By Francisco Alvarado, FloridaBulldog.org
At the Floridean Nursing and Rehabilitation Center in Miami, a man developed a pressure sore on the bridge of his nose that medical staff left untreated for weeks. In Hollywood, nurses at Hillcrest Nursing and Rehabilitation Center failed to provide medication to a resident who suffered intermittent pain in her chest, shoulders and thigh. Approximately 35 miles south, at the Heartland Healthcare Center Kendall, workers allowed an elderly woman who couldn’t stand on her own to fall and fracture her hip.
For these and seven other nursing homes, incidents of negligent care are so common the facilities have received abysmal reviews from federal health-care regulators. FloridaBulldog.org researched an online database administered by the U.S. Department of Health and Human Services to determine the worst nursing homes in South Florida.
We focused on facilities for the elderly within a 100-mile radius of Miami. Medicare.gov, grades each nursing home on a scale of five stars to one star, the lowest score a facility can receive. A nursing home with a one-star overall rating is considered “much below average,” according to Medicare.gov. One-star nursing homes are typically cited for more health-care deficiencies than the national average of 6.9 and the state average of 6.2. Some have paid tens of thousands in dollars in fines.
Medicare.gov rated 145 nursing homes in South Florida. Only 10 got just one star. They are listed below in alphabetical order.
Coral Bay Health Care and Rehabilitation
120-bed facility at 2939 South Haverhill Road in West Palm Beach
Health deficiencies: 19
2013-2015 federal fines: 0
According to 2015 inspection reports, some of the deficiencies at Coral Bay include failure to provide daily showers per an incontinent resident’s request; failure to provide housekeeping services in order to maintain a sanitary environment; and failure to provide evidence that a patient with a catheter was getting appropriate care.
During an inspection on April 8, 2015, a unit manager (who is not identified) admitted to investigators that there was no evidence in the record and treatment book that a resident’s Foley catheter and catheter bag was being changed monthly and every two weeks, respectively.
“The catheter tubing was discolored with light brown film and the tubing was not secured to the resident with a leg strap to prevent pulling,” the report states. Investigators also monitored the resident from 8:45 a.m. to 2 p.m. They noted, “at no time did a staff member checked on the resident’s incontinence status,” the report states.
While observing a nurse’s aide bathe a resident the same day, investigators determined the shower room “was dirty and had a strong foul smell. Brown color material was observed on the shower floor.” the report states. The aide then “coached the resident to stand up on the dirty floor. The resident was encouraged to urinate and defecate on the floor. The aide picked up the fecal material with her gloved hands, leaving small particles on the floor.”
Jennifer Trapp, the spokeswoman for Orlando-based Consulate Health Care, the company that owns Coral Bay, did not return two emails and a phone message after initially telling FloridaBulldog.org she would respond to a list of written questions.
Coral Reef Nursing and Rehabilitation Center
180-bed facility at 9869 SW 152nd Street in south Miami-Dade
Health deficiencies: 10
2013-2015 federal fines: 0
According to 2014 and 2015 inspection reports, some of the deficiencies at Coral Reef included failing to report to Florida’s Department of Health allegations by a patient who had been mistreated by a nursing assistant; failing to develop a pain relief care plan for a patient with bad teeth; failing to provide emergency dental care to another patient and only providing 48-hours notice of discharge to short-term residents instead of the 30-day notice required by state and federal law,
On Oct. 21, 2014, investigators observed a resident eating a breakfast consisting of one hard boiled egg, hash, two slices of toast, coffee and juice. According to the inspection report, the resident chewed her toast in the left side of her mouth and had a pained facial expression. She pulled down her lip to reveal a sore in the right side of her mouth.
The woman told a social worker at the facility “in order to try to get an appointment with the dentist, but the social worker had not gotten back to her,” the report states. “She also indicated that she told her son about it because she felt facility staff was likely ignoring her.”
Investigators interviewed the son two days later. He said his mother had been experiencing pain for more than a year. The report blamed Coral Reef staff for “failing to accurately assess resident’s pain and dental status, which caused actual harm to the resident in that she experienced significant pain which affected her ability to chew her food.”
Coral Reef administrator Ingrid Perdomo did not return three phone messages seeking comment.
Fair Havens Center
269-bed facility at 201 Curtiss Parkway in Miami Springs
Health deficiencies: 13
2013-2015 federal fines: $6,955
According to 2015 inspection reports, some of the deficiencies at Fair Havens include failing to prevent a patient from assaulting his roommate; failing to report what happened to the alleged victim’s spouse; failing to implement abuse prevention measures; and not having a program in place to prevent infections from spreading.
The records show that on June 12 investigators met with a resident and his wife who reported that his roommate had assaulted him, which was confirmed by a nursing assistant who witnessed the incident.
The wife complained to investigators that it was the second time the roommate went after her husband and that Fair Havens staff did nothing to prevent it. A week earlier, she found her husband with a swollen eye and a busted lip, yet no one called her about his injuries and none of the medical staff knew how he sustained them.
The woman told investigators Fair Havens staff could have avoided the second incident by moving her husband to another room or keeping a closer eye on his roommate. When investigators interviewed the Fair Havens abuse prevention coordinator, she said the nursing home did not report the first incident to the wife or any investigative agency because “we determined it was nothing.”
During an Aug. 25 inspection, investigators watched a nursing aide clean up a patient who had soiled himself without changing her gloves. “She was removing dark brown material that resembled feces to the buttocks area with the washcloth,” the report states. “After cleaning the buttocks, [the nursing aide] did not remove her gloves. [She] was touching the resident’s arm and face with the same gloves and proceeded to change the linen on the resident’s bed with the same gloves.”
Fair Havens Administrator Jose Andres Suarez did not return three phone messages seeking comment.
Floridean Nursing and Rehabilitation Center
90-bed facility at 47 NW 32nd Place in Miami
Health deficiencies: 23
2013-2015 federal fines: $16,100
2015 inspection reports show that Floridean’s health deficiencies included giving the wrong medications to residents; allowing unqualified personnel to assess residents’ wounds; failing to prevent the hospitalization of some resident; and letting patients’ sores fester.
For instance, on Feb. 25, 2015 inspectors discovered a resident with a pressure ulcer on the bridge of his nose, according to a report filed two days later. The injury was so bad it had a film necrotic skin that prevented Floridean medical staff from properly diagnosing the extent of the injury, one report states. Inspectors said the wound was avoidable.
Floridean health-care workers told inspectors the resident, admitted on Dec. 19, 2014, refused to wear a protective foam pad under his oxygen breathing mask to prevent the skin on his nose from breaking. The report, however, cites care plan for the resident that stated he was “at risk for skin breakdown due to impaired mobility, fragile skin, and needs assist with turning, repositioning and hygienic needs.’’ The ulcer remained untreated until inspectors paid their visit, the report states.
Inspectors identified eight Floridean residents with pressure ulcers. Floridean Executive Director Susan Murray Prado did not return three phone messages seeking comment.
Franco Nursing Home and Rehabilitation Center
120-bed facility at 800 NW 95th St. in Miami Shores
Health deficiencies: 16
2013-2015 federal fines: 0
According to 2015 inspection reports, some of the deficiencies at Franco include failing to provide residents with their requested food items; failing to provide residents medical and dental services; storing food in unsanitary conditions; and improper disposal of garbage, including soiled adult diapers.
On March 31, 2015, investigators found both of Franco’s dumpsters overflowing with trash, according to an inspection report. “Bags of trash were not sealed and they contained personal care items including soiled briefs and pads,” the report states. “The dumpsters could not be closed due to an excess amount of trash. The surrounding area was littered with several empty trash bags and two rubber gloves on the ground.”
Two days later, investigators interviewed a resident who complained that Franco staff were ignoring her requests to only feed her cold cut sandwiches during her evening snacks. According to the inspection report, investigators reviewed the dietitian’s progress notes from Feb. 23, 2015, which specified that the resident was to receive one cold cut sandwich and eight ounces of milk at bedtime. The resident also said she did not want peanut butter and jelly sandwiches.
According to the dietitian’s March 26, 2015 progress notes, the resident complained that on some nights she sometimes got chicken salad, egg salad, and peanut butter and jelly sandwiches. During an interview with investigators a week later, the dietitian (who is not identified in the report) said the Franco’s dietary manager (who was also not identified) said “sometimes the kitchen ran out of stuff and they substituted with what they had, meaning peanut butter and jelly.”
Despite the dietary manager’s assurances the kitchen would adhere to the resident’s request, the problem continued. “The registered dietitian said after that conversation he checked other evenings before he left the facility and saw (the) kitchen sent peanut butter and jelly sandwiches to resident instead of the resident’s choice,” the April 6, 2015 report states.
Consulate Health Care owns Franco. A spokeswoman did not respond to a list of emailed questions.
Golden Glades Nursing and Rehabilitation Center
180-bed facility at 220 Sierra Dr. in Miami
Health deficiencies: 12
2013-2015 federal fines: $138,841
According to health inspection reports, some of the deficiencies at Golden Glades include entering residents’ rooms without asking permission; risking injury to patients by not securing their bed rails properly; not regulating hot water temperatures in their bathrooms; and bug infestations.
During a Feb. 2, 2015 inspection, investigators observed seven small winged insects on a sandwich next to a bedside. “There were other small winged insects observed on the straw and tray next to the sandwich and flying around the sandwich,” the report states. “The resident entered the room during the observation and picked up the sandwich with his bare hand. He then threw it away.” Two days later, investigators noted small-winged insects flying around the third-floor nursing station and in another resident’s room.
During the same inspection period, investigators also cited Golden Glades for allowing the hot water temperature in five residents’ rooms to exceed 115 degrees Fahrenheit. “The facility’s corporate maintenance staff explained the boiler was set to not exceed 115 degrees,” the ieport states. “He could not say why the temperatures taken exceeded 115 degrees F in the resident rooms, but explained it had something to do with the outdoor temperature fluctuation recently.”
Golden Glades administrator Marc Douglas Grant did not return three phone messages seeking comment.
Heartland Healthcare Center Kendall
120-bed facility at 9400 SW 137th Ave. in south Miami-Dade
Health deficiencies: 11
2013-2015 federal fines: $2,015
Deficiencies at Heartland include failing to take precautions to prevent infections from spreading; and allowing a resident to fall and fracture her hip, according to 2015 inspection reports.
On April 28, investigators noted that Heartland staff had failed to provide personal protective equipment and a biohazard waste container inside the room of a resident with a MRSA infection, which is highly contagious.
Three months later, investigators visited Heartland again following a serious injury to a resident who fell while trying to get up from her wheelchair unassisted. According to a July 22 inspection report, Heartland’s administrator (who is not named) said that the resident got up very quickly before a nurse could assist her. The woman was transported to a hospital, where she was treated for a fractured hip. She also suffered bruising on her arms and a scraped elbow. Investigators reviewed the resident’s medical file and found that she had trouble maintaining her balance and required assistance standing up.
Julie Beckert, a spokeswoman for Ohio-based HCR Manorcare, the company that owns Heartland, said Medicare’s star rating system does not reflect the quality of care provided to its residents on a yearly basis. “Our employees are committed to providing quality care to the patients they serve and the well-being of our patients and residents is of utmost concern to us,” Beckert said. “Whenever we identify a patient care issue or if state surveyors have a concern, we aggressively address the matter in a plan of correction, training or other measures to ensure patient comfort and safety.”
Hillcrest Health Care and Rehabilitation Center
240-bed facility at 4200 Washington St. in Hollywood
Health deficiencies: 8
2013-2015 federal fines: $6,500
According to 2015 inspection reports, some of the deficiencies at Hillcrest (another Consulate Health Care-owned nursing home) include failing to monitor a resident complaining of pain; failing to require a resident to wear a hand splint per her physician’s order; failing to administer medications accurately and correctly to three residents; disposing of garbage improperly; and failing to take preventative measures against falls.
During an inspection on April 7, 2015, investigators observed a patient who was supposed to be wearing a splint on her left hand until bedtime. From 10:45 a.m. to 4:30 p.m., the resident never wore the splint, the inspection report states. When investigators asked a nursing assistant about the splint, she went to the resident’s nightstand and pulled it out of the drawer. The woman was also not being required to do range-of-motion exercises with her hands, per her doctor’s orders, investigators concluded.
During an April 8 interview with investigators, a Hillcrest healthcare worker who is not identified said the resident sometimes refused to do the exercises. “Review of the restorative tracking forms revealed no evidence of documentation the resident was refusing any services,” the report states.
Two months later, investigators interviewed medical staffers at Hillcrest about a resident who was found on the floor next to his bed, bleeding from a laceration on his eyebrow. Hillcrest had not prepared a care plan for the resident who was at risk of falling because his neurological functions were in significant decline, the June 19, 2015 inspection report states.
“Based on clinical record review and staff interview the facility’s licensed nurses failed to provide timely monitoring and implementation of interventions to meet the resident’s needs,” the report states.
According to the report, three hours after he fell, there was a “significant decline in the resident’s neurological function.” The resident was transported to a hospital emergency room, where he died, the report states.
Hillcrest is owned by Consulate Health Care, whose spokesperson did not respond to requests for comment.
The Nursing Center at Mercy
120-bed facility at 3671 South Miami Ave. in Miami
Health deficiencies: 15
2013-2015 federal fines: $9,300
2015 health inspection reports list deficiencies at The Nursing Center that include failing to notify a resident’s daughter when her father suffered medical complications and injuries; logging the wrong number of pills prescribed to a resident; failing to document when medication was administered to residents; allowing infections to spread; and not using proper hygiene controls when changing residents who soiled themselves.
On April 21, 2015, investigators observed a nursing assistant don gloves and clean up a resident who had defected himself. The assistant “moistened a disposable wash cloth, removed stool and cleansed buttocks,” the inspection report states. The assistant did not remove the gloves or wash hands after cleansing the resident’s back side and continued to apply ointment to his buttock, investigators noted.
Wearing the same gloves, the assistant then put new clean briefs on the resident and a new pillow underneath his head, according to the report. “Certified nursing assistant continued to provide care, rubbing resident’s head with the same gloves,” the report states.
Investigators also discovered The Nursing Center was prone to infectious outbreaks. Another inspection report says a review of the facility’s infections log showed that 11 residents contracted urinary tract infections last July. A review of the previous month’s log documented eight cases of skin infections.
Edwin Ortiz, the head administrator at The Nursing Center, did not respond to two phone messages seeking comment.
South Dade Nursing and Rehabilitation Center, also known as Gramercy Park Nursing Center
180-bed facility at 17475 South Dixie Highway
Health deficiencies: 11
2013-2015 federal fines: $177,873
According to 2015 inspection reports, some of the deficiencies at South Dade included failing to prevent residents from being abused and mistreated by staff; failing to report an employee who stole money from a resident to authorities; not following procedures to prevent the resident from getting scammed; and not providing an environment where a resident can have dignity and self-respect.
On March 12, investigators interviewed a resident who complained that a former South Dade nursing assistant borrowed $400 from him in November 2014 and did not pay some of the money back. The woman “approached the resident with her daughter and gave the resident a sob story about living in a car and needing money,” the inspection report states. “When the certified nursing assistant got her next paycheck, she only paid $160 of the $400 she owed him.”
The resident told investigators the nursing assistant was later terminated and moved to Connecticut. During a telephone conversation with the ex-employee’s sister, the resident claimed he overheard the nursing assistant in the background say he would never get his money back. “Resident said the certified nursing assistant sent a letter with a $100.00 money order, but that she canceled that money order too and as of this date the money was still owed to him,” the report states. He also provided investigators with the letter, dated Dec. 6, 2014, and the voided money order.
The resident told investigators that he informed several South Dade staffers, including the chief administrator, George Hernandez. He claimed Hernandez chided him for lending the nursing assistant money.
While the resident’s therapy director was aware the nursing assistant had cheated him, Hernandez and the nurse director (who is not identified) denied knowing anything about the problem, the inspection report states. “They acknowledged that the allegation was something that was required to be reported and investigated immediately upon the resident making the allegation,” the report states.
Hernandez did not return two phone calls seeking comment.