Neglected: Florida's largest nursing home chain survives despite legacy of poor patient care

They told Billy Seigler he’d never walk again. Not because of his broken pelvis or busted right leg, but because his nursing home refused to provide the therapy he so desperately needed.

Seigler relied on Governors Creek Health and Rehabilitation in Green Cove Springs to help him return to the independent life he lived before a 2010 attack and attempted robbery. Each time Seigler pleaded for physical therapy, the nursing home's rehabilitation director told the 45-year-old his government benefits didn't pay for it.

But that was a lie.

The state paid the Jacksonville-area nursing home a flat rate to provide Seigler care, including his needed therapy. But Governors Creek routinely denied treatment and services to patients like Seigler, according to a 2011 federal whistleblower lawsuit filed by a former nurse.

"I think it's all about money," Seigler's older brother Philip said. "I think profit and money and benefits come before patients."

Seigler's case is among a dozen cited in the lawsuit against Consulate Health Care, the state's largest network of nursing homes and the nation's sixth-largest. Consulate denied the lawsuit's claims.

While last year's trial didn't focus on mistreatment and neglect, a jury found that Consulate homes, including Governors Creek, systematically bilked government programs by misrepresenting care provided to patients and overcharging for medically unnecessary treatments.

The jury issued a stunning $347.8 million judgment against Consulate, which executives argued would have forced closure of the company's 77 nursing homes in Florida.

The Consulate case shows how a jury took action when the state wouldn’t. It also shows how the state's failure to act has prevented the jury from holding Consulate accountable.

A federal judge in Tampa overturned the jury's verdict in January, in part because he noted that nothing Consulate was accused of doing ever triggered action by state and federal regulators.

“The evidence and history of this action establish that the federal and state governments regard the disputed practices with leniency or tolerance or indifference, or perhaps with resignation," U.S. District Court Chief Judge Steven Merryday wrote in his order, which is under appeal.

Consulate noted in its defense that state inspections of its nursing homes often resulted in no fines. But recent years have shown that doesn't mean the company's homes are free of problems.

Inspectors with the state's Agency for Health Care Administration have repeatedly cited Consulate homes for mistreating and neglecting patients, including violations serious enough to shut them down. But the agency rarely responded with anything more than a small fine, records show.

As the judge issued his ruling, AHCA took aim at Consulate homes for poor patient care. The agency, in an unprecedented action, threatened in January to close 53 of the company's nursing homes across the state.

But AHCA backed down in an April settlement that allowed all Consulate homes to remain open and put only eight under stricter state review. One home remains in litigation with AHCA.

A USA TODAY NETWORK - FLORIDA investigation in February detailed AHCA's practice of allowing poor performing homes to operate despite long histories of patient health and safety violations. Consulate owned many of those homes, including one where a patient in a wheelchair was struck by a car and another where diabetic patients went without regular blood sugar tests for more than a month.

AHCA leaders declined multiple interview requests for this story. In a prepared statement, they denied being lenient or indifferent when it comes to overseeing nursing homes, and they defended the agency by noting that federal data shows Florida’s nursing homes as a whole have improved in recent years, including declines in infection rates and patient falls.

“The narrative you have laid out is inaccurate," AHCA spokeswoman Mallory McManus wrote in an email. "AHCA takes our responsibility to hold facilities accountable for patient care very seriously.”

Repeated attempts to reach Consulate CEO Chris Bryson and Chief Corporate Counsel Daniel Dias by email and certified mail failed.

Dias told the industry magazine Provider that the legal fight “was not about Consulate Health Care,” despite the fact that the company that originally owned the nursing homes purchased Consulate and adopted the company name.

“It has been a pretty aggravating process since it is not our claims in question, not our issue, and none of the allegations are about us,” Dias told the publication in January.

Consulate, which reported $1.7 billion in operating revenue in 2016, represents a growing trend in the nursing home industry. The homes are evolving into national corporations that funnel profits to wealthy investors. State action against the chains would impact a large part of the nursing home population.

“It's like these chains are so big, they’re too big to fail,” said Charlene Harrington, a University of California, San Francisco nursing professor and researcher. “And that’s one reason the enforcement is so weak.”

A plea for care

Billy Seigler made his living remodeling houses and laying carpet around Jacksonville. On weekends, the divorced dad of one son enjoyed watching Florida Gators teams and playing his guitar along with Bob Seger songs.

That all changed in a moment on Sept. 12, 2010.

That Sunday afternoon, two men in a red Ford F-150 pickup pulled next to Seigler while he walked around his apartment complex. One man reached out from the passenger's window and grabbed Seigler by the shirt, according to a Jacksonville Sheriff's Office report.

The men were trying to steal his wallet and his oxycodone. Seigler fought back, holding on to the truck as his attackers sped away. He was hurled from the moving vehicle. His pelvis was shattered.

Following surgery, doctors eventually sent Seigler to Governors Creek for therapy.

At the nursing home, Seigler was depressed, in pain and dependent on drugs, medical records show. He struggled to walk from his bed to his wheelchair, dragging his right foot. He wanted more pain pills and begged for physical therapy, which the lawsuit claims he didn't receive.

Seigler left the home after more than a year. He never stopped dragging his foot when he walked, and he couldn't hold the construction jobs he once did. Seigler, who had a history of drug use, turned again to abusing opioids, relatives said.

Seigler was 48 when he died on March 30, 2014, in a rented room littered with empty pill bottles. The medical examiner found Xanax, Fentanyl and oxycodone in his system and ruled the cause of death accidental drug intoxication.

Proper care and therapy could have saved his life, relatives said.

Lauren Seigler, Billy's sister-in-law, said Consulate failed him and other patients.

"I think they should be held accountable for all of the people that they didn't help, that they were hired to help," she said. "Those people are depending on these nursing homes and rehabilitation centers for that help."

Follow the money

Nursing home patients like Seigler don't generate big profits. Like most patients receiving government aid for nursing home care, Seigler was on Medicaid.

The joint state-federal program for the poor pays a flat fee to a nursing home for each patient, and the nursing home agrees to provide needed care. Medicaid, which pays Consulate homes an average of about $206 a day, pays less for each patient than Medicare and private-pay plans.

For Consulate, any care beyond the basics for a Medicaid recipient hurts the nursing homes’ bottom line, the federal whistleblower case against the company claimed.

If the nursing home can't charge Medicaid separately for therapy and treatments, there's a good chance patients will be warehoused, said Tom Edwards Jr., a Jacksonville lawyer specializing in nursing home neglect cases.

“They get them up, stick them in a wheelchair and leave them sitting all day,” Edwards said.

Consulate nursing homes also profited from billing the government for unnecessary treatments, the jury found. The homes padded bills to increase payments from Medicare, the federal health insurance program serving those 65 and older, for unnecessary treatments that at times were harmful to patients.

Medicare allows nursing homes to bill separately for certain services and therapy, and that makes patients valuable. For example, Consulate received more than $224.5 million in Medicare payments for its 77 Florida homes in 2015, the most recent year available.

“The day they hit the door they are a profit center,” Edwards said.

An elderly man who sought hospice care in February 2011 at Consulate's Marshall Health and Rehabilitation Center in Perry, southeast of Tallahassee, hoped for comfort and pain relief during his last days. Instead, he "spent hours performing pointless and potentially counterproductive physical and occupational therapy,” according to the whistleblower lawsuit.

“They either are doing things that aren’t medically necessary, and the motive is money, or they’re not doing things that are medically necessary, and the motive is money," Jeffrey Dickstein, a former assistant U.S. attorney who prosecuted fraud cases, said of nursing homes that defraud the government.

Poor performer

Kim Duda spent five months last year at Consulate Health Care of North Fort Myers after suffering a stroke.

Ants and roaches scurried through her room, the 52-year-old Cape Coral mother of two said. AHCA cited the two-star home last year for poor housekeeping, including rooms that smelled of urine and had roaches.

Duda said she received little rehab, developed sores on her feet and had to have both pinky toes amputated. She still can't walk and uses a wheelchair.

“You have to realize, these places don’t care,” Duda said, “as long as they get the money from the state.”

From January 2011 through November 2017, AHCA's inspectors continued to cite Consulate's homes for the same problems detailed in the lawsuit. Consulate nursing homes were cited at least 154 times for not developing comprehensive care plans, 49 times for not having enough nursing staff to provide care, and at least 18 times for mistreating and neglecting patients, inspection records show.

The violations stem from patient problems that include not providing a plan or necessary dental services for a woman with no teeth or dentures; not providing enough staff to watch a man who wandered away and was struck by a car; or neglecting a woman confined to her bed for five days because her wheelchair was outside in a shed.

Typically, the agency levied only small fines and ordered corrections, records show. Since 2013, Consulate’s 77 Florida nursing homes have averaged less than $4,500 each in state penalties, according to a USA TODAY NETWORK - FLORIDA analysis.

“They’re just not that interested in regulating,” Harrington, the nursing professor and researcher, said of the nation’s nursing home inspectors. ”And they don’t want to pick a fight with these big companies.”

Founded in 2006, Consulate controls one in every nine nursing homes in Florida, operating in 32 counties and in every metro area. Headquartered in Maitland, an Orlando suburb, Consulate manages 210 homes and 22,059 beds in 21 states, according to a 2016 American Health Care Association report.

Forty-eight Consulate homes in Florida, or 62 percent, are currently rated either one or two stars on a federal five-star quality scale, according to the U.S. Centers for Medicare & Medicaid Services, the federal agency that helps fund nursing homes.

“The worst actor that’s out there is also the biggest player on the block,” said Brian Lee, former head of Florida's Long-Term Care Ombudsman Program in the Department of Elder Affairs and now heading the nonprofit Families for Better Care.

Missed opportunities

When AHCA regulators had opportunities to take serious action against Consulate, they didn’t.

AHCA can revoke a nursing home license when inspectors find two of the most serious violations, known as Class 1, in separate inspections within a 30-month period or during the same inspection, according to state law.

But at least twice since 2012, the agency opted against shutting down Consulate homes after finding they met the criteria for closure.

In August 2012, the agency conducted a standard inspection while also performing a separate one in response to a complaint at Consulate Health Care of Jacksonville. Inspectors cited a total of three Class 1 violations during the visits.

The home failed to follow protocol for a patient with a severe and contagious bacterial infection, and failed in a separate review to investigate a bruise on a patient's genitals, and to protect her from falling and hitting her head.

AHCA agreed “solely for settlement purposes” to reduce two of the Class 1 violations to Class 2, an agency report noted. The agency fined the nursing home $26,000, according to a settlement agreement, and temporarily blocked admission of new patients.

Since then, the Jacksonville nursing home consistently has received low state and federal ratings. It was cited for another Class 1 violation in February 2015 after a nurse found a patient with severe dementia performing oral sex on another patient. The director of nursing didn’t report the abuse, declaring the dementia patient a consenting adult.

Consulate Health Care of Melbourne had two Class 1 deficiencies within a 30-month period but also remains open.

In June 2015, inspectors found the home failed to protect a patient who fell, hit her head and died. Seventeen months later, in January 2017, inspectors cited the home again after staff failed to look at, let alone treat, a patient’s surgical wound for over two weeks, instead plying her with drugs when she cried out in pain.

AHCA has designated the home a priority and has inspected it a dozen times since January 2017. But an appeal of AHCA's findings by the home has handcuffed the agency from acting further, said McManus, the agency’s spokeswoman.

AHCA could have taken emergency action to suspend the home’s license, as it did with The Rehabilitation Center at Hollywood Hills last September after Hurricane Irma knocked out the air conditioning and 12 patients died. But emergency shut-down orders are hard to get and lead to long, costly legal battles, so "the state looks to settle," said Martin Goetz, CEO of River Gardens Senior Services, which operates a five-star nursing home in Jacksonville.

"Closing a facility is a last resort," Goetz said, and often residents and their families oppose that action. "You can go into the worst nursing home in the state and you would find customers who swear they love the place and tell you, 'Please don’t close it.' "

An April audit by the U.S. Department of Health and Human Services' inspector general found that AHCA inspectors failed to ensure some nursing home violations cited in 2015 were corrected.

"The agency bends over backwards to help the facility fix the problems," said Lee, the elder care advocate. "AHCA affords the facility every opportunity for due process. But you know who doesn't get due process? The residents."

Feeble enforcement

A federal jury tried to hold Consulate accountable after a 22-day trial. In February 2017 the jury found that Consulate nursing homes filed hundreds of false Medicare and Medicaid claims, part of a company scheme to overcharge and misrepresent patient care.

While the jury's verdict focused on fraudulent billing practices, those bills misstated the care given to patients who at times were neglected and mistreated.

But Merryday, the federal judge in Tampa, neutered the jury and wiped out its $347.8 million judgment in January. Citing a lack of evidence of a scheme, Merryday wrote there was no proof Consulate knowingly misrepresented Medicare and Medicaid claims, or that AHCA and federal regulators were concerned about the company's actions.

“The governments paid and continue to pay to this day despite the disputed practices, long ago known to all who cared to know,” Merryday wrote in a decision on appeal with the U.S. 11th Circuit Court of Appeals.

The same week Merryday issued his order, AHCA sent notices to 53 Consulate homes stating the agency’s intent to deny renewing their licenses. Three other Consulate homes received notices in 2017.

AHCA took the action because the nursing homes had the same “controlling interest” as two other Consulate homes — Largo Health and Rehabilitation Center near Clearwater and Oakbridge Healthcare Center in Lakeland. Medicare and Medicaid payments stopped to both homes due to poor patient care.

Weeks later, AHCA agreed to place eight of the 56 homes on quality improvement plans. Oakbridge received a conditional license and is still in litigation with AHCA.

Another 26 homes, rated among the state's worst, continue operating without increased oversight or significant sanctions. The remaining 21 homes had histories of good inspections but were threatened with closure because state law allows AHCA to target other homes also owned by Consulate.

Near the end of a two-year struggle with dementia, Matina Austin’s husband, Dick, ended up at Largo Health and Rehabilitation Center in Pinellas County in June 2015.

In the mornings, staff would wheel patients into a communal room and leave them sitting all day, Austin said. She visited daily to make sure her husband was fed and bathed, tasks she said the staff often didn’t do.

“I just wanted them to be decent to him in his last days. He got worse and worse there," she said.

The Largo nursing home is one of the Consulate homes on an improvement plan. A six-page compliance agreement states Consulate's management company has increased the minimum wage for nursing assistants, increased nursing staff and decreased turnover since 2016 leadership changes.

AHCA said it will monitor the eight homes on quality improvement plans over the next two years using data from customer satisfaction surveys, staff turnover rates and staffing levels. The agency vowed to force the company to give up ownership of a home if a major violation at one of the eight contributed to the death or hospitalization of a patient.

“They’re doing something, but it’s not clear that it’s going to be very effective,” nursing professor Harrington said. “They’re basically giving them a pass."

Related coverage

Read part one of our series: Florida's worst nursing homes left open despite history of poor care, deaths

Part of a trend: Florida's largest nursing home owner represents trend toward corporate control

Dick Austin profile: Retired electrician spent his last days immobile in a troubled nursing home

Kim Duda profile: With her toes amputated, a mother can't walk after staying at Florida's largest nursing home chain

Bill Seigler profile: Man hurt in assault was sent to nursing home for therapy. He never received it

10 to know: Ten questions to answer before picking a Florida nursing home

Ryan Mills and Melanie Payne, reporters with USA TODAY NETWORK – FLORIDA, can be reached at Ryan.Mills@naplesnews.com and mapayne@gannett.com.