A state inspector who checked out the Sea Breeze Rehabilitation and Nursing Center after the daughter of a COVID-positive patient called in a complaint issued a lengthy report last week, largely backing up the accounts of families who have told Vero Beach 32963 of outrageous problems at the facility where nearly 60 coronavirus cases left seven patients dead in June and July.
The state report told of a broken hot water heater that “intermittently” left the building without hot water in the middle of a pandemic. One former staff member as well as family of residents at the facility told Vero Beach 32963 the faulty hot water heater had been on the blink for as long as three months.
It also cited inadequate nursing staff that, among other problems, caused residents to go without showers and baths for weeks, residents said. The inspector spoke with multiple residents who said they had gone three weeks without a shower.
The lack of hot water also affected laundry procedures at the facility, according to the former staff member. She said that staff members were forced to pile dirty laundry in the nursing home’s van and drive it to a laundromat.
The report also finally offered an explanation as to why resident phones weren’t working properly when families needed them most to check on loved ones: a phone line had been cut outside the facility and no one had been called in to repair it.
“We were running out to Walmart to buy people cellphones and setting them up for them so they could talk to their families,” said the former staff member.
Multiple attempts over two months to reach Sea Breeze and its Brooklyn-based corporate parent, Citadel Care Centers, for comment have been unsuccessful.
That includes as recently as Friday, when Vero Beach 32963 asked to speak to Sea Breeze’s new executive director, Donna Wildes, and was told she was unavailable. Pressed to provide a better time to call, the receptionist said Wildes would remain unavailable.
Even something as minor-seeming as a problem TV remote took on compounded significance to a resident newly isolated with COVID-19. The state report relates that staff said the room’s prior occupant had left her TV but taken the remote. For days, the new room-bound resident had been unable to operate the TV. Finally, staff provided her with another remote, but it wouldn’t turn the TV on or off, or lower or raise the volume.
“(The resident) voiced frustration with the inability to control the TV for the past week, explaining that it was the only thing she had to do while being ‘stuck in this room’ because of the COVID-19 pandemic,” the report read.
Even more distressing, the inspector noted that a resident was left in a broken bed stuck in the upright position – at nearly a right angle – for more than two days. The resident said it had broken before and the repair was done with Superglue.
The inspector also verified through interviews with families that Sea Breeze was not keeping them or their loved ones in the facility apprised of the COVID-19 outbreak there, as required by the state.
Two out of three residents interviewed by the inspector said they had not been bathed or showered in three weeks. A third resident is quoted as saying, “I’ve been lying in this bed for a week without a bed bath.”
That resident told the inspector that the facility was short staffed. When the inspector asked how she knew, she said “they tell her so.” She said the staff told her “they only have three CNAs for the unit,” which had 38 patients, according to the report.
A registered nurse told the inspector there should be five CNAs on the day shift, but there were “usually only four.” The RN said residents should be getting showers twice a week and a bed bath every day.
According to the report, nearly all of the 79 residents at Sea Breeze needed staff to help them shower or to give them bed baths. Fifty-eight residents were “totally dependent” on staff.
Melissa Schwanke says her mother was among those who went for three weeks at Sea Breeze without being bathed. She took photos of her mom’s matted hair, saying it had been that way for days.
Schwanke grew so frantic over her mother, who had tested positive and had a horrible cough, she called the police non-emergency number. They sent an ambulance to take her mother to the ER, but Sea Breeze turned it away.
It was Schwanke’s sister Laura Schwanke who called the Agency for Healthcare Administration to register her concerns. In all, seven out of eight complaints arising from Schwanke’s call were substantiated by the AHCA inspector.
“Staffing is horrible,” one certified nursing assistant, or CNA, told the inspector. The facility is “always running short yet they expect the same work,” said another CNA.
That CNA was one of eight the inspector interviewed, out of a total of 12 CNAs at the facility. She also spoke with five out of seven licensed nursing staff – LPNs and RNs.
The CNAs spoke of having only two on a unit at a time, making it impossible to shower a patient weak enough to need two people to assist, since that would leave no one free on the floor.
One CNA told the inspector that the prior weekend, there had been only one CNA present on the night shift.
CNAs are paid between $11 and $14 an hour for work that involves intimate care and comfort for the patient.
Family members told the inspector about more than the missed baths. The conversations “revealed multiple complaints that they had not been able to reach residents in the facility due to problems with the phone lines, staff not answering the phones, and/or staff being too busy.”
One former landlord of a Sea Breeze resident contacted Vero Beach 32963, frantic with concern after not being able to learn anything about her tenant, whom she regarded as a friend.
The tenant had been hospitalized after collapsing in the rental condo and was discharged to Sea Breeze. Though the landlord had concerns that clearly had the tenant’s interests in mind – what to do with her car, and how to stop her automated rent payment – she was told repeatedly she couldn’t speak to the Sea Breeze patient. Turned out, the resident’s phone was broken.
That wasn’t the only communications failure at Sea Breeze. According to the state report, Sea Breeze neglected to file the mandatory daily COVID-19 reports to AHCA’s Emergency Status System, which monitors not only COVID-19 cases, but also PPE and facility census.
The report said Sea Breeze failed to file those figures on 13 out of 31 days, presumably in July, when the outbreak was at its worst. That means media outlets including 32963, which checks the state charts daily, were looking at outdated figures for nearly two weeks out of that month.
Family members also told the inspector they were not getting required updates on the COVID-19 status of the facility.
The report spells out the AHCA rule that facilities must give at minimum weekly COVID-19 updates to residents, their representatives and families. And if they learn of a COVID-19 positive case or know of three or more residents or staff coming down with new-onset symptoms within 72 hours of each other, the facility has to inform residents and families by 5 p.m. the following day.
The AHCA report pointed to staff shortages as a cause of Sea Breeze’s failure to inform resident families of the status of their loved ones and the facility at large, or even respond to phone calls. The report said the facility’s staffing levels were “insufficient” to provide the basic activities of daily life.
Some staff quit because they were afraid of getting sick, others because they were told they could not work at multiple facilities. Still others got COVID-19 themselves and had to stay away for two weeks or more.
The resulting staff shortages put stress on the workers who remained, causing others to get discouraged and leave.
Leadership is in turmoil too. Along with maintenance supervisors coming and going, the facility’s dietician left in mid-August. A new director of nursing, Steve Pendleton, arrived in May, and the executive director, Loudins Geffrard, left in July to go to another Citadel facility, Sandgate Gardens, in Fort Pierce.
Wildes, Sea Breeze’s new administrator, has worked for the past nine years at Sandgate. For the last two years, she has been Citadel’s regional director over the Fort Pierce and Vero facilities.
As for the hot water, the maintenance director from Sandgate came the week of the inspection to finally install a new hot water tank. He wasn’t much help to the inspector, though.
“He was unable to access the electronic work order system to verify when the hot water issue first began or when other repairs were made,” the inspector wrote in the report.
The state is finally showing one project completed at Sea Breeze: the implementation of its emergency power plan. That plan required the installation of a state-mandated backup generator, which was supposed to be installed in April.
Sea Breeze got a six-week extension from the state, blaming delays on crews not wanting to work around nursing homes during COVID-19, and the state subsequently granted a second extension to June 1. Sea Breeze sailed past that deadline, but the generator finally was in place by June 30, according to the project’s Miami contractor, who added there are still a few kinks to work out.