in the State of Florida, pursuant to § 429.19(10), Florida Statutes (2016). Respectfully submitted this / ) _ day of June, 2018. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1947 / Fax: (727) 552-1440 walsht@ahtca.myflorida.com &Ahomas J. Walsh II, Esq. Fla. Bar No. 566365 NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form 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. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing hag been served by U.S. Certified Mail, Return Receipt No. 7004 2510 0001 4448 4651 on June/ —, 2018, to Michael Sparks, Administrator, WG Heritage LF, LLC d/b/a Atria Park of Lake Forest, 5433 West State Road 46, Sanford, Florida 32771, and by Regular U.S. Mail to C T Corporation System Registered Agent for WG Heritage LF, LLC, 1200 South Pine Island Road, Plantation, Florida 33324. VA 7 omas ¥. Walsh II Copy furnished to: Theresa DeCanio Field Office Manager Agency for Health Care Administration 13 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: WG Heritage LF, LLC d/b/a AHCA No. 2018006813 Atria Park of Lake Forest ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed within 21 days of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 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 #7 Tallahassee, Florida 32308. Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, 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 to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, 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 contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an dministrative Law Judge appointed by the Division of Administrative Hearings. 14 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 agency 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. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License Type: (ALF? Nursing Home? Medical Equipment? Other Type?) Licensee Name: License Number: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: USPS Tracking: Tracking FAQs Track Another Package + Remove Tracking Number: 70042510000144484651 Your item was delivered to the front desk or reception area at 11:04 am on June 14, 2018 in SANFORD, FL 32771. Status Delivered June 14, 2018 at 11:04 am Delivered, Front Desk/Reception SANFORD, FL 32771

Docket for Case No: 18-005173