Neglected to Death

Indictment, fines didn’t stop ALF operator

When Florida’s Statewide Grand Jury charged Arturo Godinez with taking part in a conspiracy that sold counterfeit and diluted drugs to unsuspecting cancer patients, state health regulators say they had no authority to strip him of ownership of some of South Florida’s largest assisted-living facilities.

Conditions at Godinez’s Grand Court ALFs, though, offered regulators plenty of ammunition:

In the eight years since Godinez’s indictment, one elderly man plunged to his death from the balcony of a third-floor Alzheimer’s wing, gushing blood onto the pavement before a caregiver heard his cries for help. A woman, her mind ravaged by dementia, drank from a bottle of Pine Sol and died 10 days later. Yet another woman wandered from her ALF and was found two days later lying near railroad tracks — starving, dehydrated and comatose, her body riddled with painful red ant bites, sending her into shock. She now is bedridden in a nursing home.

Even when a new state law was passed a year ago forcing anyone with pending criminal charges to lose their license until the case is resolved, the state did nothing — allowing the 52-year-old operator to stay in business.

Not until The Miami Herald inquired into Godinez’s standing did the Agency for Health Care Administration take action two weeks ago, asking a judge to strip Godinez’s licenses.

In two complaints, healthcare administrators accused Godinez of lying under oath in relicensing forms, of failing to submit criminal history records, and failing to pay $7,400 in fines.

The agency’s action could well prove academic. Awaiting trial for more than eight years on a racketeering indictment, Godinez, free on $600,000 bond, could soon see his fate determined. He is set to stand trial on Oct. 10.

“Anybody who would move or sell ineffective medications to someone in a time of desperation or need, it seems to me they are indifferent to humanity,” said Florida Statewide Prosecutor Nick Cox, whose office is trying Godinez next month.

Godinez’s defense attorney, Marcos Beaton, said his client expects to be vindicated in court.

“Mr. Godinez entered a plea of not guilty over eight years ago and he has insisted on clearing his name through a trial ever since,” Beaton said.

“We look forward to finally moving past what has until now been only an ugly accusation, and getting into what really matters — a trial based on the facts and the law.”


For now, Godinez is giving up his operational duties and transferring stock ownership in light of AHCA’s recent complaint. “He will not be the owner anymore,” said Julie Gallagher, a former AHCA general counsel who represents Godinez’s ALFs

Godinez’s facilities were well known to state regulators: Seventeen times since 2004, the Agency for Health Care Administration has fined Godinez ALFs for violations of state law.

Since 2006, three facilities linked to Godinez in Miami-Dade and Broward counties have racked up 180 violations — sweeping deficiencies that increased year after year.

In 2007, healthcare inspectors threatened to revoke Grand Court Village I’s license after they watched a man with a swallowing disorder suffer a “severe choking episode” because his caregiver failed to thicken his punch, soup and coffee, as a doctor ordered. The man had choked before.

But Godinez kept his license. The punishment was reduced to a $1,824 fine.

The next year, inspectors fined the home $875 after finding infestations of German cockroaches, mice, “ghost ants and crazy ants.” During one visit that year, a mouse skittered across a reception desk in front of an inspector from the state attorney’s office. Another inspection turned up “rodent fecal matter” in dresser drawers and bathroom cabinets.

Other fines resulted from failing to assess the medical needs of residents and provide them with crucial medications; failing to adequately train staff; and failing to perform criminal background checks on staff.

The home also was fined for serving pudding and ice cream cake to residents with life-threatening diabetes — and hot dogs and French fries to residents who could swallow only pureed food. In 2009, inspectors watched caregivers force a resident to take his medicine by pinching his nose shut. They called the incident “abuse.”

At Grand Court II, Godinez was fined $2,150 when inspectors said the home failed to ensure that a locked Alzheimer’s wing was “safe.” Inspectors turned up a host of hazards, including a rusty nail sticking out of a shower, missing floor tiles creating a “tripping hazard,” a missing doorknob leaving only protruding metal, an uncovered electrical outlet, peeling paint and leaking toilets.

Time and again, Godinez’s facilities were cited by AHCA or the Department of Children & Families for failing to provide adequate or well-trained staff to supervise and protect the frail elders in their care — often with dire consequences.

Diagnosed with severe diabetes and Alzheimer’s disease, 83-year-old Berta Gil was so confused that she would regularly wander from Grand Court Lakes in search of her long-dead parents. When Hurricane Wilma struck in October 2005, Gil strolled out an open gate and simply disappeared.

“She should have had proper supervision,” a DCF investigator later wrote.

Gil was discovered two days later lying unresponsive near railroad tracks behind a warehouse. She was dehydrated, her extremities had turned blue from lack of oxygen, she had bruises on her right hip and left shoulder, a laceration over her left eye — and had been gnawed by fire ants on her abdomen, legs and arms. She was comatose and in renal failure when she arrived at Parkway Regional’s emergency room.

Gil recovered from her injuries, but she has remained bedridden in a nursing home ever since.

Though Gil’s family was awarded $300,000 by an arbitration panel, it took relatives two more years to collect the money as Godinez filed paperwork claiming he had sold the facility — though he still keeps an office there. Gil’s relatives finally collected in December 2010 after a Broward judge authorized police to break into Godinez’s beachfront apartment to seize his personal belongings.

AHCA never investigated Gil’s injuries. But one month after arbitrators sided with the family in a lawsuit, AHCA finally acted. The agency allowed Godinez to transfer his license in a transaction the family called a “sham.”

“They permitted him to do this — over the family’s objections,” said Sunrise attorney Jeffrey M. Fenster. “They facilitated a fraud.”


Some of Godinez’s residents paid with their lives for the facilities’ corner-cutting and carelessness.

In June 2006, 89-year-old Bernadine Wylie had become so frail that she kept falling out of her wheelchair. Administrators at Grand Court Village I returned the stroke victim to the ALF — instead of moving her to a nursing home for round-the-clock care — after she fell on her head, sustaining large bruises on her face and forehead. A week later, Wylie’s leg got caught inside the wheel of her wheelchair as an aide pushed her. Later that night, Wylie complained of severe pain in her left leg, and refused to go to dinner. “I’m hurt. I’m hurt,” she told a caregiver.

Wylie’s thigh bone was shattered — her daughter said X-rays showed a portion of the bone protruding from the skin — requiring surgery to repair it. She stopped breathing at North Ridge Medical Center, and died on June 11, 2006.

The Broward Medical Examiner’s Office called the death accidental, and listed the cause of death as atherosclerotic cardiovascular disease, with a leg fracture as a contributing cause.

Until last week, Wylie’s daughter said she believed her mother broke her leg while sleeping.

“They told us she was in bed napping and woke up and her femur just popped out,” said 64-year-old Jane Glatz. “Oh, my gosh. We never knew this information.”

A year after Wylie’s death, another woman also perished at Grand Court Village I — after drinking a deadly cleanser.

At 81-year-old Jean Kramer’s last checkup, her doctor ordered that the Alzheimer’s patient be closely monitored for her own protection. But just five days later, a caregiver found her in the cafeteria pouring an industrial-size bottle of Pine Sol cleaner into a glass to drink. Her breath reeked of the cleaner, and a nurse told investigators Kramer probably thought it was Kool Aid. Kramer died on April 27, 2007, 10 days later.

An administrator insisted she had no idea how Kramer found the Pine Sol and told an AHCA investigator she had “taken steps to prevent recurrence of the incident.” But a tour of the home showed nothing had changed: “The housekeeping cart was observed unlocked, unsupervised and unsecured sitting in the hallway,” containing solvents, bleach and toilet cleaners, an AHCA report says.

“They were supposed to watch her,” Kramer’s daughter told a DCF investigator. “They weren’t supposed to leave things like that around.”

The punishment for Kramer’s death: a $2,000 fine.

One of the home’s must troubling deaths was never investigated by any state agency.

Grand Court Lakes’ nursing director said in a sworn statement that the home submitted a required incident report to the state when 80-year-old John Pribil Sr. died in October 2005, but there are no records that AHCA ever investigated the death. Nor did DCF.

Though Pribil’s family paid $2,900 each month so the World War II veteran could be supervised in a specialized Alzheimer’s wing with two aides on duty each night for the residents’ protection, neither caregiver showed up for work the night Pribil plunged to his death from a third-floor balcony.

For Godinez, the death was yet another crisis that would underscore the dangers of ALFs — and the lack of state oversight.

His own foray into the industry began in the 1990s when he and his wife, Judith, began buying, selling and managing ALFs in South Florida.

He bought Salmo 23 in 1994 for $125,000, and sold the Hialeah home a decade later for $700,000. In 1998, Godinez paid $400,000 for an unlicensed ALF in Hialeah, renovated the 48-bed home, called Alpha & Omega, obtained a license and sold it four years later for $1.4 million.

Godinez bought his two biggest prizes — Grand Court Village I and II — about three months before he was indicted. Until September 2008, he also owned Grand Court Lakes, a Miami ALF with 140 beds.


Court records and prosecutors say Godinez’s dabblings in the prescription drug trade were far more profitable. Though his 1999 federal tax return listed a family income of $70,000 — his income grew to $100,000 the next year — the family had “extravagant expenses” on such luxury items as a $74,382 Hummer and a 50-foot Hatteras yacht, prosecutor Oscar Gelpi said in court earlier this month.

When Godinez was arrested in 2003, Florida’s top statewide prosecutor called the ring’s crimes “horrific.” Conspirators, the state said, created four bogus drug wholesalers that shipped diluted and sometimes phony drugs by UPS to chain pharmacies throughout Florida and other states, including Maryland, Texas and Missouri. In some cases, the ring shipped bottles of chalk and tap water to terminally ill patients, investigators said.

The investigation was sparked by the theft of $250,000 worth of Epogen, a drug for kidney dialysis patients, from Miami’s Jackson Memorial, the county’s struggling public hospital.

Investigators say Godinez and at least 17 others stole or bought brand-name drugs — sometimes illegally paying Medicaid recipients for the medications — diluted and relabeled them, and then sold them with false documentation, or pedigrees, to chain pharmacies such as Walgreens and Eckerd, private dealers and directly to consumers. Hundreds of elders and poor people on Medicaid were victimized, investigators said.

“It’s not a garden-variety case,” Broward Circuit Judge Jeffrey Levinson said of the 100-page indictment at a hearing in early September.

Nicknamed “Farm Boy” by his cronies, Godinez owned a nursery where, investigators charge, runners picked up bags and boxes of cancer drugs that were delivered to an alleged ringleader.

“I have evidence that he sold large amounts of pharmaceuticals. I don’t know where they came from. And I have no evidence that he obtained one dollar of them legally,” Florida Department of Law Enforcement Agent Gary Venema said in a sworn statement.

In all, Venema said, the ring netted about $20 million.

And some of that went to Godinez. “He said that he had a profit of a million dollars” selling HIV and schizophrenia drugs to the group’s alleged ringleader, a former colleague testified against Godinez in pre-trial depositions.

Jane Glatz, whose mother died of a broken leg, said she never knew that the owner of her mother’s ALF stood accused of being part of a massive fraud scheme. “If I had known about this man way back in 2003, there would have been a major change,” she said.

“I would have been seeking another facility,” Glatz added. “I would have been up and out — absolutely.”

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