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The Florida Times Union

Authorities make rare move to shutter Jacksonville nursing home

Resident abuse and neglect are issues due to a lack of monitoring.

Posted: July 15, 2010
By Deirdre Conner

FRIDAY UPDATE: For the most part, it seemed quiet outside Glenwood Nursing Center on Friday. Lois Craig, arriving for her regular visit to her 85-year-old husband, Gordon, who has Alzheimer's disease, said she didn't know what was happening at the center — and, she said, she was upset to hear that it could close. 

DON BURK/The Times-Union
This week, the Agency for Health Care Administration revoked the license of Glenwood Nursing Center and ordered it to relocate its 107 residents by Aug. 26. It would be only the second nursing home in Florida to be shuttered by licensing authorities in five years.

DON BURK/The Times-Union This week, the Agency for Health Care Administration revoked the license of Glenwood Nursing Center and ordered it to relocate its 107 residents by Aug. 26. It would be only the second nursing home in Florida to be shuttered by licensing authorities in five years.

"I really feel my husband gets good care here," she said.

Her son, Paul Craig, drove up a short time later. He said he was at the center Thursday night and heard nothing of the license revocation, and instead read about it in the paper this morning. He comes to the center every third day to bathe and visit his father.

"This has absolutely been the best place," he said.

Robert Lambert arrived at the center later in  the day to check on his sister, 63-year-old Gail Stezer. He said he hasn't encountered significant problems with the facility and mainly wanted to make sure they did not move his sister to another facility without his consent.

He said the only problems she's encountered over her six year stay there have been a few falls and times when other residents ran over her foot with their wheelchairs.

But Leon Jenkins had another perspective. His mother, Veronica Williams, is 70 and has been there between eight and nine years. Jenkins said he has filed "lots of complaints" about the center because his mother always has bruises and falls frequently. Jenkins said he didn't take her word for it at first because she has "mental problems." But then she began to identify other residents who harmed her, and at times, he said, has been mistreated by staff.

How to get help

If you are a resident of Glenwood Nursing Center, or have a relative that is, you can call the Long-Term Care Ombudsman at (904) 391-3942 or toll-free at (888) 831-0404.  You can also call the Agency for Health Care Administration’s Long-Term Care Office at (850) 412-4303.


June 2001: Southwood Nursing Center is incorporated with an Orlando address.

July 2002: Ivy Edwards, then 83 and a resident of Southwood Nursing Center at 40 Acme St., was arrested and charged with raping a 77-year-old woman, Virginia Thurston, in her room at the center. He was a convicted sex offender.

November 2002: Southwood Nursing Center submits documents to the Florida Division of Corporations listing its address as 40 Acme St. Its officers have the same address as parent company Sterling Healthcare in Roswell, Ga.

November 2003: The family of the woman raped sues Southwood Nursing Center and Sterling Healthcare, saying they failed to protect her from a known sex offender.

February 2007: A jury awards the family of Virginia Thurston $750,000 in a lawsuit against Southwood Nursing Center and Sterling Healthcare.

April 2007: Riverwood Nursing Center is incorporated in Georgia and later applies to do business in Florida. It is now listed as the owner of the property at 40 Acme St.

October 2008: An Agency for Health Care Administration complaint investigation found the facility failed to prevent residents from being physically aggressive against other residents.
June 2009: A recertification survey found 127 deficiencies, including a citation for the center’s failure to identify residents that were inclined to physically harm others and protect other residents from them.

February 2010: A complaint investigation found that the facility failed to prevent abusive episodes of three of five sampled resident, and failed to prevent a fourth from escaping.

May 2010: A recertification survey found 257 deficiencies. AHCA files for a revocation of the center’s license to operate.

July 2010: A final order revokes the center’s license, and gives it until Aug. 26 to relocate its 107 residents. The center plans to appeal in the First District Court of Appeal, saying it was denied a hearing on a technicality.

Jenkins said his mother has also had jewelry stolen over the years and the family has had to remove most of her belongings from her room to prevent theft. He's not waiting to see what comes of the case. He will take her home in three days.

Nathan Carter, an Orlando attorney who sued the center when it was called Southwood, as well as parent company Sterling Healthcare, said the center has problems. He sued on behalf of the family of a woman who choked to death at the center after she was left unattended.

"I've done a lot of nursing home cases all over Florida and that facility, in my opinion, was one of the poorest-run facilities in terms of staffing, supplies and things of that nature," Carter said.
Carter said the center was "chronically understaffed" and took very sick patients, and at the time was one of the few in the city willing to take patients with severe psychosis and severe Alzheimer's.

Mary Lee Wright arrived at the center on Friday afternoon with the intent of having her husband, 80-year-old Johnny Wright, transferred. She said he has been at the center for three to four years. She said she had wanted to transfer him before because of problems with his care, but backed off because she didn't have anywhere else to send him.

"As someone who works in the medical field, I know the signs and how things should work, and the proper care has not been given," she said.

Wright said of the center's staff: "I don't care for them in there, and they don't care for me."
Staff writer James Cannon contributed to this report.

State authorities are closing a Jacksonville nursing home because of abusive conditions — a measure so rare that local authorities can’t remember it ever happening here.

This week, the Agency for Health Care Administration revoked the license of Glenwood Nursing Center and ordered it to relocate its 107 residents by Aug. 26. It would be only the second nursing home in Florida to be shuttered by licensing authorities in the past five years.

The agency says the center put its residents in jeopardy when it didn’t prevent them from hurting themselves and other residents. According to an AHCA review, one-on-one staff monitoring of patients who were at risk of absconding or becoming physically aggressive was needed but discontinued because of budget constraints.

The facility is the same one where, in 2002, a known sex offender raped a comatose woman. The victim’s family later sued, and a jury awarded them $750,000 in a judgment against Southwood Nursing Center and Sterling Healthcare. The facility, on Acme Street off Atlantic Boulevard, also has operated under the names Riverwood Nursing Center and Southwood Nursing Center.

The center is part of Georgia-based Sterling Healthcare, according to the company’s website, which refers to it as Riverwood Nursing Center. The site says the company runs Edgewood Nursing Center in Jacksonville as well, and a total of 15 facilities in the Southeast, including six in Florida. A representative of Sterling did not return a call for comment Thursday, nor did the administrator of Glenwood.

Inspection reports dating back to at least 2008 document out-of-control patients who became violent. In one case, a patient broke another resident’s hip; in another incident, a patient was removed from Glenwood by the Jacksonville Sheriff’s Office when he could not be controlled. One resident at the facility told investigators she was “deathly scared” of another person there.

Other findings in inspection reports since that time include fire code violations and inadequate fall prevention measures, which led to some patients falling over and over again. The center also faces a $25,000 fine.

Attorneys for Glenwood said the facility denies the allegations and will fight the revocation. Their request for a hearing on the matter was dismissed because AHCA attorneys say it was not filed by the deadline. John Gilroy, one of the attorneys for Glenwood, said the firm has filed an appeal of that technicality with the First District Court of Appeal. He said the center learned of AHCA’s decision Wednesday and would be alerting residents and their families starting Thursday afternoon.

Gilroy said the center is asking a judge to stay its closure to give residents stability while it fights the license revocation.

“We want to let folks know, hey, this is not a done deal, at all,” he said. “We believe we will overturn the decision.”

Gilroy said he could not comment on the substance of the allegations against Glenwood.
In the meantime, he said it would comply with the order to begin relocating residents. Authorities with the state Department of Children and Families as well as the Long Term Care Ombudsman will be helping with the case.

DCF will be helping find available beds at other nursing homes for the residents, most of whom are seniors and many of whom have dementia. Ombudsmen, who are mostly composed of volunteers, will meet with each resident individually to make sure they know what their rights are and that their belongings stay with them when they move, said Michael Milliken, First Coast District ombudsman manager.

Even under the best circumstances, switching nursing homes can be traumatic.
“When you’re dealing with a vulnerable population, then it becomes an event,” he said. “We want to make sure that it’s handled as smoothly as possible.”

He said he can’t remember a time when a nursing home in Northeast Florida had its license revoked. Nor could authorities with the local DCF, said spokesman John Harrell.
Statewide, the only other case of a license revocation in the last five years came in 2008, against the nursing home Long Term Care of St. Petersburg. It included some similar charges of residents abusing other residents.

AHCA staff have been to Glenwood dozens of times over the past two years. In addition to regular inspections every six months — required by law when certain problems are found at a facility — investigators also looked into complaints.

One recent report resulted in 257 deficiencies. But the final straw came during a February investigation, when it found some residents were hitting other residents, falling repeatedly and attempting to escape, including one resident who got as far as St. Johns County and another who attempted to climb the exterior fence.
One resident’s day-long rampage included multiple doses of the anti-anxiety medicine Ativan and ended with the resident being taken away by Jacksonville police.

And as far back as 2008, a staff member told authorities that “the facility does not investigate resident aggression as possible neglect as it happens all the time due to the residents there.”
According to the investigative file, the worker said residents frequently slap each other, hit or run over each other’s feet with their wheelchairs.

Yet more than six months later, residents were still at risk of being hurt. In May 2009, one resident shoved another from their wheelchair, breaking their hip.

After the one-on-one monitoring of disruptive patients was discontinued in January, some of the workers told AHCA investigators there was no way they could take care of the disruptive patients along with everyone else. In May, the department filed a complaint to revoke the center’s license.

Ultimately, it wasn’t the only agency to investigate abuse and neglect at the center.

Harrell said DCF, which does its own investigations of adult abuse and neglect, said the department has had 12 investigations against Glenwood in the past three years. Nine were unsubstantiated. One documented some findings of physical injury in 2009, another had some findings of inadequate supervision in 2010, and there was a verified finding of medical neglect in late 2008., (904) 359-4504