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Florida Nursing Homes Worst Offenders

Florida Nursing Homes Worst Offenders

Caring for the elderly can be a difficult, thankless job. Many elderly nursing home residents require around-the-clock monitoring and well-trained staff to protect them from harming themselves or others. Nursing staff are humans and can make mistakes, which is why strict protocols need to be put in place to catch any errors. These protocols also prevent lazy or incompetent staff members from endangering your loved ones by cutting corners or neglecting their duties.

Most nursing homes do implement and follow adequate guidelines to protect residents. However, there are a significant number that have failed -- either through malice or incompetence -- to maintain even basic standards of care, resulting in serious violations and hefty federal fines.

ProPublica published a vast survey of nursing homes nationwide based on Medicare’s very detailed nursing home compare tool. We pulled from their database to compile a list of the 11 nursing homes in the state of Florida with the worst violations in recent years. These committed offenses at level K and J (on an A-L scale) by Medicare inspectors, meaning they created “immediate jeopardy to resident health or safety” and whose deficiencies are “widespread or part of a pattern”.

Marshall Health And Rehabilitation Center -- Perry

The most recent rating from Medicare gives Marshall Health and Rehabilitation Center an overall rating of “Much Below Average.” That is the worst rating possible.

In their most recent inspection report the facility was cited for not maintain proper staffing. Regular readers of this site know our number one pet peeve is poor staffing. If a facility lacks proper staffing (or properly trained staff), mistakes are inevitable. Medication errors, choking deaths and bedsores have a direct correlation to staffing inadequacies.

That same inspection report found that Marshall Health “failed to ensure that handwashing was performed during incontinent care and wound care, and failed to ensure that proper Personal Protective Equipment (PPE) was worn for residents on contact isolation precautions for 4 of 29 sampled residents.” We have investigated several deadly Candia Auris in other nursing homes that were directly related to poor hygiene and sanitation practices.

Avante at Orlando, Inc. -- Orlando

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This facility has the dubious honor of committing two egregious violations that resulted in serious injury and/or death. In April of 2017, a staff member took nine residents to a local shopping center for an outing. The ratio of residents to staff was too high, apparently because one wheelchair-bound resident couldn’t find the staff member when he needed assistance using the toilet. To avoid an embarrassing accident in the store, he decided to visit the toilet by himself. He wasn’t strong enough to transfer himself out of his chair and managed to soil himself in the attempt. He then fell into his own feces, breaking his hip in the process. The staff member eventually came to help, cleaning the resident and get him back into his chair. In doing so, the staff member left the other eight residents unsupervised in the 150,000 square-foot store for an hour.

Inspectors found that Avante at Orlando did not have enough staff to supervise outings of that size and also did not have a system in place to let residents in need contact help during these outings. For this violation, the facility was fined.

But that’s not the most egregious error they made. Just three months prior, in January of 2017, a newly admitted resident had been released from the hospital with advisement from her doctor that her kidney functions should be closely monitored because of disease. The doctor also noted that she required regular medical treatment because her kidneys were failing. The facility, however, failed to obtain these orders, resulting in the resident’s health rapidly deteriorating. Within eight days of admission, she had to be re-hospitalized because her failing kidneys were not properly filtering toxins from her body.

Despite being transferred to emergency care, the patient was too far gone. She was transferred to hospice care and died within five days. For this gross error resulting in a resident’s untimely death, Avante received a substantial fine.

Speaking of fines, many nursing homes go years without fines. Most never have any violations serious enough to be fined. Avante at Orlando? According to Pro Publica, they received more fines than any other Florida nursing home.

Heartland Health Care & Rehabilitation Center -- Sarasota

Heartland Health is a for profit nursing home chain. Many of their facilities receive average or better ratings. Not Heartland Health Care & Rehabilitation Center. This 140 bed facility has a “much below average” rating for health inspections and an overall rating of “below average”. If that isn’t bad enough, Medicare also warns that this facility has been cited for abuse.

The opioid epidemic is still raging in the United States, which means nursing home residents who on pain medication are prime targets for theft. In early 2019, 13 residents of the Health Care & Rehabilitation Center in Sarasota, Florida, were the victims of such medication theft. A staff nurse realized that a medication blister pack containing narcotics had been tampered with, the medication stolen, and replaced with unknown pills. The nurse reported it to management who found that many such “medication cards” had been tampered with. At least one patient received unknown medication before the problem was detected.

A staff member was the culprit, but a bigger problem stemmed from management. The HR Director admitted she did not perform necessary reference checks for the new employee, whose background check forms had errors and inconsistent information. A simple phone call or two could have prevented putting over a dozen residents’ health in jeopardy -- and prevented controlled substances from being stolen from the facility.

Melbourne Terrace Rehabilitation Center -- Melbourne

Earlier in this post we said the worst rating from Medicare was one star or “Much Below Average.” That’s not quite accurate. There are a handful of nursing homes that are considered so bad, they aren’t rated. Instead they are designated as “Special Focus Facilities” meaning Medicare has found that they have a “history of persistent poor quality care.  Melbourne Terrace Rehabilitation Center is one of those very unlucky designees.

In a random sample of medication records, an 8% medication error rate was detected. Medication errors are a leading cause of death for people hospitalized or in nursing homes. An 8% medication error is never acceptable and is a death waiting to happen. This is especially true in nursing homes where many residents already suffer from compromised immune systems.

The facility was also cited for failing to properly treat pressure ulcers. These ulcers, more commonly known as bedsores, are 100% preventable. While we understand that a resident may be admitted to a nursing home with an existing bed sore, facilities have a duty to properly treat those ulcers and prevent them from getting worse.

Perhaps the scariest incident is that from January, 2017. On New Year’s Day, Melbourne Terrace Rehabilitation Center lost an elderly resident who was suffering from advanced dementia, diabetes, and other physical ailments. The patient had already been identified as a wandering and elopement (i.e., escape) risk. However, the patient was able to leave the facility through the front door and managed to wander a long distance, eventually crossing a four-lane highway without a crosswalk. A quick-thinking passerby saw the elderly woman needed assistance and stopped his vehicle to help her. He contacted police who were able to identify where the confused woman had come from.

Fortunately for her and her family, she was not injured or hit by a car.

Avante At Ormond Beach, Inc. -- Ormond Beach

The second Avante facility in our list, Avante at Ormond Beach, was cited for causing immediate jeopardy to residents in April of 2018. Three out of three nurses in the facility were observed failing to clean and disinfect finger-prick blood glucose monitors. At the time, there were 27 patients all receiving regular blood glucose checks, meaning the chance of spreading blood-borne infections increased dramatically with the failure to clean the monitoring devices. One of the nurses claimed she couldn’t remember receiving training in properly disinfecting the devices.

The facility administrator admitted there was no on-site staff developer and that there were gaps in the formal training nurses received. This kind of neglect could have spread serious bacterial or viral infections to a large number of residents and brought about many complications. For this error, the facility received a large fine.

Readers of this site know there have been several nursing homes that were hit with fast spreading Candida auris outbreaks that resulted in multiple fatalities. The reason? Poor sanitation practices by staff. Healthcare workers should always change gloves, wash hands and disinfect equipment between patients.

North Rehabilitation Center -- Saint Petersburg

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Oftentimes residents are not able to communicate their medical issues with staff, whom they rely on to monitor simple things like breathing, eating and drinking, and bowel movements. That might sound minor, but bowel health is a serious issue, especially for the elderly. A May 2018 report identifies one North Rehabilitation Center resident dying from constipation. The resident was identified as at-risk for constipation due to prescribed opiate use; however, the facility did not have an adequate plan to identify and intervene when a resident was constipated. By the time the staff even identified the problem, it was too late. The resident was rushed to the hospital with a perforated colon, where she eventually died.

By simply identifying if a resident was having ordinary bowel movements, this extremely painful death could have been avoided. But the staff at North Rehabilitation Center failed to do even this basic check, earning the facility an enormous fine. 

Ocean View Nursing & Rehabilitation Center, LLC -- New Smyrna Beach

A lack of training strikes again as a nurse was observed not adequately disinfecting a blood glucose monitor at the Ocean View Nursing & Rehabilitation Center in Smyrna Beach. Like the incident at Avante At Ormond Beach mentioned above, a glucose monitor can spread blood-borne diseases from patient to patient if it’s not properly disinfected.

Rehabilitation Center at Park Place – Pensacola

The Rehabilitation Center at Park Place is a 118 bed for profit nursing home. In its most recent ratings on Medicare Compare, it only received one star, “Much Below Average.” It’s health inspection rating is also much below average. The facility is also one of just a few Florida nursing homes presently designated as having been cited for abuse. (Depending on the facts surrounding the abuse designation, facilities can have the abuse designation removed in as little as one year after correcting whatever deficiency caused the rating.)

According to a 2019 inspection report, “Based on review of the facility's security recorded camera video, record review, staff interview and policy review, the facility failed to promptly initiate basic life support including Cardio-Pulmonary Resuscitation (CPR)… The facility neglected resident [name redacted] needs for emergency care by failing to commence CPR until almost an hour after [the] resident respirations and heartbeat had ceased. The resident was full code status. The facility's failure to provide CPR, which resulted in a terminal neglect, was identified as past noncompliance Immediate Jeopardy.

According to court records, the Escambia County Sheriff’s Department arrested a Certified Nursing Assistant employed at the Rehabilitation Center at Park Place after “she allegedly placed her knee on top of a 73-year-old patient's broken leg and applied pressure for several minutes, laughing when the man cried out in pain.” The worker, Precious Adams, was charged with criminal abuse of an elderly or disabled person.

Florida Nursing Home Abuse Lawyers

No matter their age or mental ability, nursing home residents are human beings with all the rights that come with that. No one should be subjected to unnecessary infection risks, low staffing levels, medication theft, poor care or abuse. Yet as we can see here, these things do happen -- and often aren’t caught or reported. If something like this happens to you or your loved one, contact us immediately.

Because Florida is such a huge retirement destination, the Legislature has enacted many laws to protect elderly and disabled residents including residents of nursing homes, assisted living facilities and hospices. These facilities can be made to pay damages for pain and suffering caused to residents. Families of these residents may also be entitled to damages.

For more information, visit or nursing home abuse page. Ready to see if you have a case? Contact us online, by email [hidden email] or by phone 833.201.1555. All inquiries are protected by the attorney – client privilege. Cases handled nationwide.

[Our nursing home abuse cases are limited to serious bodily injury, sexual assault, death and bedsore cases. If we can’t help, someone in our network probably can. Please note that we have lawyers licensed in many states including Florida.]








Related topics: assisted living facilities (20) | poor staffing (24) | proper training (8) | substandard care (67)

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