Since at least 2013, when a severely disabled Broward County girl died in slow agony from an untreated illness, the Carlton Palms Educational Center has been under an administrative microscope as state regulators sought vainly to shut it down.
But even under intense scrutiny, the Central Florida institution continued to be racked by spasms of casual, horrifying violence.
One man was raped by a known predator who was supposed to be under constant supervision. The alleged rape of another resident was witnessed by a caregiver who chose to do nothing. One resident was reportedly locked in a bathroom for four hours and tortured by staff members. Yet another resident was burned when a caregiver apparently doused the resident with scalding water. Another man died after staffers allowed him to repeatedly bang his head.
Many of the incidents are documented in a disturbing administrative complaint that seeks to revoke Carlton Palms' license, citing a years-long culture of abuse and neglect that was "either fostered, condoned or negligently overlooked" by administrators.
"Protecting the health and safety of APD customers is the top priority of the agency," said Agency for Persons with Disabilities director Barbara Palmer.
"We are actively working to close Carlton Palms as soon as possible, and we have taken multiple actions in the past to hold (operator) Bellwether Behavioral Health accountable, including an agreed moratorium on new residents, extensive video monitoring in all homes, an outside monitoring and transition team, along with other administrative sanctions and ... fines."
Brian Burgess, a spokesman for Carlton Palms, declined to discuss the state's actions with a reporter.
Two years ago, APD and the home's operators agreed to shut Carlton Palms down by March 2019. The settlement was reached after a caregiver was videotaped pushing a resident — identified as W.H. — against a wall, throwing him to the floor, shoving him into a corner, choking him and thrusting his elbow into W.H.'s head, a police report said.
Since then, 52 residents have been moved out of Carlton Palms and into community group homes. The moves also are part of a state effort to dramatically decrease the number of disabled Floridians who live in large, segregated institutions, instead of group homes or other community settings, as federal law now encourages.
The transition has been difficult, as Florida lacked both the group homes capable of supervising residents with extremely complex behavioral needs — and the money necessary to develop them.
And as the home remained open, the abuse continued, records show. In the past six months, police were dispatched to the facility 13 times, according to the Lake County Sheriff's Office.
One man, "Resident 1," was supposed to be under "line of sight" supervision at all times to ensure that he was not injured by himself or others, the April 17 complaint says. But on Sept. 18, 2017, APD inspectors found Resident 1 "alone, standing on a ledge" outside the center, completely unsupervised. A door alarm that should have notified caregivers that Resident 1 was leaving the building had not been properly maintained, the complaint said, and an employee had "propped open" a door, allowing the resident to wander out.
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Resident 1's departure from the facility was particularly galling, the complaint said, because both APD and the Department of Children & Families, which investigates abuse and neglect of disabled people, had warned Carlton Palms repeatedly to properly supervise its residents. Indeed, DCF had substantiated neglect allegations on May 20, 2017, and Aug. 19, 2017, after caregivers had "left residents unattended and failed to conduct head counts," the complaint states.
In one instance, a resident was left alone in an elevator, officials say. His caregiver forgot about him or her.
On Nov. 9, 2017, a man identified as "Resident 2" sustained "significant" head and hand injuries after a Carlton Palms caregiver shoved him or her from behind, causing the resident to fall so hard he or she needed stitches, the complaint says. DCF's investigation into that incident also was closed with a substantiated allegation of abuse.
The 17-page complaint details the plight of a man identified only as Resident 4 — a man so developmentally disabled that he cannot care for or defend himself. Resident 3 appears as both an assault victim and a symbol of state administrators' years-long inability to either shut down the Mount Dora facility or protect its residents from abuse.
Carlton Palms records said Resident 3 had "a history of intense sexual aggression toward others," and required constant "line of sight" monitoring to protect other residents. Yet sometime earlier this year, a caregiver left him alone and he allegedly raped Resident 4 in his bedroom. Even after the assault was reported, Carlton Palms staff gave Resident 3 a roommate — contrary to agency rules that forbid such contact with sexual predators. "Any roommate of Resident 3," the complaint said, "is put at risk of sexual assault by Resident 3."
An August letter from Palmer, APD's top administrator, to Bellwether listed 14 separate incidents at the facility, including a May 2017 rat infestation that was considered especially dangerous as some residents have serious medical conditions, such as one person who suffered from a "compromised immune system."
One staff member, the Aug. 15 letter said, failed to report when he witnessed a resident rape another resident. The staffer then threatened the alleged rapist with what he saw. But by the time the incident was disclosed to abuse investigators, any evidence of the assault had vanished, the letter said.
Another resident was badly burned by scalding water on his or her head, shoulder, back and elbow, the letter says. A staff member was captured on video carrying a cup of liquid from a microwave oven outdoors. The victim "was then heard screaming," according to the letter, though no video cameras were mounted outside, preventing investigators from determining precisely what happened. References to the results of investigations by both police and the Department of Children & Families were redacted.
One particularly harrowing incident occurred on June 9, 2017, when two staff members "taunted, ridiculed and humiliated" a resident, and locked him or her in a shower naked for four hours, the letter said. The caregivers "threatened to kill (redacted) by breaking (redacted) neck and told (redacted) that (redacted) was nasty and needed to die," the letter said. At one point, one of the staffers went into the bathroom where the resident had been locked up, and shut the door.
From inside, witnesses heard slapping noises, "hitting sounds and the sound of (the resident) screaming," the letter said. Another employee who witnessed the abuse was captured on video wearing "noise-blocking headphones" so that he didn't have to endure the resident's cries for help.
And just last week, a resident originally from Miami was charged with biting off a piece of another resident's nose.
The rapes — and the other abuse and neglect incidents — occurred even as state disability administrators had warned Carlton Palms repeatedly to knock off the abuse and neglect. The state Agency for Persons with Disabilities has been trying for years to shut down the facility, but an inability to find alternate homes — and sufficient money — for the Central Florida facility's residents made closure impossible.
The results of that failure didn't just end with rape and assault — but with death.
Last month, 26-year-old William James Lamson, who was supposed to be supervised, died after beating his head against objects in his bedroom, police say.
Five years before that, a severely disabled, non-verbal Broward girl, Paige Elizabeth Lunsford, succumbed to dehydration days after her arrival at her new home. And in 1997, 14-year-old Jon Henley was found dead in his bed with low levels of anti-seizure medicine in his system.
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