Before 8 died at Hollywood nursing home, inspectors found deplorable conditions

Before the deaths of eight elderly residents of the Rehabilitation Center at Hollywood Hills thrust the nursing home into a harsh national spotlight this week, health inspectors documented deplorable conditions that corroborate horror stories relayed by family of patients.

Some elders sat in soiled diapers while others received showers about every 10 days. They were served meals that were not prepared according to doctors’ orders or kept in sanitary conditions, and they slept in linens that may have been contaminated with dust and trash. Medical records were poorly kept, if at all.

The findings are contained in federal health inspection reports shared with state officials and obtained by the Miami Herald on Friday.

After Hurricane Irma struck Florida on Sept. 10, the 152-bed nursing home lost power to run its air conditioner for several days — culminating in an evacuation of the center and an adjoining psychiatric hospital, and the deaths of eight residents on Sept. 13.

Hollywood police have begun a criminal investigation into the patients’ deaths, while federal, state and local health officials have descended on the nursing home to assess its compliance with regulations for healthcare facilities.

Three reports from the federal Centers for Medicare and Medicaid Services, or CMS, dated March 2017 and February 2016 indicate that the Hollywood nursing home had failed its patients in many ways.

State regulators cleared the nursing home to continue operating after administrators fixed the problems in March. But the details are disturbing.

One woman, who was not identified in the report, complained to CMS inspectors in March that she had received two showers in the 25 days she had been living at the facility — despite being incontinent.

“She stated that she would like a shower in the morning before breakfast, because she has episodes of incontinence overnight and has urine on her and wants to be clean when they serve her breakfast in the room,” according to the March 31 report from CMS.

The March report also said the facility “failed” to prepare soft foods that met the medically prescribed diets of 44 patients, whose meals were supposed to be pureed, and that the nursing home had shortchanged other residents by serving them veal Marsala portions that were smaller than the cook said.

“It was determined that the facility failed to provide residents with foods prepared by methods that conserve nutritive value, flavor and appearance,” the report states. “Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for the food service safety.”

The inspections are conducted by state regulators in conjunction with federal officials, who certify nursing homes for Medicare. The reports are kept by CMS.

In the reports, inspectors also noted that the alleyway behind the rehab center was “strewn with trash, garbage, plastics, and used nursing [and] medical supplies.”

Nursing home officials submitted plans to fix the problems, and state health officials cleared the nursing home to continue operating in March.

“The deficiencies were corrected and the air conditioning systems never had any issues. It was never cited in any reports,” said a nursing home executive who spoke on the condition of anonymity because of the ongoing investigation.

But federal officials said Friday that they had reopened an investigation into the nursing home.

“There is an ongoing federal assessment under way and during this time CMS is unable to comment further on any specific findings or actions related to that survey until it is complete,” said CMS Administrator Seema Verma. “CMS is working to provide whatever assistance and coordination is necessary to ensure nursing home residents receive care in safe and stable environments.”

The critical observations noted in federal regulators’ reports were backed up by family members who complained this week about the rehab center’s treatment of their loved ones after the facility was evacuated and authorities launched investigations.

Carmen Veroy, a limousine driver from Hollywood, said her parents, Libia and Gabriel Giraldo, both 89, lived in the nursing home during the past year. Veroy said she complained to administrators about mold on ceiling panels and leaking air conditioning units. She said she also complained about her parents’ being left in soiled diapers and her parents not being bathed.

Veroy showed a reporter pictures of the sores her mother’s skin would get from her diapers not being changed.

“I would find her crying, saying how bad it hurt,” Veroy said. “Her skin was burned.”

A family friend who often visited with Veroy’s parents at the rehab center said there were problems with the center’s air-conditioning system long before it lost power due to Irma.

“Somebody needs to be held accountable for this,” Ana Mangialla said. “This was avoidable.”

Veroy said her biggest concern is finding another nursing home for her mother and father in the Hollywood area. Libia Giraldo suffers from dementia and Gabriel from Alzheimer’s, she said.

For now, Gabriel Giraldo is at Memorial Regional Hospital, where some of the 141 patients evacuated from the nursing home were taken Wednesday. Libia Giraldo is at Memorial Regional South.

Before the storm, administrators at the rehab center assured visiting relatives of residents that everything would be safe.

Vendetta Craig, whose 87-year-old mother, Edna Jefferson, lived in the center, said she was assured the it had generators, blankets and food — “Everything they possibly needed,” she said.

“The whole week I was going through this emotional battle,” Craig said. “What do I do with my mom? It didn’t come out as best as we hoped, but mom is OK now.”

Craig’s mother was taken to Memorial Regional, across the street from the nursing home. But Craig was still livid. “How mad would you be if somebody didn’t take care of your mom and they said they would?” she said. “You’d be stuttering mad.”

This story was originally published September 15, 2017 at 9:43 PM.