To ensure that the health and well-being of every resident in a nursing facility is maintained, the Centers for Medicare and Medicaid Services (CMS) and the State of Florida conduct routine surveys at nursing homes statewide. Their efforts help to identify serious concerns, health violations and deficiencies that could cause harm, injury or premature death.
In serious cases, state and federal government regulators will designate the nursing home as a Special Focus Facility (SFF) and place the Center on a federal Medicare watch list. This designation means the facility must undergo more than routine surveys, investigations, and inspections until the nursing home is taken off the list. If sufficient changes are not made promptly, the facility may lose their contract to provide care to Medicaid and Medicare-funded patients.
In 2017, state and federal nursing home regulators added Gracewood Rehabilitation and Nursing Care to the watch list and designated the Center as a Special Focus Facility. Some of the concerns over health violations, deficiencies and citations are listed below.
This Long-Term Care Home is a 120-certified bed Center providing cares and services to residents of Pinellas Park and Pinellas County, Florida. The ‘not for profit’ Facility is located at:
8600 US Hwy 19 N.
Pinellas Park, FL 33782
(727) 541-7515
In addition to providing skilled nursing care, Gracewood Rehabilitation and Nursing Care Center offers residents:
When the problems and nursing homes are identified as serious deficiencies and dangerous conditions, federal and state regulators can issue monetary penalties as a wake-up call to ensure residents remained safe in the facility.
Within the last three years, CMS and the state of Florida have issued numerous fines to Gracewood Rehabilitation and Nursing Care. This includes a $22,500 fine on August 20, 2015, a $66,046 fine on May 6, 2016, and a $158,425 fine on October 11, 2016. Additionally, Medicare denied a payment request by the facility on August 20, 2015, due to substandard care. There were also 19 formally filed complaints in the last 36 months that resulted in citations.
The Florida and federal government nursing home regulatory agencies routinely update their care home database system containing the complete list of all incident inquiries, dangerous hazards, filed complaints, health violations, safety concerns, and opened investigations. This information can be found on numerous websites including Medicare.com.
Currently, Gracewood Rehabilitation and Nursing Care maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and four stars for quality measures. Some major concerns, deficiencies, and violations identified by state investigators are listed below.
In a summary statement of deficiencies dated July 20, 2017, the state investigator noted the facility’s failure “to ensure prevention techniques were implemented per facility Abuse Prevention Policy.” This deficiency affected one resident who was “reviewed for an allegation of abuse.” The surveyor’s investigation included a review of the resident’s June 2017 Medical Record Physician Summary Report that revealed that the “cognitively intact” resident “was admitted in early March 2017” with “bilateral hand contractures.”
The investigator interviewed the resident on the afternoon of July 18, 2017, who was asked if “staff, resident, or anyone else here abused you – this includes verbal, physical, or sexual abuse?” The resident responded that they had been physically abused and continued to state “that the CNA [Certified Nursing Assistant] is no longer here. He slapped me during my second week. It was back in March. I’ve never known his name. He no longer works here. I haven’t seen him. I asked him to do something, and he said he didn’t like my attitude.” The surveyor noted that “911 was called and the Administrator called the State.”
The facility’s Director of Nursing was interviewed on the afternoon of July 19, 2017, who stated “she was the Abuse Investigator at that time.” On March 29, 2017, the resident told the Director Nursing when she arrived on the floor at about 5:00 AM that he had his hand slapped by the Certified Nursing Assistant (CNA) on the 11:00 PM/7:00 AM shift.” The Director stated that the “CNA was cleaning the floor in his room and he did not want the CNA in his room cleaning [and claimed that there was] a verbal altercation.”
The resident described the CNA as “a tall, thin light-skin Cuban male with an accent. The suspected employee was immediately suspended when it was reported, and everyone was questioned.” The Director stated that the accused nurse “was not working that night. The employee was brought back, and the police and State abuse agency were called. They determined it was unsubstantiated [and the employee returned to work as normal]. The facility had two staff members going in at a time to the room when needed, but this was no longer being done.”
The state investigator showed the Director of Nursing the CNA Assignment Schedule and was told that the resident was assisted by the allegedly abusive CNA “in the middle of the night last night and verbalized to the surveyor that he still feels threatened an unsafe.” The Director “apologized and shook her head” stating that “she will make sure [the alleged abusive CNA] will work another hall from now on.”
During an interview with the Social Services Director on July 20, 2017, it was affirmed that the resident “was specific back in March that he did not want the CNA to continue to assist him.” As a part of the investigation, the surveyor reviewed the facility’s Abuse Investigation documentation. The document revealed that the “Director of Nursing [recorded] on April 3, 2017, that she told the resident the outcome of the investigation and that the employee [the alleged abusive CNA] would come back to work but would not be working in his section.”
The investigator reminded the nursing staff and Administration of Gracewood Rehabilitation and Nursing Care of their Abuse Prevention Policy (revised April 10, 2017) that reads in part:
“The facility has implemented the following processes in an effort to provide residents and staff a safe and comfortable environment. Section G states the facility must ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employment through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. The facility must identify areas where mistreatment are more likely to occur.”
In a summary statement of deficiencies dated July 20, 2017, the state investigator noted the facility’s failure to “ensure wound care was completed according to the physician’s orders related to the nurse omitting part of the treatment while changing the wound dressings for [a resident] observed for wound care.”
The investigator reviewed the July 2017 Physician Order Sheet (POS) clinical record “which contained the following order for wound care: Apply collagen into the sacral wound and cover with the calcium alginate daily and as needed (PRN).” The start date for the order was May 30, 2017.
However, an observation was made on the afternoon of July 19, 2017, With the North Unit Manager (NUM) who medicated the resident “for pain beforehand. He assessed her pain level to ensure comfort during the procedure.”
The North Unit Manager “washed his hands, and donned gloves. He explained his purpose to the resident as he raised her bed. He removed the outer dressing and discarded in a bag that he had placed on the floor. He removed his gloves and sanitized his hands.” At some point, the NUM realize he had forgotten to attain scissors for the procedure and instead tore the gauze and packaging.
After observing the North Unit Manager throughout the entire procedure, the surveyor asked him to “read the order back again. It was at this point that the North Unit Manager stated ‘oh, I missed the collagen, and I will have to do it again.’” The surveyor reviewed the facility’s Dressings/Dry/Clean Level III Policy revise in October 2010 that reads in part:
“The following equipment and supplies will be necessary when performing this procedure. 4. Scissors. Steps in the procedure: 3. Tape A biohazard or plastic bag on the bedside stand or open on the bed. 9. Pull gloves over dressing and discarded in the plastic or biohazard [bag].”
In a summary statement of deficiencies dated July 20, 2017, the state surveyor noted the facility’s failure “to ensure one of eight residents… received the appropriate level of supervision during meals in order to ensure he consumed items of property diet consistency.”
The surveyor made general observations of the facility’s Unit Dining room on July 17, 2017, during the lunch hour that revealed a resident “grabbed a while chicken thigh off another resident’s tray and began to eat it.” Two Certified Nursing Assistants (CNAs) were in the dining room at the time. However, “they were busy assisting other residents with their meals and did not observe the resident taking the chicken wing and eating it.”
Further observation of the resident’s “lunch tray and meal ticket revealed he was on a puréed diet. The surveyor intervened and informed [one of the CNAs] who removed the chicken wing from the resident’s grasp.” At this time, “the resident had multiple chicken meat including skin in his mouth. No effort was made to remove the food from the resident’s mouth, and nobody left the Dining Room to inform a nurse. The resident did not display any outward signs of choking such as coughing at this time.”
In a separate observation in the same dining room three days later on July 20, 2017, during the new lunch hour, it was revealed the resident “was seated in a wheelchair with his lap tray in place and feeding himself. The resident was observed with one end of a paper napkin in his mouth with a remainder [of napkin] hanging from his mouth.” While the napkin was in his mouth, he was chewing at along with a large mouthful of puréed food.”
During this observation, it was noted that there were to Certified Nursing Assistants “in the dining room assisting others to eat and were not in view of [this resident]. The surveyor quickly left the dining room to get a nurse. The surveyor immediately returned to the dining room with the Unit Manager.” Upon returning to the dining room, a Certified Nursing Assistant will “was observed removing the resident’s napkin from his mouth [and informed the Unit Manager] that the napkin was in the resident’s mouth.”
The Unit Manager “attempted to look in the resident’s mouth to clear the contents [and stated] ‘he appears to be swallowing okay.’” The investigator reviewed the resident apposite as Clinical Record that revealed “he has been on a puréed diet since the time of admission in February 2017” due to a medical condition.
The investigator interviewed the facility’s Director of Rehab who stated that “the resident has not received any Speech Therapy since the time of admission.” In an interview with the Assistant Director of Nursing on the same day, it was revealed that “she could not see whether the resident was on a puréed diet but stated he was admitted on a puréed diet.
The Unit Manager stated during an interview that “this was the first time she had seen him eating things.” The manager stated that “I have never been informed of him trying to [eat] anything in the past.” The investigator asked if the Unit Manager “was informed of the surveyor’s observation in the dining room on July 17, 2017, involving the chicken wing.” The UM replied that “I did not know anything about the chicken wing.”
If you, or your family, believe that your loved one was victimized by caregivers while a patient at Gracewood Rehabilitation and Nursing Care, contacting a personal injury attorney can help. A skilled lawyer who specializes in abuse and neglect cases can handle every aspect of your compensation claim. Their efforts include filing all the necessary documents, building a case, negotiating a settlement, or taking the case to court to present evidence in front of a judge and jury, when necessary. Contact us today.
Personal injury attorneys accept nursing home abuse compensation claims and wrongful death lawsuits through contingency fee arrangements. This agreement means your legal fees are paid only after the attorneys have negotiated an out of court settlement on your behalf or have successfully resolved your recompense case in a court of law.
Attorney Blair N. Mendes, Esq.
Licensed in Florida
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home