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Oversight lacking for Florida assisted living facilities

For more than a decade, Bruce Hall ran his assisted-living facility in Florida's Panhandle like a prison camp. He punished his disabled residents by refusing to give them food and drugs. He threatened them with a stick. He doped them with powerful tranquilizers, and when they broke his rules, he beat them — sending at least one to the hospital. "The conditions in the facility are not fit even for a dog," one caller told state agents. When Florida regulators confronted Hall in 2004 over a litany of abuses at his facility in the rolling hills of Washington County, they said he chased them from the premises while railing against government intrusion.

Under state law, regulators could have shut down Sunshine Acres Loving Care or suspended the home's license, but they did neither. Instead, they ordered the 50-year-old Hall to see a therapist for his anger and to promise not to use "any weapon or object" on his residents — allowing him to keep his doors open for five more years.

In that time, Hall went on to break nearly every provision of Florida's assisted-living law: He threw a woman to the ground and forced her to sleep on a box spring for six days after she urinated on her covers. Though the temperature outside reached 100 degrees, he forced his residents to live without air conditioning. And during a critical overnight shift, he fell asleep on the job while a 71-year-old woman with mental illness wandered from her bed, walked out the door and drowned in a nearby pond.

In a state where tens of thousands reside in assisted-living facilities, the case of Hall's Sunshine Acres represents everything that has gone wrong with homes once considered the pride of Florida.

Created more than a quarter-century ago, ALFs were established in landmark legislation to provide shelter and sweeping protections to some of the state's most vulnerable citizens: the elderly and mentally ill.

Tragedies revealed

But a Miami Herald investigation found that the safeguards once hailed as the most progressive in the nation have been ignored in a string of tragedies never before revealed to the public.

In Clearwater, a 75-year-old Alzheimer's patient was torn apart by an alligator after he wandered from his assisted-living facility for the fourth time.

In Kendall, a suburb of Miami, a 74-year-old woman was bound for more than six hours, the restraints pulled so tightly they ripped into her skin and killed her.

In Hialeah, in Miami-Dade County, a 71-year-old man with mental illness died from burns after he was left in a bathtub filled with scalding water.

The deaths highlight critical breakdowns in a state enforcement system that has left thousands of people to fend for themselves in dangerous and decrepit conditions.

The Miami Herald found that the Agency for Health Care Administration, which oversees the state's 2,850 assisted-living facilities, has failed to monitor shoddy operators, investigate dangerous practices and shut down the worst offenders.

Time and again, the agency was alerted by police and its own inspectors about caretakers depriving residents of the most basic needs — food, water and protection — but didn't take action.

When AHCA agents were forced to end their inspection of Sunshine Acres in 2008 due to threats by the owner — the second time in four years — the agency didn't return for eight months.

By the time agents went back, they found a resident eating from a filthy food bin, four inches of dirt on the floor of a dorm room and six residents drugged on tranquilizers without doctors' orders.

"Lord help us all if he gets mad," one resident told state regulators about the owner.

Frustrated over the state's inability to close Sunshine Acres, neighbors began gathering at the local fire station to launch a plan to prompt regulators to act.

"It took the whole damn neighborhood," said Dewayne Anderson, 55, who lives next door to the home.

A representative of the group fired off several e-mails to AHCA, demanding the state enforce its laws and pointing out a litany of problems created by the facility.

After 14 years of running the home and racking up more than 100 violations, Hall was finally told by AHCA to sell Sunshine Acres. But once again, regulators struck another deal: Hall was given a year to find a buyer.

Failure to protect

The Miami Herald spent a year examining thousands of state inspections, police reports, court cases, autopsy files, e-mails and death certificates and conducting dozens of interviews with operators and residents across the state.

Reporters found that as the ranks of assisted-living facilities grew to make room for Florida's booming elderly population, the state failed to protect the people it meant to serve.

For example:

Nearly once a month, residents die from abuse and neglect — with some caretakers even altering and forging records to conceal evidence — but law enforcement agencies almost never make arrests.

Homes are routinely caught using illegal restraints — including powerful tranquilizers, cages and ropes — but the state rarely, if ever, punishes them.

State regulators could have shut down 70 homes in the past two years for a host of severe violations — including neglect and abuse by caretakers — but in the end, closed just seven.

While the number of new homes has exploded across the state — 550 in the past five years — the state has dropped critical inspections by 33 percent, allowing some of the worst facilities to stay open.

Though the state has the power to impose fines on homes that break the law, the penalties are routinely decreased, delayed or dropped altogether.

The state's lack of enforcement has prompted other government agencies to cut off funding and in some cases refuse to send clients to live in homes AHCA won't close.

For example, the Miami-Dade Court's mental health project won't send clients to All America ACLF, where Angel Joglar, a 71-year-old man with schizophrenia, was scalded in a bathtub after his caretaker left him alone in 2006, dying from the burns weeks later.

Since the death, AHCA has cited the home for at least 100 violations — including untrained staff failing to stop residents from beating each other with two-by-fours.

After Hillandale ALF was caught locking residents with mental illness in a closet to punish them — along with a host of other violations — the state Agency for Persons with Disabilities cut off hundreds of thousands of dollars it was sending to the home in Pasco County.

Both facilities are still licensed by AHCA.

AHCA, which is empowered with tough tools to enforce the law, said its goal is to get facilities to obey the rules — and imposing fines or other penalties are secondary measures.

Reluctant to punish

The agency, which would respond to questions only in writing, said pushing to revoke a home's license is a "very harsh penalty" used as a last resort. Before doing so, it considers several issues, including the immediate danger to residents and the ability to relocate them to a new home.

Each penalty is considered based on "unique circumstances," and other actions are explored "prior to the most serious sanction of revocation," the agency wrote.

But the Herald found that AHCA repeatedly catches homes breaking the law but fails to act, at times with dire consequences.

At Hampton Court in Haines City, regulators caught caretakers 11 times in the past five years failing to give out medication, not keeping records of drugs given to residents and falsifying records to show drugs had been given when they hadn't. The state could have imposed emergency measures, including a ban on new residents until the home cleaned up its practices, but never did.

Eventually, someone died.

Norman Dube, a 74-year-old retired postal worker suffering from diabetes and depression, went 13 days last March without crucial antibiotics and several days without food or water. As he slipped into unconsciousness, he began telling people "things were crawling on his skin," a state report said.

At the same time, the home failed to tell his doctor he wasn't getting his drugs, which included blood pressure medications and antipsychotics.

The next month, Dube died. A state Department of Children and Families investigation concluded the home committed medical neglect.

But the problems didn't end. On June 25, two months later, state agents returned to the home and found two more residents languishing without their medication, despite doctor's orders.

The home promised to correct the problems, but in August it happened again. This time, three more residents were not getting their drugs. Two months ago, the facility was taken over by a new owner.

When it comes to imposing fines, AHCA said it doesn't routinely drop or reduce them, saying it only lowered fines by 7 percent this fiscal year.

But an analysis shows the agency rarely asks for what's allowed by law. Consider: In 2009 — the same year lawmakers expanded AHCA's power to levy fines — the agency could have imposed more than $6 million, but took in just $650,000.

Homes of horror

The law that empowered the state to discipline homes was passed three decades ago in response to a growing crisis: Elderly people moving to Florida were ending up in group homes run by abusive caretakers.

The state passed a celebrated Residents Bill of Rights in 1980 — championed by veteran Miami congressman Claude Pepper — pledging that people in those homes would be protected and treated with dignity.

The homes would shelter two of the state's fastest-growing groups — the elderly and mentally ill — and at the same time offer an alternative to nursing homes.

Now, people who needed help with everyday chores but didn't require 24-hour nursing care could live independently.

But as the industry boomed, the state began a series of crucial moves that would change the way it regulated homes.

Instead of inspecting ALFs once a year like most large states — including Arizona, Texas, Pennsylvania, North Carolina and Illinois — Florida cut inspections to just once every two years.

The same trend took place with investigations of serious incidents like deaths and injuries, known as adverse incidents. These investigations were slashed by 90 percent between 2002 and 2008.

Regulators never investigated Isabel Adult Care III after the owner reported that Aurora Navas, an 85-year-old grandmother with dementia, had quietly wandered from the Miami-Dade home and drowned in a pond in the backyard in 2008.

"Her lack of ability to find her way back caused her accidental death," wrote the home's administrator, Isabel Lopez, in a report to AHCA. "We found that all procedures were followed. The facility has door alarms, proper door locks, and a fenced backyard."

But records show that if regulators had carried out what was once a routine exercise, they would have found just the opposite: The door alarm and videocameras weren't working, the back gate was unlocked and an attendant had fallen asleep, Miami-Dade police records show.

Navas, who had a history of wandering, was found floating in 18 inches of water, clad only in her lavender sleeping gown, a blue slipper on the ground nearby.

To this day, Alfredo Navas says he's enraged the state never investigated his mother's death at the quiet suburban home.

"You don't follow up when it comes to human beings who are supposed to be watching other human beings. They get nothing," said Navas, 59, adding that his mother was afraid of water most of her life. "The safeguards you thought in place weren't in place."

In an interview, Lopez said she was ordered by fire inspectors to remove the locks from the rear door. But county records show that was not the case: Inspectors simply told her to get new locks.

New heights of abuse

While inspections of homes were dropping across the state, another troubling trend was under way that would set new records.

The state Department of Elder Affairs ombudsman program was uncovering more cases of abuse and neglect than it had seen in the past three decades, with numbers doubling in the past five years.

Though the program sends its findings to AHCA, regulators failed to investigate the vast majority of the cases, records show. In fact, a state audit in 2008 found that AHCA couldn't locate two-thirds of the complaints sent to the agency.

"It's baffling to me," said Brian Lee, the ombudsman program's past director. "We find things, and it's like, how did they not see the same things?"

Even when AHCA does find problems — including people dying from abuse and medical neglect — it rarely moves to close homes, allowing the same dangerous violations to turn up again.

Though Briarwood Manor has been the target of more than 1,200 police and rescue calls in the past five years — with residents stabbing, fighting and suffering psychiatric breakdowns — the Broward County facility has been allowed to stay open.

The drab, stuccoed home in the heart of Lauderhill has been slapped with scores of violations by AHCA — 100 in the past five years — including an episode when a man slashed his roommate with a knife during a crack binge while the night caretaker was sleeping in the office. Twice in the past five years, the state could have revoked or suspended the home's license, but did neither.

Instead, AHCA allowed Briarwood to operate for four years while it owed huge fines that peaked at more than $370,000, with AHCA eventually agreeing to reduce the amount by 74 percent in 2008.

Briarwood is among the hundreds of ALFs that opened their doors in the past decade, driven by the closing of state mental health institutions.

But as the industry boomed, AHCA failed to keep up with the growth, with state agents taking longer to respond to dangerous breakdowns. A Miami Herald analysis shows it took inspectors an average of 37 days to complete complaint investigations in 2009, 10 days longer than five years earlier.

At least five times, other agencies were forced to take the lead in shutting down homes when AHCA didn't act.

One Hardee County sheriff's detective said he was unable to prod AHCA to shut down Southern Oaks Retirement Center last year after he found residents sleeping on torn, urine-soaked mattresses surrounded by moldy, cracked walls and boarded-up windows.

Though AHCA had turned up the same hazards at the Central Florida home for eight years — including just a month earlier — the facility stayed open until fire officials ordered the evacuation of all 49 residents on June 22, 2010.

Not until the home made critical repairs five weeks later was the order lifted.

For Rosalie Manor, it was a longer battle.

For years, Pinellas County sheriff's deputies had been forced to round up dozens of residents with mental illnesses found wandering Dunedin, breaking into a school and homes, and shop­lifting from businesses.

When deputies finally investigated, they found Rosalie Manor owner Erik Anderson had placed a 53-year-old man just released from a psychiatric ward in charge of dispensing powerful psychotropic drugs to others in the home.

When two residents suffered breakdowns after not getting their crucial medications, detectives sent a warning to AHCA: Shut the place down.

But regulators dropped the case a month later, citing a lack of evidence — prompting an angry response from Sgt. J. Michael Daily, who slammed AHCA for its "inability to take action on this and other valid complaints at Rosalie Manor," records show.

During the next two months, deputies joined prosecutors in a rare effort to close the 34-bed facility.

Detectives brought forward reams of paperwork in 2006 detailing abuse and neglect inside the cluster of cottages near downtown Dunedin — including violations turned up by AHCA year after year.

They found Anderson had covered up crucial evidence in death investigations of the home's residents.

In one case in 2003, he threatened to fire any employee who called police after finding blood splattered on the walls of a 72-year-old man's bedroom and a suicide note on the dresser.

Drugged, raped

In 2005, he drove a male resident with a criminal history to a pharmacy to fill a prescription for powerful narcotics but failed to collect the drugs from the man, who then fed them to a 20-year-old female resident with mental illness. She was then raped by the man and died in her bedroom from an overdose.

In the end, prosecutors charged Anderson, 60, with neglect, witness tampering and falsifying medical records. He pleaded guilty and surrendered his ALF license. His sentence: probation.

Caretaker Mary Pressley, 47, who worked at Rosalie for nearly a decade, said she couldn't understand why AHCA never moved to close the home. "I don't know how he got away with what he did," she said.

Since 2005, Rosalie was among more than 40 homes found to be placing residents in immediate danger — the most serious breach of Florida's ALF law — with a quarter of the homes going on to do it again.

Even after AHCA inspectors warned their own agency that Bruce Hall was running a dangerous facility in 2004, he was allowed to renew his license and expand the home to make room for eight more beds.

It was the third time the troubled facility was granted a renewal by AHCA, despite breaking the state's ALF law 51 times.

The next year, Hall fell asleep on night watch duty just long enough for 71-year-old Elnora Shuler to wander out the door with her baby doll and slip into a pond on the premises.

When AHCA investigators asked Hall why the fence around the pond was only half-finished, an inspection report states he responded: "My complacency is the reason … I knew I'd find [Shuler] down there in that pond someday."

When agents visited the ramshackle 52-bed home in North Florida to investigate a tip that Hall threatened residents with a gun, he flew into a rage, referring to the residents as "deranged, mental retarded sons of bitches," while lashing out at state agents, reports showed.

In the end, inspectors Patty McIntire and Kara Cowart, along with a Washington County sheriff's deputy, left the property without completing their investigation, citing "safety concerns."

For his tirade, Hall was fined $1,756 and ordered to visit a therapist because of his anger. But just 17 days later, he shoved a woman diagnosed with mental retardation to the ground, sending her to the hospital with a sprained ankle and cuts on her arm, elbow, knee and shin.

Hall told regulators he was protecting his wife after the resident grabbed her arm, but state agents cited him for abuse.

In an interview with the Miami Herald, Hall said he had a right to impose force on residents when they got unruly — and that regulators were "bureaucrats" who didn't understand the challenges of dealing with people with mental disabilities.

"If one of them jumps on you and you got to beat the hell out of them to get them off you, then you get held responsible," he said. "I'm the damn culprit that's the bad guy in all this?"

He blamed residents and his neighbors for bringing unwarranted scrutiny to the facility.

"These mentally handicapped residents, they know the game," he said. "They will play you. They are of the system, they know the system — just like a prisoner. They know what they can get away with."

He said if he hadn't imposed discipline on his residents, they would have taken control of the facility. "They're going to realize they can continue to treat you like a dog," he said.

During a state inspection in 2006, 14 residents at Sunshine Acres refused to give their names to AHCA agents, saying they feared retaliation.

Between 2007 and 2008, five employees quit their jobs, saying they were tired of the abuse at the home, state reports show.

During that same period, sheriff's deputies and rescue workers were called to the home more than 400 times for, among other things, fights between residents and people suffering psychiatric breakdowns.

In 2008, Hall ran AHCA agents off the premises a second time after berating an elderly female resident who was trying to talk privately to them.

Hall "dropped to his knees in front of the resident" and with "flushed face, clenched jaw, rapid, loud speech, flaying arms," he said he was throwing her out for complaining about him.

"The survey was discontinued at this point due to a fear for the safety of the surveyors," inspectors wrote.

After the event, the state threatened to kick Hall out of the business.

In April, agents sent a letter saying Sunshine Acres' license would not be renewed. But it was. In October, regulators told Hall to get out — but once again, bargained the punishment down, giving him a year to sell the troubled home.

Through it all, agents continued to find more problems: Six residents were illegally given powerful drugs known as "chemical restraints," designed to keep them under control — without a doctor's consent, agents wrote.

Finally, after more than 115 citations from AHCA, Hall sold the home in September 2009 — still holding the mortgage in a deal that will earn him $1.1 million during the next 10 years.

By the numbers

70 People who died from abuse or neglect at assisted-living facilities since 2002.

1,732 Number of times homes were caught using illegal restraints like cages, ropes and drugs like tranqulilizers since 2002.

26 Number of facilities closed down by AHCA since 2005. There are currently 2,850 in Florida.

13,250 Police or rescue calls to a cluster of a dozen ALFs in Broward County since 2005 — essentially one every four hours.

181 The number of times the state caught homes falsifying records — including medical records in death cases — since 2005.

On the web

Go to miamiherald.com for more stories, to see videos and explore a database of the state's assisted-living facilities.

Assisted living facilities | A special report

Oversight lacking for Florida assisted living facilities 05/01/11 [Last modified: Sunday, May 1, 2011 12:00am]

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