The Florida nursing home’s final inspection report painted a grim picture.
More than 100 residents were rushed out of Destin Healthcare and Rehabilitation Center and shuttled to nearby nursing homes after state inspectors found “grossly inadequate” staffing at the Panhandle facility.
A nurse wept when he discovered that a woman with dementia had been left alone for so long that a plant grew in the crook of her arm, sprouting two leaves and roots.
Another resident was found with two fentanyl patches on their arm, exposing them to possible overdose.
A third had a wound dressing that hadn’t been changed in nearly 20 days.
Until earlier this month, the May 6 inspection report detailing these violations was absent from state records that help the public vet nursing homes.
The Tampa Bay Times found that eight of 83 serious violations in Florida nursing homes last year were missing from the state website that publishes inspections.
The website promises a “complete list of inspections” and is run by the regulator of the state’s long-term care facilities, Florida’s Agency for Health Care Administration. While the agency isn’t legally required to publish nursing home inspections under state or federal law, it refers consumers to these findings, agency documents show, to help them select a nursing home.
The agency posted the missing reports to its website the day after a Times reporter asked about them.
Spokesperson Bailey Smith said that the omission was caused by a “technological glitch,” and that agency employees followed normal protocol in reporting and uploading these inspections.
But nursing home advocates and families of residents say the missing inspections exact a steep toll: When consumers need to choose a nursing home quickly, they often struggle to find information about a facility’s prior history of care.
“When we have to make determinations about life and death … we should have the best tools possible,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a New York-based nonprofit that advocates for nursing home residents’ rights.
Destin Healthcare and Rehabilitation Center shut down in May 2022. A year later, the beach town’s only nursing home has been transferred to a new owner, though its licensure is still pending.
The owner at the time of its shutdown, 195 Mattie M. Kelly Boulevard Operations LLC, as well as its management company, Independence Living Centers, didn’t respond to requests for comment. Nor did representatives for the new owner that applied to run the facility, Destin Senior Care LLC, or its management company, VIP Senior Living Solutions LLC.
Starting this week, the nursing home is able to admit new residents.
Missing reports
Violations at other Florida nursing homes were missing from the state’s inspection data until April 4, the day after the Times notified the agency about the website’s missing reports.
Among those was one in January 2022: Inspectors found that nursing home staff at a Fort Walton Beach facility asked police to remove a resident with dementia from the property without notifying them of his condition, leading him to wander the streets alone for almost an hour.
Another missing inspection, from February 2022, detailed how a resident ran away from a Pensacola nursing home. A second resident escaped out of the same door a month later, it said.
At a nearby Pensacola facility that April, a partially paralyzed resident who needed supervision while smoking was left alone with a cigarette between his lips. It fell onto his neck pillow, where embers began to burn before an inspector brushed them off. This report was also missing online.
Most of these inspections were still posted on Care Compare, a federal website established in 2008 that shows how nursing homes rank on inspections, staffing and quality of care.
Destin Healthcare’s four serious violations, which were detailed in two inspections from last April and May, were not.
When a nursing home fails to meet basic health and safety requirements, the Centers for Medicare & Medicaid Services may pull its federal funding. The move is generally considered a “last resort,” made only when “all other attempts to remedy the deficiencies at a facility have been exhausted.”
When that happens, its profile disappears from Care Compare.
Destin Healthcare’s federal funding was revoked in May 2022, shortly after it was cited for serious violations detailed in the missing inspection reports.
A spokesperson for the Centers for Medicare & Medicaid Services, the federal agency that oversees nursing homes and runs Care Compare, said the agency doesn’t receive or post information about places that no longer get federal funding.
Inspections for these nursing homes can still be found in archived data and on its Quality Certification and Oversight Reports database, a website often used by researchers and providers.
But a consumer must know how to dig for this information, advocates say.
“I can’t imagine most family members doing that,” Mollot said. “Most people don’t have a lot of time (to select a nursing home) and are not looking at this with any kind of background — and they shouldn’t have to be.”
The Agency for Health Care Administration’s website periodically posted information about these serious violations in other types of filings.
Destin Healthcare’s April violations, for example, were mentioned in a 17-page emergency order.
The nursing home’s administrator and the attorney representing its former owner settled with the state in December, agreeing to pay $114,000 and transfer the facility to a different owner.
Details of the May 6 violation became available in settlement filings at that time, but remained missing from the facility’s “Inspection Reports” page.
According to that database, Destin Healthcare had not had a violation since 2021.
Inspections given to federal government
Agency for Health Care Administration staff didn’t identify any missing inspection reports beyond those that the Times found, Smith said.
The state agency doesn’t have to make these reports public, she said, and inspections can usually be found on the Centers for Medicare & Medicaid Services’ website.
Even though it hadn’t posted the inspections online, the Agency for Health Care Administration provided all of them to the federal government in a timely manner, Smith said.
It’s unclear exactly when Destin Healthcare and Rehabilitation Center will officially reopen. But starting April 17, the new owner could start admitting residents while its licensure application is pending, according to Smith.
The facility is actively hiring care and administrative staff, according to online job postings.
Earlier this month, the new owner applied to change the facility’s name to “Destination Health and Rehabilitation Center,” according to Smith. It has not yet been approved.
The change of ownership application, which the Times obtained through a records request, suggests the nursing home aims to eventually re-enter the Medicare & Medicaid program, which will require the facility to show it can comply with federal regulations.
The federal agency did not comment on the status of this reinstatement process.
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