Theodore and Dorothy Archer retired to Hernando County in 1981 but never really settled down. For 20 years, the Archers did the Lord's work, driving a recreational vehicle from Florida to Canada, California to Maine, renovating churches with a group called Servants on Wheels.
It was the sudden onset of Alzheimer's disease that finally slowed Dorothy Archer.
Unable to cope with his wife's forgetfulness and agitation, Theodore moved her to an assisted living facility called Edwinola Manor. There, he thought, she would get the care and service she had given so selflessly as a church outreach worker.
Instead, nurses ignored a gaping pressure sore on her lower back until it had filled her body with raging toxins.
"There is no valid reason for such a wound developing undetected in an ALF resident," wrote Tim McClain, a registered nurse who investigated for the Department of Children and Families.
Archer, 90, was not the first Edwinola resident to fall victim to shoddy care.
In April 2008, 79-year-old resident Carmen DeArmas was hospitalized with a rotting, oozing foot, requiring surgery. Family members told investigators the injury was so bad, the woman's sock was "embedded into the skin," a DCF report says.
Two months later, Edwinola administrators told the Agency for Health Care Administration they had retrained workers to better recognize and report signs that a resident's health had deteriorated.
But in October, more problems emerged: AHCA found the home had failed to keep records on three more residents — including one whose pressure sore forced a hospital stay.
Once again, Edwinola administrators submitted a detailed plan for doing better.
The plan had just been put in place in October 2008 when Dorothy Archer was admitted to the retirement home, diagnosed with acute psychosis — the result of quickly progressing dementia.
The Archers had been inseparable for 37 years.
"We were always together,'' Theodore Archer said. "Everywhere I went, she was with me.''
But the retired naval chief petty officer — who survived the sinking of the USS Hornet at the Pacific battle of Santa Cruz in 1942 — was no match for his wife's Alzheimer's.
Confused and agitated, Archer had been hospitalized under Florida's involuntary commitment law when a neighbor suggested Edwinola, a 170-bed home in Dade City. Archer said he visited his wife every day — usually more than once.
Medical notes suggest Archer was faring well until March, when nurses feared a raspy cough might be pneumonia.
When Archer was sent to a nearby hospital for treatment, the home's notes documented only a "small" skin lesion, described two days earlier as a "red area" on her lower back.
But doctors immediately said the home's description of the wound was far from accurate. The festering sore, as large as a grapefruit, had become so infected it had turned black — and her kidney was failing, said Dr. Keith Rosenbach at Pasco Regional Medical Center.
"The poison is all throughout her body. There's no way I can save her,'' her husband said he was told by a doctor.
Archer was transferred to hospice. Aides cleaned her, and put her in a crisp new gown. Within 30 minutes, she was dead.
Later, state investigators questioned the home's treatment of Archer's blackened sore.
"It is obvious that ALF staff should have noticed the buttock wound,'' McClain, the DCF nurse, wrote. "It is also clear that there was a serious systemic failure at the ALF.'' Archer, he concluded, "was inadequately supervised and medically neglected.''
Janice Merrill, an Orlando lawyer who represents Edwinola, declined to comment.
The problems at Edwinola continued.
A month after her death, a woman was hospitalized with bruises on her arm, wrist, chest and buttocks. She also had been given three pain patches — triple the dose her doctor prescribed.
The woman, an investigator wrote, had been "overmedicated to the point of losing consciousness.''
During DCF's investigation, the home's director of nursing resigned. The facility once again told state agents it had "incorporated new safety measures and training to prevent recurrence," DCF records show.
But in November, regulators found more breakdowns — this time, after relatives complained a resident of the home was "acting strangely and no one knew why." Inspectors found the home had failed to provide crucial psychiatric and heart medications.
Once again, Edwinola promised to retrain its workers to make sure the problems didn't happen again, records state.
For Theodore Archer, 91, who is suing the home, learning that the facility had been warned twice before his wife's death to pay better attention to residents' health has made his loneliness even more difficult.
"Miss her? God, yes,'' Archer said. "I guess it'll be a long time missing her till I go.''