Before rotting body found, state ripped North Miami nursing home for nasty conditions

One month before the body of an elderly man was found decomposing in the closet of a North Miami nursing home, Florida health regulators rebuked the home for failing to treat residents “in a dignified manner and…with respect,” accusing caregivers of mocking residents who can’t feed themselves and feeding others what one resident called “lousy” food.

Conditions at the North Dade Nursing and Rehabilitation Center were considered so poor a year earlier that the state Agency for Health Care Administration designated residents in the home in “immediate jeopardy” of “serious harm,” based upon the facility’s inability to maintain proper infection control procedures. Such a designation is among the most severe by the agency, which oversees all long-term care facilities in Florida.

Last year, health regulators placed the home on the state’s “watch list” of facilities that have failed to meet minimum standards of care. It appears the home remained on the list for 24 days for violating the state law governing the discharge of residents, and their right to return, if they wish.

North Dade has been well-known to state health administrators: In 2020, it was sold by disgraced nursing home mogul Phillip Esformes, who was convicted a year earlier in what was called the “largest healthcare fraud scheme ever charged by the [U.S.] Justice Department.” He was ordered to serve 20 years in a federal prison, but that sentence was commuted by President Donald Trump shortly before he left office.

The new owner has been enveloped in scandal, as well. Bent Philipson, a controversial healthcare investor, bought the facility for almost $24 million, according to Miami-Dade property records. He also purchased at least two other assisted living facilities from the Esformes family, Fair Haven and Harmony Health, The Real Deal previously reported.

Philipson and his son have had ownership stakes in dozens of nursing homes across the country. In December of 2022, New York Attorney General Leticia James charged the pair and 10 others with diverting $22.6 million in Medicaid and Medicare funds meant for patient care at a nursing home they owned in Woodbury, New York. In March of this year, a Nassau County Supreme Court judge ordered Philipson to be removed as an owner .

Though the healthcare agency, often called AHCA, has documented a litany of violations at North Dade over the last five years, elders and their family members considering the home might have real trouble understanding the citations. AHCA uses redaction software that often makes it impossible to discern the documents, where virtually all dates, diagnoses, body parts and other words are blacked out – even though the agency already protects the identities of residents.

One family told the Herald their short-lived experience at the home was frustrating and disappointing. Claudia Carvajal’s 76-year-old mother, Maria, had been in the end stages of colon cancer when family members decided to move her to North Dade Nursing and Rehab Center in late February.

The ‘most depressing’ place

She told the Herald her mother needed 24-hour care and the family had to accept that she needed the kind of attention only a nursing home could give. After a couple of days, Carvajal and her sister visited their mother at the home.

“Truly that place is the most depressing you can imagine,” Carvajal said in Spanish. “The smell was horrible. The place was dirty. The people who worked there lacked humanity.”

Carvajal’s mother only lived at the facility for about a week before she fell, prompting staff to call 911. Carvajal said the staff was so disorganized that no one could ever tell her how her mother fell or what exactly led up to the 911 call. It took about a month to get her mother’s belongings back.

“Those people [staff] didn’t care about anybody,” she said. “They couldn’t tell us anything.”

Carvajal’s mom was taken to Jackson Memorial Hospital, and, when she recovered, Carvajal pleaded with a social worker to place her mother in a different home, she said. She ended up elsewhere, and Carvajal said the new facility made a world of difference.

Carvajal said she wasn’t too surprised when she learned that a man’s remains had been found inside a closet. “It did make me very sad knowing my mother was there and it very easily could’ve been her when she lived there,” she said.

Administrators at the nursing home, at 1255 N.E. 135th Street in North Miami, did not reply to a request for an interview by the Herald. The Agency for Health Care Administration did not respond to an email from a Herald reporter.

On Sept. 2, the body of 71-year-old Elin Etienne was found decomposing in a nursing home storage closet. Etienne, who suffered from dementia, had been reported missing on Aug. 22. Ruth Etienne, the man’s granddaughter, told the Herald he had suffered an aneurysm.

North Miami police on Monday said the Miami Dade County Medical Examiner’s Office had confirmed his identity. The cause of death has not been determined, and police continue to investigate the circumstances surrounding Etienne’s death, said department spokesman Maj. Kessler Brooks.

When AHCA investigators visited the facility for an unannounced inspection last month, they wrote that staff “failed to promote and ensure [that] residents are treated in a dignified manner and treated with respect.”

Inspectors wrote that, when they observed breakfast that day, they saw staff members standing up while feeding residents who can’t feed themselves. Residents who were too disabled to eat on their own were referred to as “feeders,” the report said. Some of those residents had to wait a half-hour, and watch as their non-disabled peers finished their meals, before they could eat their own.

“At the time of the meals all the [nursing assistants] have been assigned their section and they assist all the feeders that they have in their section. If there are not enough staff, they have to wait a few minutes,’” the report quotes one nurse as saying.

“Sometimes it takes a while for the staff to come; I assume it’s because they are busy. When they serve the food sometimes some residents had to wait a little longer than usual ones because the staff are busy or there are not enough,” said one resident to the AHCA inspector. The resident had been living at the facility for more than a year.

Naked resident

The inspectors also witnessed one resident who was not wearing pants and was exposing himself while other residents were eating. “I need some clothes,” the man, identified as Resident 48, said, when questioned by inspectors. When a nurse called for help to dress the man, “no one responded,” the report said.

It took a while for staff to take the man and get him clothed, the report said. Inspectors watched as another resident propelled himself around on his wheelchair with his feet, which had no socks or shoes, they wrote.

Reacting to the staff’s treatment of residents, the home’s nursing director told inspectors: “we need to do an in-service [training] on dignity.”

The inspection, which was completed Aug. 1, faulted the home for failing to offer residents an appropriate diet. One woman, identified as Resident 186, called the food “lousy.”

“They give us a ham and cheese sandwich on Sundays. Who wants to eat a ham and cheese sandwich on a Sunday?,” the woman said to an inspector.

As it turns out, Resident 186 was on a limited fat diet. A review of the home’s menu confirmed the resident’s complaint. Three weeks in a row, residents were given a “hot roast beef sandwich [or] hamburger” with french fries or a baked potato and either buttered carrots or chilled beets for both lunch and dinner on Sunday.

The home’s dietary manager also confirmed residents weren’t happy about the menu: “She stated ‘the residents were complaining about the same food being repeated…and there were no changes’.” The dietician told inspectors she had asked a food company to vary the food choices, but, the report says, “changes were not made to the menu.”

The report cited the home’s lack of cleanliness in the kitchen, as well. A microwave oven that was used to warm food for residents was found to be “not clean,” and had “brown, dried substances and contained brown-like rust stains.”

At the August inspection, monitors also noted issues with a resident’s care plan, no access to dental care for another resident, improper drug storage, and safety hazards.

In the August report, the home was cited for failing to provide proper care for residents. Among the missteps mentioned in the report: One woman, Resident 186, was found sitting in bed watching television without what appeared to have been her dentures. When asked where they were, the woman said “I have not seen the dentist since I have been here. I want to see the dentist.” The nursing home records confirmed she had never seen a dentist.

A year earlier, AHCA inspectors faulted the home for several additional lapses, including the presence of “strong odors” and an unclean, disrepaired and unkempt appearance throughout the facility.

State inspectors were so concerned by what they saw that day that they designated all 209 residents at “immediate jeopardy” of “life threatening” harm. Details of what inspectors saw are redacted in the report, except that some kind of “monitoring equipment” was being shared by “multiple residents” – leaving them at risk of “contamination.”

On the day of the inspection, March 23, 2023, the report said, the floor of Resident 146’s room “was noted to be covered in” something the state redacted and in need of housecleaning. Whatever was on the floor, it smelled bad, though the home’s housekeeping director insisted to inspectors “there is nothing they can do.”

That same day, inspectors reported seeing “a long line and a crack in the ceiling with a brown, rust-like water spot in the ceiling” in Resident 91’s room.

The toilet in Resident 51’s room was in “disrepair,” with loud, running water. The maintenance director promised to “work on it and fix it.”

The previous year, in October 2022, inspectors faulted the home for failing to “timely report suspected abuse, neglect or theft and report the results of the investigation to proper authorities.”