Neglected: Florida's worst nursing homes left open despite history of poor care, deaths

Eighteen hours after the nursing home’s staff realized he was missing, Coleman Felts was found dead several hundred yards away, face down and fully clothed in the shallow water of a lake.

The 75-year-old Vietnam veteran had a history of wandering. His guardian moved him from an assisted living facility to Golden Glades Nursing and Rehabilitation Center in Miami, believing it would be more secure.

It wasn't.

At some point during the evening of Dec. 1, 2015, Felts walked out of the nursing home. Golden Glades staff realized he was missing at about 9 p.m. A maintenance worker from the assisted living home next door found his body at about 3 p.m. the next day.

This wasn’t a single, tragic incident. This was just one in a series of problems at one of Florida’s worst nursing homes.

For more than four years, government inspectors repeatedly gave Golden Glades poor scores. The home averaged 1.6 on a 5-point scale over 18 quarters from the federal Centers for Medicare and Medicaid Services. Inspectors identified 186 state and federal violations, the fourth-highest number cited among Florida’s 684 nursing homes during the period.

Database: Nursing home ratings in Florida

Golden Glades staff has been accused of negligence in the deaths of at least five patients, according to lawsuits filed since 2013. The nursing home's owners denied the allegations, but settled three cases. Two others are pending.

Felts' family has not filed a lawsuit. Inspectors cited the home for several violations after reviewing his death, including failure to remove hazards and to provide enough staff.

That history of problems hasn't stopped Golden Glades from caring for some of the state’s most vulnerable residents.

Dozens of Florida nursing homes with long records of failing to meet state and federal standards operate with little risk that regulators will shut them down, a USA TODAY NETWORK - FLORIDA investigation found.

Among the Network’s findings:

Since 2013, 54 Florida nursing homes scored the lowest in the state for at least 14 of 18 quarters and received 100 or more violations. Dozens of other homes also received either low scores or numerous violations.

Forty-six of the worst 54 homes have settled or have contested lawsuits claiming mistreatment, abuse or neglect led to at least 191 deaths since 2013. The nursing home owners denied the claims, but settled 87 cases. The remaining 104 are pending, including the case of a man killed by his roommate in a Miami home.

State fines for nursing home violations are low — not quite $5,000 on average — compared to the millions homes receive each year from taxpayer-funded Medicare and Medicaid programs.

Florida’s Agency for Health Care Administration, which licenses and regulates nursing homes, rarely uses the toughest sanctions at its disposal. Since 2013, AHCA has closed two homes and blocked new admissions for three.

Flaws in the state's nursing home oversight threaten thousands of frail patients, said Brian Lee, former head of Florida's Long-Term Care Ombudsman Program in the Department of Elder Affairs who now heads the nonprofit Families for Better Care.

“You have these facilities string along for years and they never shut down. They just continue on,” he said. “What does it take to close down a bad nursing home?”

Irma's lesson

Nursing homes came under scrutiny last fall after 12 residents of the Rehabilitation Center at Hollywood Hills died following a power outage caused by Hurricane Irma. The home's 141 patients remained for three days in the sweltering mid-September heat without air conditioning. The medical examiner declared the deaths homicides and the criminal investigation continues.

The Hollywood Hills nursing home had a history of patient neglect and poorly maintaining the facility, and its owner previously faced federal Medicare fraud allegations that he settled without admitting guilt. But it wasn’t until the deaths that state officials said the home didn’t “deserve to be trusted with patients’ lives.”

AHCA closed the facility, only the second nursing home the agency has shut down since 2013, records show.

Gov. Rick Scott, who blames the Hollywood Hills staff and owners for the deaths, is leading efforts to require nursing homes to install and maintain generators. But the governor’s plan to add another rule in a state where nursing homes repeatedly violate rules ignores bigger problems.

"The Hollywood Hills situation was about so much more than lack of a generator or lack of power to the air conditioning units," said state Sen. Gary Farmer, D-Fort Lauderdale, who is advocating an overhaul of nursing home oversight. "This was a systemic buildup that allowed the conditions to exist that resulted in that tragedy."

Scott said he expects his administration to provide close oversight of Florida nursing homes. He expressed confidence in AHCA.

"I expect people to take care of the patients, and my goal is that government holds everybody accountable." he said.

More: Florida regulators wrongly accused some nursing homes of violating post-Irma emergency rule, officials say

AHCA holds nursing homes accountable by prodding them into compliance with citations and fines, "and we do find that we have a good reaction to it," said Secretary Justin Senior. He argued the agency is limited in what serious actions it can take.

"We are required by Florida law to take the least invasive, least intrusive licensure action that we can take under the circumstances," Senior said, "and in every single situation, whether it’s a small fine or whether it’s a moratorium or if it’s a suspension, our action is going to be reviewed and vetted."

Tragic death

Coleman Felts was known at Golden Glades as a tall, elegant man who enjoyed walking the grounds and talking to people, inspectors wrote after his death.

Felts twice walked away from the assisted living facility he lived in before being moved to Golden Glades, once making his way to a busy intersection near a highway after jumping a fence.

Despite Felts' history of escapes and a deteriorating mental capacity that left him forgetful, confused and paranoid, Golden Glades’ primary care physician stopped one-on-one monitoring after only three days, according to an inspection report.

Felts “did not show any signs of risk,” the doctor, unnamed in the report, told inspectors.

A few days later, Felts was found dead. Miami-Dade County's medical examiner determined he drowned.

“I think what really happened, they wasn’t taking care of these people,” said Larry McFarley, Felts' brother. “I don’t think they were doing what they were supposed to be doing.”

More: Gov. Rick Scott wants nursing home rules in constitution

Douglas Grant, Golden Glades’ director, referred questions about the home to lawyers for Kabirhu Associates, the owner. Lawyers did not respond to phone and email messages seeking comment.

“The only thing it tells me, to be honest with you, if you’re not a person of importance, then why should they care?" said Ritchie McFarley, another Felts brother. "Who cares about a person who’s not important?”

Worst homes

Nearly three years before Felts died, Golden Glades closed its pediatric wing after two teenage patients died. At least five lawsuits have been filed since 2013 against Golden Glades claiming patients died from neglect.

The home's owners denied all the claims, but settled three cases. Two are pending, including a man who bled to death and a woman left untreated after suffering a stroke.

In 2016, Golden Glades’ controlling owner, Philip Esformes, was indicted in a $1 billion Medicare fraud case. Patients were routinely “given medically unnecessary, and at times harmful, treatment,” then-Assistant U.S. Attorney General Leslie Caldwell said when announcing the indictment.

Other Florida nursing homes also continue to serve elderly patients despite years of poor inspections and numerous violations.

The USA TODAY NETWORK — FLORIDA identified 54 of the state’s worst nursing homes by examining 4½ years of violations and federal ratings. Each home had 100 or more violations from January 2013 through June 2017 identified in data provided by AHCA and scored a 1 or 2 on a 5-point scale for at least 14 of the 18 quarters during the period.

Those nursing homes had a worse history with AHCA than Hollywood Hills before the deaths.

Another 70 homes either fared poorly on inspections for 14 quarters since 2013 or received more than 100 violations.

The Network analysis focused on the 54 homes that met both criteria.

More: Gov. Scott directs health, elder care leaders to adopt nursing home generator rule

State inspectors identified patients in those homes who were sexually assaulted, beaten by staff members and other residents, or denied medication needed to survive.

Lawsuits cited 46 of the homes in at least 196 deaths since 2013, claiming patients died because of staff negligence. The homes' owners denied the claims, which included patients dying from bed sores, falls and infections. They settled 87 lawsuits and continue to fight 104 others. Five were closed for other reasons.

“I believe people are dying every day in nursing homes across the state of Florida because the nurses aren’t doing their job,” said William Dean, a Miami attorney specializing in elder abuse. “A simple call to a physician, a simple call to 911 would save that person’s life. But they remain in bed, no one's paying attention, and they have a change of condition and die tragically. And nobody knows anything about it.”

Map/Database: Click here to see ratings of nursing homes in Florida

Statewide problem

Since 2013, inspectors found more than 7,200 violations in 54 of Florida's worst homes, including 261 of the most serious violations that relate to immediate harm or threats to patients. Among violations found were:

291 for failing to guarantee patients’ rights to adequate and appropriate care, a broad category that can include the most serious violation involving the death of a patient. In 2013, AHCA cited South Dade Nursing and Rehabilitation Center in Miami for violating 73-year-old Robert Verser’s rights after he was beaten to death by his 41-year-old roommate, Michael Poole.

215 for failing to follow doctor’s orders. Inspectors cited Heritage Healthcare Center at Tallahassee in October 2014 after they found 60 diabetic residents had gone weeks without regular blood sugar tests.

40 for failing to investigate or report abuse allegations. Consulate Health Care of Jacksonville was cited in February 2015 after investigators learned a patient with severe dementia performed oral sex on another patient. The director of nursing deemed the dementia patient a consenting adult and did not report it.

Kristen Knapp of the Florida Health Care Association said there’s too much attention paid to poorly performing homes. The Network's analysis identified 146 nursing homes that always received the highest scores over the 18 quarters.

“I think for us, we’re focusing on what’s going right in these facilities,” she said.

Bad things can happen in nursing homes that serve very ill people in difficult situations, but frequent problems shouldn't be the norm, said Elliott Palevsky, CEO emeritus at River Garden Senior Services, which includes a 5-star Jacksonville home.

"When you have a record of consistent poor performance, that's different than a one-off terrible thing," Palevsky said.

Few sanctions

On Jan. 12, 2015, Christopher York left Heritage Park Rehabilitation and Healthcare in Fort Myers in his motorized chair to buy cigarettes and beer at a nearby gas station. It was dark as he attempted to cross six lanes of traffic along a busy stretch of U.S. 41 and was struck by a gold 2009 Lincoln.

State inspectors cited Heritage Park for failing to assess York's ability to navigate the area safely. And York's situation deteriorated.

Following a brief hospital stay with broken bones, the care he received at Heritage Park made matters worse, his son Nicholas York said. The wounds became infected and the pain so intense that his father’s leg had to be amputated, leaving the 60-year-old more dependent upon nursing home staff.

"Every time we went to visit there was urine on the floor," Nicholas York said. "He couldn't get in the bathroom by himself and there was feces on his sheet."

Investigators have cited Heritage Park several times for unsanitary conditions, although it's not clear in inspection reports if the violations were tied to York's care.

Again in December 2015, York was struck by a vehicle that destroyed his power chair and sent him briefly to the hospital, according to a police report about the accident. Months later he was assaulted by another patient, another police report shows.

Inspectors did not document the incidents in state reports or take action.

The family started searching for another home, Nicholas York said. But Christopher York died last August before they could move him.

"He kept saying, 'I don't want to die here. I don't want to die in this place,' " the son said.

Heritage Park averaged a 1.2 score over 4½ years, was cited for 121 violations and was never fined.

Dawn Stanfield, the nursing home's executive director, said the inspections and scores aren't an accurate reflection of Heritage Park's care.

"If the state would walk through the door right now, they would see the happy residents and happy families and see good care," Stanfield said.

AHCA rarely levies its most significant penalties, even at homes like Heritage Park where, inspectors and lawyers argue, patients died unnecessarily.

The agency closed two homes since 2013 — the Rehabilitation Center of St. Pete in 2016 and Hollywood Hills after Irma last year.

AHCA briefly blocked new admissions of patients at three homes — Community Convalescent Center in Plant City for about four months in 2013; Excel Care Center in Tampa for nearly two months in 2015; and Hollywood Hills last year for a week before closure.

The agency recommended shutting off Medicare to five troubled homes since 2013.

Senior defended AHCA's efforts, arguing the agency uses other methods such as threatening to revoke or withhold licenses to bring homes into compliance.

More: Nursing home deaths: Owner challenges state's move to block patients, payments

Owners have incentive to improve to protect their investments, he said.

“They lose the license and they no longer have any value in their facility,” Senior said.

He said AHCA's efforts can force improvements, ownership changes or eventual closure, such as the shuttering of Lakeshore Villas Health Care Center in Tampa after regulators targeted it in 2013.

Of the 16 homes that changed owners since 2013 after AHCA intervened, four showed improvement in scores after inspections, agency records show.

Recent state push

Heritage Park is among 53 homes targeted in January by AHCA to lose its license, not because of the poor history documented in inspections but because of ties to two other facilities, records show.

After months of scrutiny following Irma about oversight of nursing homes, AHCA sent a flurry of notices in January to Heritage Park and 52 related facilities stating their licenses would not be renewed, according to agency records. The notices, sent to homes owned by companies controlled by national senior care provider Consulate Health Care, cited two homes specifically and targeted the other 51 because of their common ownership.

Consulate, which identifies itself as Florida's largest nursing home provider, owns some of the state's worst facilities, according to the Network's analysis.

Inspectors in December targeted Consulate's Oakbridge Healthcare Center in Lakeland for a history of poor patient care, including patient abuse, staffing shortages and failure to follow patient care plans.

Inspectors also singled out Consulate's Largo Health and Rehabilitation Center in Pinellas County. AHCA cited problems dating back to 2015 through at least eight inspections that included numerous patient falls, abuse and improperly dispensing medication.

More: Nursing home deaths: Owner's hospital was paid $48 million for state prisoner health

The 53 Consulate homes are fighting to keep their licenses. And AHCA's history of attempts to revoke or withhold licenses shows most homes likely will stay open without improving quarterly performance scores.

“If they’ve come into compliance, they probably can stay open," Senior said.

In the 4½ years before Irma, AHCA attempted to revoke or deny license renewals for 39 homes, according to records provided by the agency. Three homes closed and 36 remain open after negotiations with the agency, the records show.

The agency's actions didn't improve the scores most of the homes received after inspections. Only 11 homes saw improved scores, while 26 scored the same or worse after AHCA intervened, records show.

Some of the 26 homes with scores that stayed the same did not have a history of poor performance, but were targeted by the agency because their owners had homes with major violations.

Small fines

While AHCA routinely levies fines against nursing homes, they are usually small, as low as $250 for installing unapproved fire alarm equipment at the Ocean View Nursing & Rehabilitation Center at New Smyrna Beach. The average state fine between 2013 and June 2017 was just over $4,500, according to the NETWORK analysis.

Florida law sets the largest AHCA fine for a single violation at $15,000, although that can double if a home is cited for a severe deficiency during its previous inspection.

Senior said fines are “generally enough" to prompt improvement. The number of fines and violations a facility racks up can adversely affect license renewal, he said.

“It’s not really the amount of the fine, it’s the fact of the fine that gets the facilities really working hard,” Senior said.

But Farmer, the Fort Lauderdale state senator, said he's concerned low fines may actually hinder improvement at homes.

“Here’s a reality of capitalism,” he said. “If there is no financial disincentive, safety and responsibility tend to become just bottom-line numbers."

Consulate Health Care of Vero Beach, for example, was fined $5,000 in 2013 but continues to rank among the state's worst homes. Inspectors cited the home for 100 violations and gave it the lowest score of 1 for 17 straight quarters. Last June, the home received a score of 2, records show.

The federal government's fines tend to be higher, according to a Network analysis. The average federal fine in Florida from 2013 through 2016 was about $27,000, although the Trump administration is scaling them back under a broad deregulation effort.

Another action Senior said AHCA takes is to request a temporary block of federal payments for new patients at poorly performing nursing homes. But most of the time the block lasts a month or less, and critics argue it's not much of a punishment because the homes are still paid for existing patients.

The block of federal payments for new patients lasted longer than two months in eight of the 92 cases since 2013, records show.

There are other ways to compel poorly performing nursing homes to improve, Florida Health Care Association leaders argue. Low-rated nursing homes struggle for state, federal and private contracts and take a public relations hit when there are problems, they said.

“I don’t think fines are an incentive to improve quality,” said Knapp, the association’s spokeswoman. “I think continuous quality improvement is a journey.”

More: Nursing home deaths: Police investigate detainee death at hospital owned by same doctor

AHCA tries to encourage improvements at troubled homes by publicly identifying them on a "Watch List," a 30-month designation for nursing homes that file bankruptcy, fail to meet minimum standards or ignore violations.

There's a national pattern of poor-performing nursing homes that "stay that way year-after-year," said Robyn Grant, public policy director for The National Consumer Voice for Quality Long-Term Care, a Washington, D.C.-based advocate for nursing home residents.

"The problem is that the survey and enforcement process doesn’t send a strong enough message from the get-go,” she said. “The bottom line, poor care should not be continuing."

Lethal neglect

Few nursing home deaths lead to fines, or even make it into federal and state inspections.

Inspectors documented staff violations after reviewing 19 deaths in the 54 homes reviewed by the Network, according to three years of inspection reports available online and five years of AHCA settlement agreements with nursing homes. This compares to the lawsuits settled or pending claiming staff negligence in at least 191 preventable deaths in 46 of those homes.

Diane Soza’s 2014 death at Consulate of Jacksonville is one of those cases the public would never discover on state or federal websites.

William Soza said in an interview that his wife consumed her meals in minutes, a problem the nursing home knew about, a Duval County lawsuit states.

A month after the 60-year-old arrived at Consulate on Sept. 18, 2014, Diane Soza was found unconscious. Staff administered CPR, according to medical records cited in the lawsuit.

When she was intubated, "copious amounts of food materials were found in her mouth" and the intubation tube, medical records show. Diane Soza suffered a severe brain injury from lack of oxygen and died the next day after she was removed from life support, the records show.

Lisa Ellen Wold, Consulate's former manager, declined to comment and referred questions to Orlando-area corporate headquarters. Jennifer Trapp, Consulate Health Care spokeswoman, said she couldn’t speak about individual homes because she didn’t have details.

Numerous attempts to reach CEO Chris Bryson and Chief Corporate Counsel Daniel Dias, by phone, email and certified mail failed. The company is contesting the claims in the ongoing Soza lawsuit.

Regulators may not be aware of all preventable deaths, such as Soza's, in Florida nursing homes.

Even though AHCA is required by law to receive a copy of nursing home lawsuits, not all lawyers comply. Senior said they review the suits received, but he argued they are of little value in enforcement because they cite incidents from years earlier.

Dean, the Miami attorney specializing in elder abuse, said prospective residents and their families should review a nursing home’s lawsuit history.

“I’ve seen everything, from people baking in the sun, people being eaten by alligators, people eloping, drowning, bed sores, maggots in bed sores,” he said. “Employees raping elderly people, I can’t make this stuff up.”

But Deborah Franklin, senior director of quality affairs for the Florida Health Care Association, defended care at Florida’s 684 nursing homes. She said it has evolved in the 33 years she’s been in the business.

“Have we arrived? Absolutely not,” she said. "Do we have a lot more to do? Absolutely.”

Florida’s residents deserve better, Dean said.

“People are becoming rich at the expense of elderly abuse, neglect and death,” he said. “And the people who are supposed to be paying attention to them, the state of Florida, aren’t.”

Contact Ryan Mills at Ryan.Mills@naplesnews.com and Melanie Payne at Mapayne@gannett.com

The USA TODAY NETWORK – FLORIDA identified 54 of the state’s worst nursing homes:

Mobile and app users: View list of state’s worst nursing homes