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Neglected: Florida’s Worst Nursing Homes Left Open Despite History of Poor Care, Deaths

Naples Daily News

By Melanie Payne and Ryan Miller

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.

Golden Glades staff has been accused of negligence in the deaths of at least five patients, according to lawsuits filed since 2013. The nursing homes’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 they 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?”


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.”