Piercing veil of secrecy, a second Broward ALF is linked to coronavirus infection
The coronavirus pandemic gripping South Florida is now being linked to a second Broward County elder care home, a facility run by one of the state’s most powerful and controversial owners — with a spotty record for resident care.
Recordings from Hollywood emergency dispatchers show that an employee of the Lincoln Manor assisted living facility has tested positive for COVID-19 and that two residents had been removed from the home after exhibiting symptoms consistent with the coronavirus. The home’s owner said both residents have since tested negative.
Lincoln Manor, at 2144 Lincoln St. in Hollywood, holds 56 beds, according to state records. Agency for Health Care Administration, or AHCA, records show the ALF’s license is listed as “in review.” It expired March 10.
As of Monday, the last time state health administrators released such information, 33 skilled nursing or assisted living facilities in Florida had been linked to at least one coronavirus infection. The county with the largest number of reported infections in such homes was Duval, with 14 reported cases. Broward had reported 12.
Gov. Ron DeSantis and administrators at two state health agencies have refused for weeks to disclose the names of long-term care facilities linked to the infection. One home has emerged as a possible outlier: The Atria Willow Wood ALF in Fort Lauderdale has seen the deaths of three residents due to COVID-19, the disease caused by the coronavirus, and several other residents or staff members either have tested positive or are awaiting test results.
Lincoln Manor, whose positive test was first reported by WPLG Local 10, has had a spotty record with regulators for years. As recently as February, the home was faulted for failing to ensure basic safety protections, and the investigation of a July complaint concluded administrators neglected to reassess a resident’s suitability to remain at the home after he had wandered from the home and ended up at a mental health center.
The home’s owner, Larry Sherberg, has been one of the Florida ALF industry’s most powerful leaders, and an outspoken advocate for relaxing industry regulations. He is currently a member of the Past Presidents’ Council of the Florida Assisted Living Association’s board of directors.
Days after his home was slapped with a $1,000 fine in 2011 for failing to properly care for a resident, Sherberg appeared in Miami as a member of the governor’s task force to reform troubled homes.
He lobbied the group to effectively abolish administrative fines when homes run afoul of state regulations, including violations in which residents are injured or die. Sherberg argued unsuccessfully that the state should refund the money so facilities can use the proceeds to correct deficiencies.
Since then, he was fined $500 by health regulators in 2018 for failing to have a generator powerful enough to keep residents safe during an electrical shortage, such as one that might occur after a hurricane.
The reform task force was appointed by then-Gov. Rick Scott in the wake of a 2011 Miami Herald series, Neglected to Death, that found the state was allowing dozens of dangerous homes to stay open, even after investigators found residents had died of abuse or neglect. The group was packed with industry leaders and lawmakers who had been friendly with the trade, and its recommendations were largely ignored. The task force initially did not include a single ALF resident.
In an interview with the Herald on Wednesday, Sherberg said administrators acted quickly after an employee fell ill, and no residents have been infected by the coronavirus that has caused a global pandemic.
On March 12 an employee came in for training, and told the staff at lunch she wasn’t feeling well, Sherberg said. She then left.
“We didn’t know she was sick,” he said.
The ALF wasn’t screening employees or visitors for symptoms of the virus at that point, he said — though federal health regulators had suspended routine inspections in order to fight the virus more than a week earlier, on March 4.
On Saturday, Sherberg said, the healthcare worker called the facility and told the staff she’d tested positive for the coronavirus. Later that day, Sherberg’s team sent one resident with similar symptoms to the hospital.
The resident tested negative and returned to the home Monday. But then another elder came down with symptoms of the virus and was sent to the hospital.
“We just got a call about an hour ago that the test came back negative,” Sherberg said.
Staff members are now taking residents’ temperatures twice each day, and screening themselves before starting the workday. Not all of the residents have been tested for the virus, he said, just the two who were sent to the hospital.
ALF staff members also are serving meals to residents in their rooms, or to a dining room of six, Sherberg said, adding the process takes hours. Same with medicine rounds: It takes more than an hour. The home is taking all of the precautions, he said.
“Being in this business, I’m concerned all the time, even without the virus,” Sherberg said. “Our facility is a controlled facility; I’d be more concerned if they were out there with the general public.”
Sherberg said there aren’t any plans now to test all of the elders under his care, but, “I wouldn’t object to it.”
Lincoln Manor isn’t a locked facility, he said, and, under state law, residents may come and go as they please. “We’ve tried keeping them in their rooms,” he said. “We’ve tried keeping them without cigarettes because they go outside.
“They’ve gotten very antsy,” he said. “And that creates a real hardship on them and my staff.”
One or two family members have called and asked what the facility is doing to protect residents. He said he responds: “To the best of my knowledge there’s no coronavirus” there.
State records show Lincoln Manor’s license expired earlier this month. Katie Strickland, an AHCA spokeswoman, said that “if a renewal application is still being processed by the agency at the time of license expiration, the license status becomes ‘in review.’ “ She added: “A license is still valid and active while in review.”
The license appears to have lapsed after the federal health watchdog, the Centers for Medicare and Medicaid Services, suspended all nursing home and ALF licensure activities, other than the investigation of complaints involving “immediate jeopardy” to residents’ lives or welfare — and inspections linked to controlling the spread of the novel coronavirus.
It is impossible to say whether Florida ALFs and nursing homes that have seen positive coronavirus tests among staff or residents are the same homes that have drawn the attention of state inspectors in the past — because the state won’t identify the homes where positive tests have occurred.
The ALF’s history
Lincoln Manor, though, has drawn the attention of state inspectors on multiple occasions.
In the three years before Sherberg was appointed to Scott’s 2011 task force, he had been hit with 12 violations, including failing to properly care for an elderly woman who was rushed to the emergency room in a filthy gown, covered with head lice, with scabies on her face and feces caked under her fingernails. She had a pressure sore on her heel.
More recently, a 30-page AHCA inspection report dated Feb. 20 said Lincoln Manor did not have basic safety protections, such as carbon monoxide detectors, and failed to keep track of medications for some residents. The home also did not conduct mandatory drills to prevent residents from wandering away — or to find them when they do.
Lincoln Manor also failed to include in facility contracts such things as the home’s monthly board rate, and never informed residents or their representatives about the facility’s emergency response plan, the report shows, based on a visit to the ALF on Feb. 19.
Inspectors who visited the facility also found that Lincoln Manor administrators failed to keep required information on employee background checks and did not help some residents seek healthcare, including physician evaluations to determine whether one resident could administer medication without help.
During the unannounced survey in February, one resident told inspectors that he gives himself shots when his blood sugar is high, indicating the man was diabetic. Inspection reports redacted the man’s name and the type of medication he required. The man told inspectors that he did not know his normal glucose levels.
“He stated that he did not record the levels,” the report states. “He stated he wanted to see a doctor.”
When state inspectors reviewed the man’s file, they found that he needed help to administer oral medications.
The ALF’s financial officer told state inspectors that the man “never wants to go to the doctor” and always cancels his appointments, the report said.
Lincoln Manor also failed to conduct drills for preventing and finding ALF residents who “elope,” meaning wander away from the home, the report states. Drills are required at least twice each year under state rules. The report states that Sherberg could not provide evidence that the ALF had conducted elopement drills in 2018 or 2019.
Lincoln Manor administrators and workers also did not keep accurate medication observation records, which are required for all residents on supervised medication, for one resident who required help with taking medication. The same report does not name the resident or the type of medication the resident needed, but inspectors found that workers at Lincoln Manor were not properly documenting the medicines provided to residents that morning.
A worker at Lincoln Manor told the state inspector that the medication had run out. After the inspector found additional medication in the package, though, the worker said she had not conducted that morning’s medication rounds, the report states.
The home’s financial officer, who is not named in the report, told state inspectors that the medication was indeed given to the resident, but acknowledged that the observation records had not been signed.
Inspectors also found that the home had not offered contracts to residents or their legal representatives at the time they were admitted to the ALF. Family members of at least three residents were not given an accurate monthly rate, the report states.
Contracts are required to state specific services, supplies and accommodations each resident needs, and to include the daily, weekly and monthly rates. Contracts are also required to include a provision that at least 30 days written notice will be given for rate increases.
But after reviewing the financial records for two residents, inspectors reported that their contracts reflected a monthly rate of $791. A Lincoln Manor administrator acknowledged those records were not accurate. The ALF charges $2,500 each month.
State inspectors also found that though Lincoln Manor administrators had bought carbon monoxide detectors for the facility, they had not been installed throughout the ALF.
The ALF’s financial officer showed an inspector the box containing the detectors, and denied the finding, saying he had already installed one in a hallway on the facility’s first floor, the report says.
AHCA inspectors also cited the home for failing to comply with background screening requirements for an employee who was no longer listed on the state’s roster of active workers, and failing to keep screening records in employee personnel files,
The personnel file for one employee, a medical technician who provided direct care to Lincoln Manor’s residents, contained background checks that were outdated by as many as five years, records show.
Prior to the February inspection, state officials visited Lincoln Manor to investigate a complaint on July 29, 2019, records show.
During that visit, inspectors cited Lincoln Manor for not ensuring that a resident had been reassessed for continued residency after that resident began to show a “significant behavioral change” and new symptoms identified by the resident’s doctor, according to a report.
The resident had wandered away from the ALF and was later found at a local mental health center, said the July 29 report, which resulted from a complaint. The report does not state how long the resident was missing or where he was found. But Lincoln Manor administrators told inspectors that the resident knew the rules of the facility and had always signed out when leaving.
Lincoln Manor administrators knew about the resident’s diagnosis, which was redacted from the report. The administrator told inspectors that when she spoke with the resident who had wandered off, he told her it was his birthday and that voices “told him to leave and see new faces,” the report states.
The ALF administrator, who is not identified in the report, told inspectors that she had filed a missing person report, and that this was unusual behavior for the resident, the report shows.
“The Administrator admitted the resident should have been reassessed for being identified as an elopement risk,” the report states, “and further stated it is difficult to communicate with the hospitals and receive accurate health assessments.”
But inspectors reviewed the resident’s records and found evidence that Lincoln Manor administrators were or should have been aware of the man’s behavioral change.
A doctor’s order was in the resident’s file stating that he had never wandered away from the facility and had never threatened to leave as long as he had been in the doctor’s care.
Inspectors found that the latest health assessment performed by the ALF was dated before the man had wandered away from the facility, and that he had not been considered an escape risk.
A record in the resident’s file also showed that the man had been seen by a doctor after wandering away from the facility. The doctor noted under “new symptoms” that the man had left the ALF and was off his medications. The doctor also noted the man was stable, walking and feeling well at the time of the visit.
This article has been corrected to remove a photo incorrectly identified as Larry Sherberg.
This story was originally published March 26, 2020 at 9:01 AM.
