A man in a wheelchair was left outside a St. Petersburg nursing home on a 95-degree summer day. When the nursing home’s staff discovered him two hours later, he was unresponsive. His body temperature had climbed to 106.
In Brandon, a nursing home resident was found tied up in bed. The same thing happened to a cognitively impaired woman in an Oldsmar facility.
In Tampa, a nursing home resident was rushed to a hospital, where he would spend the next 11 days. The home’s staff had failed to notify his doctor about lab results that should have prompted a change in medications.
All these incidents happened in 2022 in Florida nursing homes, where serious violations have spiked over the past four years, according to records obtained by the Tampa Bay Times. Since 2019, violations have nearly doubled compared to the previous six years.
Last year, Florida nursing homes were cited 83 times for putting their older adult residents at risk of immediate danger. Eighteen were in Tampa Bay.
More than half of the serious violations involved staff shortages or insufficient training, the Times found. And 3 out of 5 violations were prompted by complaints that resulted in inspector visits.
Citations stemmed from a range of issues, including neglect, abuse and poor care.
A resident’s leg was amputated after staff at a Naples nursing home left a pressure ulcer untreated.
A man was killed after he escaped from his Live Oak facility undetected and was struck by a car. Residents escaping account for a quarter of the violations last year.
The cause of the increase in serious violations statewide is unclear. The Agency for Health Care Administration, which regulates Florida’s roughly 700 nursing homes, declined multiple requests for comment.
Elder care advocates, nursing home industry leaders and long-term care researchers offered theories for the increase. They ranged from changes in how violations are measured to staff shortages to recent legislation that critics say weakened nursing home care standards.
The consequences of repeat violations can be serious, for both residents and nursing homes. The facility with the most class 1 deficiencies last year, Destin Healthcare and Rehabilitation Center, recently lost its Medicare and Medicaid funding, a move the federal agency considers a “last resort after all other attempts to remedy the deficiencies at a facility have been exhausted.” Destin Healthcare’s leadership did not respond to requests for comment.
A spokesperson for the Florida Health Care Association, which represents 80% of nursing homes statewide, said inspections capture a specific point in time.
“Surveys are designed not only for oversight, but also to ensure centers have an understanding of what needs to be corrected so they can improve resident care,” Kristen Knapp said. She added that it’s “unfortunate” that the federal government’s Care Compare tool, which helps consumers choose a nursing home, lists inspections related to these violations but often does not show follow-up surveys that show how a nursing home may have improved.
Federal and state inspection reports detailing serious violations often note a nursing home’s “plan of correction,” a response that shows how the facility will prevent similar incidents in the future.
What caused the increase?
The Times analyzed Agency for Health Care Administration data over the last decade.
Between 2012 and 2018, the number of serious violations in Florida nursing homes remained relatively stable — averaging about 32 a year.
Starting in 2019, these incidents became more frequent.
Over the next four years, Florida nursing homes were cited for an average of 81 severe violations per year.
Knapp, of the Florida Health Care Association, noted that inspections of nursing homes changed in 2016 to follow new regulations from the federal government.
“Several of those new requirements have resulted in high-level citations for a small percentage of facilities,” Knapp said in an emailed statement. “However, the vast majority of care centers in Florida are making great strides to improve quality and better health outcomes for residents.”
After the change, which was rolled out over three years, facilities could be cited multiple times for a single case of substandard care, when previously they would have only received one violation. The new rules also added several new citations.
It’s unclear to what extent these new rules account for the recent surge.
A spokesperson for the Centers for Medicare & Medicaid Services, which issued these regulations, did not address questions sent by the Times about a possible link between the rule change and the increase in violations.
A workforce crisis
At least 53 times last year, nursing homes were cited for issues that involved limited staffing or insufficient training. Consider what happened last February at Excel Care Center in Tampa.
Just before midnight one evening, a resident at Excel called his friend. He sounded terrified.
The resident, who used a wheelchair, said he’d told staff an hour earlier that he believed he was having a stroke. But they hadn’t taken action, according to the resident.
“He doesn’t complain unless he is really hurting,” the friend, who was unnamed in public reports, later told inspectors. “Something was happening. Hearing his voice, he was scared.”
Inspectors would later find that nursing home staff had failed to tell his doctor about lab work showing that the resident was at risk for dangerous bleeding and needed to stop taking his blood thinning medication.
“I was desperate,” said the resident, whose name was also kept anonymous in inspection reports. He had crushing chest pain, and his left arm was tingling. “I pushed the call light, no one came, no one came.”
His friend kept assuring him someone would be there soon.
The friend hung up and called Excel Care Center directly, asking the front-desk person to send a nurse to his friend’s room immediately. When that didn’t work, his friend told him to start screaming for help.
A temporary nurse hired through a staffing agency who was just starting her shift was assigned to the resident. The certified nursing assistant who was supposed to care for him hadn’t shown up yet, she later told inspectors, and the other nurse assistant on duty was handling two hallways in the facility.
The friend called the home again and reached the agency nurse, telling her to immediately call 911. The agency nurse said she needed to verify that he was the man’s health care surrogate first — but she didn’t have the correct login for the facility’s electronic records. She then said they’d need to contact the resident’s doctor before calling emergency services.
Eventually, around 1:10 a.m., both he and the nursing home called 911.
At the hospital, the man had a heart attack and respiratory failure, spending more than three days on a ventilator. He lost so much blood he needed a blood transfusion.
“He might have died if he hadn’t called me,” his friend said.
In an email, an unnamed spokesperson for Excel Care Center said that while the company cares deeply about the health and safety of every resident, privacy laws prevent it from commenting on specific patients.
“Excel is and has been certified to be in compliance with all laws, rules and regulations shortly after the incident,” said the spokesperson. “Excel Care Center has had several deficiency-free surveys since February 2022.”
While low staffing levels plagued Florida nursing homes before the pandemic, the challenges have become more pronounced in recent years, industry leaders say.
“Everybody’s very open about how the real problem is staffing,” said Lindsay Peterson, a professor and researcher at the University of South Florida School of Aging Studies.
Shifting standards
The state has also changed staffing requirements for Florida nursing homes in recent years.
In summer 2021, Gov. Ron DeSantis signed a law allowing nursing homes to hire less experienced employees, known as personal care attendants, to supplement the work of nursing assistants. These workers can begin caring for residents after 16 hours of training, though they’re not supposed to perform tasks that require “clinical assessment, interpretation, or judgment.”
They’re meant to continue learning on the job, and can do so for up to four months. At that point, they must take the exam to become a certified nursing assistant if they wish to continue working at a facility.
While largely supported by lawmakers and the nursing home industry as a possible solution to the state’s long-term care staffing crisis, the elder advocacy organization AARP Florida at the time feared the initiative would dilute the quality of care for seniors.
The next year, DeSantis signed a law broadening the kinds of employees who can be counted in state-mandated staffing minimums for nursing homes, which are designed to keep residents safe.
It cut the time nursing assistants must spend with residents, allowing “non-nursing” direct care staff — such as physical and occupational therapists, activities staff and social services employees — to supplement some of their required care hours.
The law was backed by trial lawyers and the nursing home industry, which said it would give facilities greater flexibility. But AARP Florida and the state’s largest nursing home worker union again warned the new standards would harm residents.
“The last couple of legislative sessions have weakened staffing standards,” said Jeff Johnson, state director of AARP Florida. “It certainly makes sense that there’s going to be a correlation between less-trained staff and more violations.”
In one Tampa Bay case last year, a personal care attendant expressed feeling like she had “been set up for failure” after being assigned to 15 people. She attempted to turn a resident in bed by herself, leading the resident to fall and injure her neck and spinal cord.
“The facility was short on help,” the worker later told inspectors. “It was a very busy time. I wanted to try to do the resident myself.”
The nursing director said the fall wouldn’t have happened if two staffers had been helping the resident, according to the inspection report.
”It’s important to point out that despite workforce challenges, Florida nursing centers continue to make measurable improvements in quality care,” said Knapp of the Florida Health Care Association. “Our care centers are measuring better than the national average and in the top 10 nationwide for helping residents with improving on their activities of daily living, with reducing falls, depression and UTIs and with ensuring residents receive the flu vaccine.”
She added that these successes are a reflection of the dedicated caregivers working inside facilities.
Florida’s nursing homes rank 18th overall for staffing of licensed nurses — a category that does not include certified nursing assistants — which is better than the national average, Knapp said.
More complaints, more violations
Florida has conducted more inspections triggered by complaints in recent years, federal data shows.
It’s widely assumed that nursing homes often know about routine inspections ahead of time, according to Peterson of the University of South Florida. Complaint inspections keep facilities honest — they’re random and conducted in response to reports of wrongdoing from the public.
In 2018, Florida conducted roughly 1,900 complaint inspections. Last year, the state performed about 2,200 of these surprise investigations.
Not all nursing home complaints are confirmed. But research shows there’s a link between the number of complaints filed and how many violations are discovered inside facilities: When more people complain, inspectors find more credible violations.
A 2014 study found that 1 out of 4 Florida nursing home complaints made that year was substantiated, for example.
The Agency for Health Care Administration has not made all the inspection reports for last year’s serious violations public. But at least 52 of these violations occurred as a result of complaint inspections, the Times found.
The pandemic, which placed nursing homes under the microscope, may have made consumers more wary of activity inside long-term care facilities, Peterson said, increasing their likelihood to complain.
“When complaints go up, you begin to find more things,” she said. “It’s kind of concerning because it makes you wonder — when people aren’t complaining, all of this stuff is not discovered.”