Keys nursing home has become a COVID-19 cluster. Inspection turns up troubling issues

Jun. 17--A Florida Keys nursing home that has become a cluster for coronavirus cases received a second critical report in as many months detailing deficiencies that include understaffing, inadequate care and isolation for COVID-19 patients and unsanitary conditions that could promote the spread of the disease.

The report came from the Agency for Health Care Administration, which regulates Florida nursing homes. The agency in May discovered 13 people died at the Plantation Key facility, Crystal Health and Rehab Center, including seven who may have had COVID-19.

However, Crystal Health did not report the deaths to the Florida Department of Health.

The latest report, released this week, is the result of a May 14 inspection from AHCA that was a follow-up to a May 2 visit that discovered records revealing the unreported deaths.

The 44-page document's most disturbing details relate the conditions inside the facility's COVID-19 wing. Jacob Walden, one of the owners of Crystal Health, did not immediately respond to a request for comment on the report.

At the time of the May 14 inspection, the wing had 11 patients with one registered nurse and a certified nursing assistant caring for those people, the facility's director of nursing told inspectors. However, because of the residents' ages and conditions, many need constant care.

One resident inside the COVID unit who needs a wheelchair to get around had not been bathed in seven days, records showed, according to the report.

That person needed two or more staff members to bathe him and to move him in and out of bed. The director of nursing acknowledged to inspectors it had been almost a week since he had been bathed and that he could not be taken to the showers because they are located out of the COVID unit, according to the report.

"She said the COVID unit is only staffed with one RN and one CNA for 11 people and a shower schedule was not thought out," inspectors wrote. "The [director of nursing] acknowledged the care was missed."

The facility has a mechanical lift to get people in and out of their beds and into their wheelchairs, but management did not want to take the lift inside the COVID wing because it would need to be decontaminated when it was needed among the general population, according to the report.

Inspectors also found deficiencies with the facility's laundry room that included no separation between soiled laundry and clean laundry areas. Inspectors discovered the door to the laundry room open, and said it should always remain shut.

There were also box fans blowing on the dirty clothes, which inspectors said could circulate germs throughout the facility.

Inspectors interviewed the sole worker in the laundry room, and she said she was the only staff member left to clean clothes. According to the report, she told inspectors that she had started three weeks earlier, and that her manager and another laundry worker had both quit since then.

"She said she did not know the doors to the laundry should be shut. She said she did not realize the door between the rooms could close," inspectors said.

The maintenance manager told inspectors that one of the facility's washing machines had broken about a month prior to the inspection and dirty laundry had backed up.

The method of separating the COVID unit from the rest of the facility was also lacking, inspectors said.

A plastic construction tarp with a zipper down the middle was used to seal off the COVID wing, according to the report. Although it was taped around all four sides, pressure from the air conditioning blowing on the tarp caused a 2- to 10-inch gap that allowed air from the COVID unit to spread to the rest of the building, according to the report.

The director of nursing told inspectors she was aware of the problem and would go to the hardware store to buy a staple gun to seal the gap.

Inspectors also interviewed family members of residents who were frustrated that they had no reliable way to stay in touch with their loved ones. Since Florida Gov. Ron DeSantis issued an executive order in mid-March prohibiting nursing home visitors, family members could only stay in contact with residents through phone calls and the occasional visit where they had to stay outside and see their relatives through the glass door.

However, Crystal Health's phone system was beset with problems. Relatives complained to AHCA inspectors that they often had a hard time even connecting a phone call to the facility.

When calls went through, contacting the correct person was almost impossible at times, according to the report. And when someone reached the correct extension, the calls were often dropped or went to a busy signal, the report states.

But family members became increasingly desperate to get in touch with their relatives inside, especially after the first person at the facility, a staff speech therapist, tested positive for COVID-19 in late April.

Since then, the 120-bed nursing home has become a cluster for the novel coronavirus, with more than 20 residents and staff testing positive.

And, there have been continuous complaints from relatives who said Crystal Health management has done a poor job informing them of their loved ones' status during the COVID-19 crisis.

According to one woman whose 84-year-old father is a resident of Crystal Health, he tested positive for COVID-19 last Wednesday, but she only found out about the results Sunday. And the only reason the woman, who asked her name not to be published, was told is because she finally got through to the facility and asked staff if they could bring her father to the glass door to see him.

"I called 10 times before I got through to anyone. I asked if they could bring my dad to the door, and they said he was in isolation because he tested positive for COVID-19 on Wednesday," she said. "I was livid. No one called me."

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