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The Florida Times Union

Voices of Glenwood Nursing Center speak of good, bad times

The state is hoping to close the troubled nursing center.

Posted: August 7, 2010
By Jim Schoettler

Ilsetraud Hill wept recalling how her caregivers once left her in a soiled gown for hours, demanding she hold back her diarrhea until they found the time to help.

Since 2008, the state's Department of Children and Families and the state's Agency for Health Care Administration has conducted more than two dozen inspections at Jacksonville's Glenwood Nursing Center based on abuse hotline calls and other complaints. Among the most egregious findings:

A 96-year-old woman arrived at the hospital from Glenwood, unbathed and reeking from urine. She had greasy, matted hair, moldy food stuck to the roof of her mouth, her fingertips were blue and redness was noted on her buttocks. She later died.

A 69-year-old man confined to a wheelchair reported being punched in the face by a certified nursing assistant. Another assistant found the man bleeding from his eye. The first assistant was suspended.

A female patient shoved another patient to a bathroom floor, breaking that person's hip. No one at the facility investigated the incident, along with at least 13 other incidents of resident-on-resident abuse. Other patients reported incidents with the same female aggressor, including one who said, "I am deathly afraid." The inspector noted that some staff admitted they were unaware how to care for patients with aggressive behavior, and numerous patients live in fear.

A patient ransacked another patient's room, scratched two patients, threw water on another and was found with knives from the facility's kitchen. No care or intervention plans were in place for that patient or others known to be physically abusive. In other cases, staff neglected to identify such patients.

A patient with a history of running away, including a jaunt to St. Johns County 30 miles away, was found wandering the building unsupervised. As with other patients, no supervision plan was in place for that person.
A patient with a history of at least five falls and related injuries was seen rapidly walking through a congested hallway. A one-to-one supervision plan in place for that patient and others with similar problems was stopped because of budget constraints.

A patient was receiving anti-anxiety medication even though that person's records did not include a psychiatric diagnosis for such medicine.

The director of nursing came to work complaining of flu symptoms despite requirements that employees with communicable diseases stay away from the facility for the patient safety.

A patient had eaten only part of his or her breakfast, though staff noted 100 percent had been eaten. Another indicated that he or she was being fed meat despite telling staff she or he didn't eat meat. No other foods were offered to the second patient, who was given a meal of ham, spinach and sweet potatoes and ate only the potatoes.

A female patient gagging in the dining hall drew the attention of staff, who yelled across the room for her to tuck her chin. They rendered no other aid. Another female patient was seen with food running down her chin as her bib sat across her walker.

Room air conditioners were found caked with undetermined substances and a bathing area floor was soiled with an undetermined black substance.

When you have a problem
If you or your loved one are having a problem with a nursing home, there are a number of agencies that can help.

Florida Long-Term Care Ombudsman Program: It responds to resident complaints and concerns ranging from issues with medication and care administration to matters of dignity and respect. Complaints may be related to the facility, its employees, or any who threatens or violates the rights, health, safety or welfare of a resident. Call (888) 831-0404 or go to

Florida Agency for Health Care Administration: The agency regulates nursing homes, which means they inspect them on a regular basis as well as respond to complaints where individuals suspect a nursing home is breaking the law. To make a complaint, you can call (888) 419-3456 or go online to and click on "Contact Us." There is an online complaint form.

Florida Department of Children and Families: The department investigates allegations of abuse, neglect and exploitation of any vulnerable adult, in a nursing home or not. To report harm, call (800) 962-2873 or go online at The department suggests you do not use the website if there is an urgent situation.

The blind and bedridden 80-year-old woman said there were times she was shoved into a shower and tossed around on her bed while being changed. She lamented over the bedside thefts of her clothes, her stuffed animals and a boom box from which she used to listen to her favorite organ music.

The flood of painful memories returned to Hill last week from Room 116 in the home where she's lived for a little more than three years. During her talk with a friend and a reporter, Hill heard a woman speaking from just outside her door.

"That voice," said Hill, trembling as she thrust her clinched left hand to her mouth.

The voice belonged to a uniformed attendant at Glenwood Nursing Center, a 119-bed Jacksonville nursing home state officials are hoping to close following repeated failed inspections. Problems cited range from employees unprepared to handle patients with mental illness or conditions such as dementia; a lack of controls for patients who are threats to themselves and others; and the abuse of patients by staff.

The state has closed only one other Florida nursing home in the past five years. Glenwood's license has been revoked, but the owners are appealing.
Hill's story is among numerous troubling tales of daily life at Glenwood detailed in state records and recounted to The Florida Times-Union by people who either lived at the home, had or have family there, or are former employees.

"It's gotten worse and worse and worse," said Hill, who suffers from diabetes and said she has been told by the home's attendants she's in the early stages of Alzheimer's disease.

Several people with family members at Glenwood said they never witnessed abuse, found the facility clean and were thankful for the treatment provided to their loved ones.

Among the most vocal supporters of Glenwood have been Paul Craig and his mother, Lois. Craig's dad, Gordon, has been at the home for 21/2 years suffering from Alzheimer's disease. Craig said he and his mother visit the home three times a week each and have found the staff helpful and caring.
"Everybody in there is so needy, I don't know what people expect," Paul Craig said. "They do a great job."

But Mick Youngblood said he understands Hill's fears. Youngblood said his 91-year-old mother, Margaret, was at the home for two weeks in July before being removed at his insistence. On his daily visits, Youngblood said he found conditions filthy, including feces in her bathroom he had to clean himself. He said he also witnessed patients wandering hallways unattended, heard constant screaming from patients and attendants, and once saw an attendant violently pushing a patient in a wheelchair.

Youngblood said the final straw came when he found inexplicable scratches and bruises on one arm of his mother, who's illnesses include dementia.

"The place was shocking," said Youngblood, 70, whose mother is now in a Fleming Island nursing home. "I could run the place better in my sleep."
Most of the patients are in need of constant supervision. Richard Feldman, an attorney and consultant to owner Robert Hagan, noted the center has said that 85 percent of the residents are seniors who suffer from dementia or other mental health problems. While Feldman says patients get the individual attention they need, state officials have criticized the facility for canceling a program involving one-on-one contact between patients and staff because of budget concerns.

During the Times-Union's unannounced two-hour visit with Hill, whose friend suggested the trip, a reporter saw a long hallway peppered with patients either walking or in wheelchairs. Some were alone, while others were attended by staff, all who seemed to be busy at work.
Patients spotted by a reporter in the three- and four-bed sparsely furnished rooms were either watching television or appeared to be resting undisturbed. One woman was sleeping on a mattress

on the floor. A woman's cries could be heard from another hallway, though it was unclear why she was in distress. An attendant visited Hill to deliver her some food, while a nurse checked on a roommate's condition.

George Johnson, a certified nursing assistant who said he worked at the home from January to June 2008, said he quit because of poor working conditions that included neglect of patients. While some of his co-workers were overworked, Johnson said some did little.

Johnson said the worst case he witnessed involved an elderly woman he found bleeding heavily in her bathroom. Johnson said the woman's bloody sheets had been covered with a pad rather than being changed. He said her attendant told him nonchalantly she was menstruating when she was actually hemorrhaging. The woman died after being taken to the hospital. He said he reported the case anonymously to the state's abuse hotline and quit.

"When your job is to care for people, you're supposed to do your job," Johnson said. "Who was checking on these people?"

Neither Feldman nor John Gilroy, an attorney representing Glenwood, would verify information about Johnson's employment. Both have said they expect the owner to be vindicated as part of an appeal of the state's plans to close the facility.

"We challenge the [state health] agency to prove its allegations," Gilroy said.

"We don't feel there has been any abuse," Feldman said. Neither Gilroy nor Feldman would discuss specific allegations in this story.

Daniel Holmes said he's suspected abuse has occurred at the home for years. Holmes' grandmother, Marjorie McNair, spent nearly four years at Glenwood before Holmes got her out in 2007. Holmes, 53, said while she was there, she suffered unexplained bruises and other injuries on various parts of her body. Holmes said he complained to Glenwood officials and once called the state's abuse hotline, but he was only told the injuries were caused by accidents.

"We would speak with the director and tried speaking with the nurses. They told me once she had fallen a couple of times. We felt sure she was being beaten up," Holmes said.
Lucy Kloker said she is not surprised to hear recent tales of abuse and neglect. Kloker's husband, Richard, stayed briefly in the home in 2004. She remembers patients at that time roaming the halls unattended, some screaming and others striking out at anyone they got near.

"Did you ever see the movie 'One Flew Over the Cuckoo's Nest?'" Kloker said. "It was not very organized."

Phillip Ramirez visits Ilsetraud Hill at least once a month, having met her years ago in church. Ramirez said he has told staff about his concerns over her deteriorating health and that someone has been stealing her possessions, some of which he brought to the home. He said her health has not improved and no one has taken responsibility for the thefts.
Ramirez said he worries for her safety and hopes to find another home for her to live in.
"This is one step above ground," Ramirez said. "It tears my heart out for her to be here."
But Paul Craig said he would recommend Glenwood to anyone whose family member needed specialized treatment such as his father.

"All I do is see them help people in there," Craig said.

Hill said she dreams of living her final days in a home where she can be treated with respect. Glenwood, she said, is not the place.

"I hate to wake up anymore," Hill said.


Lois Craig helps her husband, Gordon, eat lunch. Gordon suffers from Alzheimer's and has lived at Glenwood Nursing Center for 2-1/2 years. Glenwood has come under scrutiny because of allegations of abuse, but Lois has nothing but good things to say.


Mick Youngblood holds an image of his mother, Margaret. On his daily visits, Youngblood said he found conditions filthy. The final straw came when he found scratches and bruises on his mother's arm.


George Johnson, a certified nursing assistant, was an employee of Glenwood Nursing Center for six months before quitting over complaints he had with the facility about patient care.

RICK WILSON/The Times-Union

Daniel Holmes displays a photo of his now deceased grandmother, Marjorie McNair. She spent nearly four years at Glenwood, where she suffered unexplained bruises and other injuries on various parts of her body.