As coronavirus spreads among vulnerable groups of Americans, as many as 450 of Vero’s most frail residents are living in nursing homes with failing grades.

The three largest nursing homes of the six in Indian River County have earned the worst possible rating on the federal Nursing Home Compare star rating system, compiled by the Centers for Medicare and Medicaid Services.

That translates to two-thirds of the county’s nursing home beds with a quality score in the bottom 20 percent nationwide.

All three of the one-star nursing homes – Consulate, Palm Garden and Sea Breeze – are in sight of Cleveland Clinic Indian River Hospital, which regularly discharges patients to the facilities with guidance that does not warn patients or families of the abysmal ratings on CMS’s Nursing Home Compare website.

The CMS ratings giving the three facilities one star out of a possible five rely on the most recent three years of inspections done by the state’s Agency for Health Care Administration. All three nursing homes have been inspected in the past 10 weeks.

Palm Garden and Sea Breeze are on the state’s nursing home watch list.

But it is Consulate that in January was found to have had a debacle serious enough to warrant a Class 1 violation, reflecting what the state terms “imminent danger to the health and safety of the residents of the facility,” after staff apparently performed resuscitation on a patient whose chart – which, in the moment of distress, could not be located – had an advance directive that no such efforts were to be performed.

“The facility neglected to ensure the advanced directives were followed as per the resident/resident’s representative wishes, potentially causing physical harm, (redacted), and mental anguish due to (redacted) efforts,” the Jan. 10 inspection report said.

The report goes on to list staff accounts saying the patient had just been fed dinner and was put to bed in her room in a locked memory care wing when she was found unresponsive. The patient’s nurse, an LPN, was called to the room. Calling out for help, she heard a voice from the hallway yell back that the resident was “full code” – the signal to start resuscitation.

Only after an ambulance had taken the patient to the hospital was the patient’s chart located with the advance directive, stating that the patient did not want to be resuscitated.

According to the report, a nurse then called the hospital and faxed over the form. The patient had been intubated prior to arriving at the hospital. When the form arrived, the tube was removed, and the patient was pronounced dead. The entire event lasted a little over an hour.

The report says the number of nurses and certified nursing assistants at Consulate was below the state-required level in five of the 14 days examined.

The report quotes Consulate’s medical director, who was interviewed by phone, as saying: “The nurse taking care of residents should know the code status of everyone they are taking care of.”

The report concluded that Consulate “failed to ensure the medical record was readily available for staff to verify code status.”

Sea Breeze, formerly Atlantic, dropped one star from its already below-average two-star rating in the latest CMS Nursing Home Compare. The site shows a total of 23 health citations issued to the nursing home over the past three years; the state average is 6.3.

In the most recent survey, four out of four residents had food complaints. In an interview last summer, the director of nursing said she was unaware of the requirement that a registered nurse be on duty for at least eight hours every day, including weekends. The government inspector found seven days in the year prior to the inspection in which there was no RN present at any time.

The third one-star nursing home, Palm Garden, was named a candidate for the Special Focus Facility watchlist last year and was hit with a nearly $82,000 federal fine after a November 2018 inspection found 20 deficiencies. That report offered a detailed litany of indignities, incompetence, physical suffering and filth.

A year later, the reports aren’t much better. One resident complained that the smell of urine was so strong in her room that her eyes burned.  An emergency pull cord could not be activated with a pull. Doors weren’t being closed to the hallway when staff was changing residents’ clothes. Residents were missing clothing, or in one case, a favorite pillow. One man wasn’t shaved often enough.

Others complained of not having showers when they wanted them, with records for one resident showing only one shower in a month. Mattresses meant to prevent bedsores weren’t properly inflated, with the inspector noting skin breaking down on one patient’s heels and buttock. In another case, treatment for a urinary tract infection wasn’t begun until three days after urinalysis results were in. 

Despite the endless problems, Palm Garden has somehow disappeared from the Special Focus Facility candidate list, which identifies nursing homes that have a history of serious quality issues. At press time, CMS didn’t provide an answer as to why.

Being on the Special Focus list would mandate increased inspections of Palm Garden. So, might legislation currently under consideration in Tallahassee that could increase inspections for problematic nursing homes while reducing the number of inspections at high-quality facilities.

But Vero’s troubled trio is already getting the eagle eye. While the proposed law might add one more inspection to the required 18-month site visit, all three sub-par Vero facilities are already getting far more than that, mostly due to complaints. State surveyors visited Palm Garden and Consulate 10 times in the past year, and Sea Breeze eight times.

Why those surveys don’t result in closure has a lot to do with need, according to AARP Florida spokesman Dave Bruns.

Bruns says the legislation that would give Florida’s Agency for Health Care Administration latitude in scheduling inspections makes sense in one way, but not in another: while spending more to check up on bad nursing homes seems logical, quality facilities can turn on a dime due to what he says is an extremely high turnover rate – many say 60 percent annually – among nursing home staff.

Key among those coming and going are certified nursing assistants, or CNAs. The best of those workers shoulder the burdens of strenuous, even repugnant, physical labor while maintaining an even disposition through chaotic calls for help and emotional interactions.

As a result, many CNAs develop relationships with their patients. They provide not only care and comfort, but company to nursing home residents who never see a visitor – which may be more than half of all residents, according to some estimates by experts on aging.

“Nursing home quality is heavily dependent on staffing, and very often, in Florida and many other places, they are having serious problems retaining trained and experienced CNAs,” Bruns said.

“You can go from a situation where you have well-trained, well-motivated, competent staff, to very problematic very quickly. That can happen in a period of months. So, it makes excellent sense to concentrate the resources where the problems are, but some attention should be paid to [monitoring] . . . rapid changes in these facilities.”

CNA pay is a main cause of the turnover problem. As Cleveland Clinic Indian River raises its entry level pay to $14 in March with an eventual ramp-up to $15, the hospital could very well drain other Vero facilities of the best CNAs, whose starting pay locally is estimated at $9 to $11 an hour.

Bruns says AARP is part of the Silver Solutions Coalition, which advocates for higher CNA pay in the state legislature. “The coalition wants to improve the entire continuum of care for older Floridians and certainly the nursing home is a very important part of that,” he said.

But nursing homes are just a fraction of the elder care need. “To put it in perspective, we have 75,000 residents in nursing homes in Florida, and slightly more than that – 85,000 to 90,000 – in assisted living facilities,” Bruns said.

“But there are 2.9 million caregivers in Florida taking care of more than 2 million frail, older loved ones. So, for every person who is in a nursing home or assisted living facility, there are more than 10 who are in the care of loved ones at home. If you’re going to address elder care in Florida, you have to look at the entire continuum including support for family caregivers.”

As for getting tough on failing nursing homes, Bruns hesitates to suggest shutting them down.

“There is a school of thought that nursing home care is not easy to find, particularly for lower-income families. Does it make sense to shut down a facility and then have people that are very frail and very vulnerable transfer to a facility that you don’t know if it’s going to be any better?”