'Money won't bring her back': Families worried about care at state's largest nursing home chain

9 Investigates questions the care in Florida's largest nursing home chain, which is based in Central Florida.

9 Investigates reporter Karla Ray started looking into Consulate Health Care after reporting on the death of a woman who was living at one of the company's Brevard County facilities.

The state Agency for Health Care Administration threatened to pull dozens of the company’s licenses a year ago. The state made that threat to 55 Consulate locations after two of the company’s nursing homes in another part of Florida lost their Medicare and Medicaid contracts due to concerns about care. The company struck a settlement with the state to stay open.

There are at least 17 Consulate facilities in Central Florida, and 9 Investigates found recent inspections with big problems at nearly every single one.

When Filomena Rosante was 83 and fighting lung cancer, her son moved her into Island Health and Rehabilitation in October of 2018.  She was only in the facility a few days before she died.

“My mother needed 24-hour care. She needed a CPAP machine. She needed those specialists to be there, to take care of her,” her son, James Rosanti, said.

Days after she moved into the facility, Rosanti found his mother complaining of chest pains after falling.

The 911 call made by a nurse at the facility revealed staff waited an hour to call for an ambulance.

“My mother was sitting up in bed, hyperventilating, and she said, ‘I can't breathe, I can't breathe,’” Rosanti said.

Rosante died, and though the Florida Department of Children and Families just closed its investigation into whether neglect at the Consulate-owned facility played a role without a finding of responsibility, her son has hired an attorney to do more digging.

“Proving that these facilities have a duty, that there was a breach of the standard of care, and showing that is directly related to the damage you're claiming, is extremely difficult,” attorney Will Sarubbi, with the Senior Justice Law Firm, said.

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Experts say that’s part of the reason why actions by the state against a facility’s license are rare, even with red flags in inspections.

9 Investigates reviewed hundreds of pages of inspection reports for Consulate-owned facilities in Central Florida.

At Rio Pinar in Orange County, inspectors found staff improperly transferred a man to a different location that was not equipped to care for him, even after he repeatedly said he didn’t want to leave and that he was being treated "like an animal." Inspectors found "actual harm" in that incident, noting that staff ignored an ongoing appeal the resident had filed in an effort to stay at the location.

Another resident at the same facility was found "trapped in a locked wheelchair against a wall with a table in front of it." Staff there admitted "they did not have time to sit with the resident to keep her from getting out of her wheelchair."

In Brevard County, at the Brookshire, a June 2017 inspection found a resident was "on the floor" for eight hours overnight after falling. The resident’s neighbor "heard the man’s cries for help and tried to find staff to help on all three floors" with no luck.

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At Consulate of Melbourne, a resident developed sepsis after not receiving treatment for an infected bedsore for more than two weeks. The injury was so severe "it exposed the bone," according to the inspection. Investigators noted that resident was transferred to hospice.

“I probably never will find out exactly what happened to her,” Debra Burleson said of her mother, Doris Martin. Martin was covered in head-to-toe bruises after a brief emergency stay at Consulate’s Vista Manor during Hurricane Irma, and died shortly after.

Burleson is filing a civil suit after a criminal neglect case was closed as unfounded in her mother’s death.

“I'm not looking for any monies, because money won't bring her back.  I'm just looking for closure,” Burleson said.

Consulate officials declined a request for an interview but sent 9 Investigates the following statement:

"As a national leader providing healthcare services to seniors, ensuring the health, safety, and overall wellbeing of our patients and residents is our highest priority. Due to patient privacy, we cannot comment on individual cases. Each of our 76 skilled nursing centers in Florida are accredited by the Joint Commission and hold the Gold Seal for quality. Currently the five centers in question provide care representative of 4 and 5 star buildings, as evidenced by their CMS ratings. Additionally, 76% of all our Florida care centers have a 4 or 5 star CMS rating in Quality Measures."

Have a tip for a story? Click here to contact investigative reporter Karla Ray

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