Bay Gardens Retirement Village seemed to get worse every year.
In 2005, state inspectors found filthy, reeking bathrooms, a raccoon living in the ceiling and a patient whose genitals had been bitten by ants.
In 2007, they discovered a demented man, smeared in his own filth, plucking at his colostomy bag in a stinking, roach-infested room.
In 2009, cutting tools and toxic chemicals lay within easy reach of mental patients. The hallways smelled of cat urine and echoed with an intermittent beeping — the sound of batteries dying in the building's smoke detectors.
After issuing 18 fines in five years, the state in 2010 stripped Bay Gardens of its assisted living license, citing a long history of endangering and neglecting its patients.
That hasn't stopped Hillsborough County from sending the needy there on the taxpayer's dime.
A Tampa Bay Times investigation has found that county officials steered scores of sick and dying homeless people to Bay Gardens even though it isn't licensed or equipped to care for them.
Public records and interviews with more than a dozen former tenants show that the home became a regular stopover for people with disabilities, terminal illnesses or profound mental or physical ailments.
One resident had a doctor's written orders not to bathe or use the bathroom without supervision.
Others sent by the county struggled to walk or couldn't control their bladders or bowels.
A few were so sick they died within months of moving in.
All of them spent their days at Bay Gardens unaided or forced to depend on untrained staff for help.
Even so, the county referrals kept coming.
Since 2011, Hillsborough County's troubled Homeless Recovery program has sent at least 130 ailing men and women to Bay Gardens, at a cost to taxpayers of more than $260,000.
County officials have acknowledged systemic shortcomings within the Homeless Recovery program, which was founded in 1989 to get the indigent off the streets.
On Friday, County Administrator Mike Merrill responded to the the facts laid out in this story by sending a memo to commissioners.
He wrote that his staff was unable to review the cases identified by the Times because of the way the county's records were kept.
He noted that an internal audit — prompted by previous stories in the Times — was already under way.
"What we are finding raises grave concern," Merrill wrote. "We have dedicated significant resources to solving these problems. Unfortunately I cannot tell you that they are all solved or even that they are all known."
Bay Gardens' owner and administrator, Elsa Thomas, said the business has operated as a legitimate independent living home since losing its assisted-living license in 2010.
She said conditions in the home only rarely were as bad as depicted in inspection reports and don't reflect the positive things that happen there every day.
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"We're not warehousing people," Thomas said. "The people who live here are cared about and cared for."
Times reporters who visited this month found clean common areas and hallways that smelled of disinfectant. Facing scrutiny by the county, Bay Gardens failed two recent code inspections, but passed a third in October after fixing exposed wiring and holes in the walls.
Even so, experts in assisted living said Bay Gardens' practice of taking in the sick and dying, paired with former tenants' accounts of life there, paint a picture of a business operating on the edge of the law.
Worse, said advocate Brian Lee, is the notion that a county program designed to help desperate people was placing them in a hazardous, unlicensed home.
The people the county sent to Bay Gardens are in "immediate jeopardy of harm," said Lee, executive director of Families for Better Care, a group that advocates for better conditions in nursing and assisted living homes. "This needs to be investigated and taken care of immediately."
The state forced Bay Gardens out of the assisted living business in 2010.
Instead of closing the 25,000-square-foot complex, the owners found a way to take in even more sick people.
Florida's Agency for Health Care Administration enforces strict rules for assisted living facilities, requiring regular inspections as part of licensing.
Unburdened by those inspections, Bay Gardens expanded from 81 beds to 101, putting as many as four people in a room. It began working with hospitals and aid agencies that pay small sums to house the poor.
One of them was the county's Homeless Recovery program.
Today, Bay Gardens exclusively takes in men and women with medical problems, Thomas said.
According to Thomas, the key difference between Bay Gardens and an assisted living facility is this: All of her current residents are totally independent.
They need no help dressing, bathing or taking medicine, she said. They don't need the monitoring that patients in assisted living are supposed to get.
"We kind of bridge the gap between living on your own and living in an ALF," Thomas said. "We do not help them in any way with activities of daily living."
But Hillsborough County sheriff's reports, interviews with former residents and visits to the home tell a different story. Several people sent to Bay Gardens by Homeless Recovery in the past three years have straddled the line between dependence and self-sufficiency.
Two were so overweight they had trouble doing simple tasks. Two were severely bipolar. Two had spinal injuries from car crashes. One was a terminal alcoholic with hepatitis, liver disease, colitis and a colostomy bag. One had Stage 4 colon cancer.
Five former tenants told the Times they saw employees of Bay Gardens hand out prescription drugs, something that, under state law, only should happen at licensed facilities.
They said the job most often fell to one employee — the janitor.
"There's a little nurse's office there," said Curtis Kingcade, 58, whose blood-clotting disorder led the county to place him in the home three years ago. "Sometimes they would lock certain people's medicine up there. They would give people pills."
Gina Abella, 50, who was sent to the home in March 2012, said she regularly saw residents sitting in full diapers. "Some of them were filthy. Some of them people are in really bad condition," Abella said, "not being cleaned up, their diapers not being changed."
When Abella got there, one resident suffered from dementia so severe he didn't know the year or who the president was, according to a nurse's evaluation described in a sheriff's report.
The 53-year-old strayed from the home one day in March 2012.
Police found him 12 hours later wandering Temple Terrace.
Other signs that residents need help literally are hanging on tenants' doors.
On a recent visit, a Times reporter saw a warning tacked up at the entryway to one room: Fall Risk. Recurrent grand mal seizures.
In her interview with the Times, Thomas said the home turns away people who need constant medical care and does not operate as an assisted living facility. She said former residents who reported seeing staff hand out medications likely mistook visiting nurses for employees.
Former tenant Dane Bowen, though, said he was sure of what he saw during his 18 months at Bay Gardens.
The 48-year-old with severe bipolar disorder said the place was full of people whose health problems should have landed them in assisted living. "Everything from bad heart problems to torn ligaments, broken arms and legs or serious mental illnesses," said Bowen, who now lives in Plant City. "I've seen people who were just straight nuts going there. And every one of them was sent by Homeless Recovery."
David Husted worked for 20 years at the same carwash on N Dale Mabry Highway.
It wasn't glamorous work, but he made enough to house himself and his 12-year-old daughter in a modest Egypt Lake apartment. He was able to afford a yellow Dodge pickup, its window decorated with the names of his three kids.
That ended in the summer of 2012, when Husted's failing health made it impossible for him to work a full shift. At 53, he lost his job and his apartment, and he sent his daughter to live with her stepsister in Philadelphia.
Then he walked into Hillsborough County's Homeless Recovery office, penniless and desperate for help.
When he met with a caseworker, Husted weighed more than 350 pounds. He was diabetic, and his joints hurt so bad he could barely walk. He was taking 17 prescription drugs, medical records show.
The county could have paid to send Husted to an assisted living facility, where trained staff would have been on hand 24 hours a day. He might have gotten a care plan that called for blood sugar monitoring, exercise or a restricted diet.
Instead, they sent him to Bay Gardens, a cheaper alternative, where workers are neither certified nor screened.
The decision saved the county more than $300 a month.
But it meant Husted had to live in a corner of a cramped, filthy room already occupied by three other men. He kept his pills by his bedside in a jumble of Ziploc bags and balanced his possessions on furniture held together by bungee cords.
He coped by eating pizzas and hot wings in his room. Relatives who visited were appalled.
Husted's brother-in-law, Robert Jordan, said he called Homeless Recovery more than 20 times to complain but never got through to a caseworker. He said he left several messages requesting better care.
"He needed medical attention," Jordan said. "He could barely walk. He was crying all the time. He was totally distraught."
As his health got worse, Husted wrote letters to his youngest daughter. In one, he promised to find a job so they could live together again.
But on March 9, eight and a half months after Husted moved to Bay Gardens, his heart gave out.
His roommates found him dead in his bed.
Later, a family friend drove to Bay Gardens to pick up Husted's things. He said he found them in a trash bag mixed with garbage.
Rifling through it, he found a bus pass, some dirty clothes and the letter — never mailed — that Husted had written to his daughter.
The county sent other people to Bay Gardens who were just as sick as Husted.
Eva Harrell, 54, was diabetic, stricken with heart problems and so overweight she couldn't walk more than a few dozen steps at a time.
Dane Bowen, the bipolar resident who saw employees handing out medication, had an active case of tuberculosis in his eyes. "I wasn't contagious, but they wanted me to keep a lid on it," he said of his county caseworker and the staff at Bay Gardens.
Loretta Houck, 46, was admitted in October 2012 with a history of seizures and a diagnosis of hepatitis C, asthma, brain lesions, hypertension and rheumatoid arthritis. She died at Bay Gardens a month later of heart failure.
It's unclear how county employees decided where to send sick homeless people.
County spokeswoman Lori Hudson has said they had no written policies to follow when deciding whether to put clients in Bay Gardens or in licensed assisted living facilities.
The two top managers who oversaw the troubled program aren't around to answer questions: One resigned in September and the other was fired.
Five people sent to Bay Gardens by Homeless Recovery told similar stories about how the county assessed their health.
All of them said they were required to show records that proved they had a medical problem. Most said they were told an outside nurse reviewed the paperwork. One said it was the head of Homeless Recovery himself who made the final call.
Then they said they got a bus pass to the home, north of E Fowler Avenue near the University of South Florida.
Christopher Scruggs, 45, a diabetic with serious memory problems, was recovering from a MRSA infection in late 2011 when he got his ticket to Bay Gardens. He said his county caseworker told him he was going to an assisted living facility. "She told me I'd be taken care of," he said.
Instead, he was hospitalized four times in the following weeks, in each case because he forgot to take his medication.
The founder and first owner of Bay Gardens was Tampa cardiologist Kiran Patel, the multimillionaire and philanthropist who made his fortune in managed care. Patel hired an experienced administrator who refused to cut corners.
But he sold Bay Gardens in the late 1990s to John Varughese, a fellow doctor. Patel financed the deal himself, agreeing to accept repayment over time, records show.
That's when the trouble started.
Varughese fired the home's administrator of 10 years and died soon after of a heart attack. That left running the home to his wife, Ramani Thomas, whose prior business experience included operating a convenience store.
Even so, Ramani Thomas and her daughter, Elsa, apparently remained on solid financial footing. In 2008, they bought a sprawling, waterfront house in a tony subdivision in New Tampa. It was 5,500 square feet, had six bedrooms and seven and a half baths and cost $600,000, records show.
At the same time, though, Bay Gardens' spotless inspection reports were giving way to a string of citations for serious problems. In 2010, the business lost its license.
The home has continued to house the sick and disabled, only now they are not in the care of trained nursing assistants.
Today, the night manager is 51-year-old Kathryn Fuller, a Homeless Recovery client. She lives at Bay Gardens and runs the kitchen during the day. Sometimes she looks in on residents at night.
On a Saturday in August 2012, she called sheriff's deputies and demanded they pick up a drunken resident who was breaking furniture in his room. Instead of jail, they took him to a hospital. He wasn't drunk, a nurse told the deputies, according to a report. He might have been having a stroke, she said.
The day manager has his own problems. George Thomas, Ramani Thomas' 34-year-old son, has been arrested 24 times since 1997 on charges ranging from theft to aggravated stalking.
In 2011, he pleaded guilty to three counts of felony battery involving a 16-year-old girl.
At Bay Gardens, he has a history of drinking and causing problems.
In 2006, state regulators documented complaints about him from residents and employees alike. They said he propositioned tenants for sex, offered them drugs and berated staff members until they cowered in back rooms, neglecting the tenants who needed attention.
The state responded with an emergency order barring Bay Gardens from admitting new patients. Regulators lifted the moratorium only after the mother agreed in court records never to let her son near residents or staff again.
Now that the home is unlicensed, George Thomas is around tenants all the time.
He was arrested at Bay Gardens in July 2011, accused of kicking a wheelchair-bound man in the face. The charge later was dropped.
George Thomas denied kicking the man and said he has never mistreated residents.
"I have 100 people out there who do care about me," he said. "The truth is, you're never going to make everyone happy."
George Thomas was there to greet Keith Reck when the county sent him to Bay Gardens in June 2012.
In another life, Reck had been a successful car salesman. He had had a wife and a daughter and had delighted in his fishing poles, his football memorabilia, his flat-screen TVs.
By the time he got to Bay Gardens, though, the 55-year-old was helplessly ill. An alcoholic with liver cancer, colitis and a colostomy bag, Reck might have gotten extra attention at a licensed assisted living facility.
Instead, he passed the time at Bay Gardens driving back and forth to convenience stores, buying booze. His roommate found him dead in his bed about three months after he moved in.
When Jamie Reck, his 28-year-old daughter, walked into Bay Gardens that October, she said she felt heartsick. She scanned the grimy floors, the dazed and shuffling tenants, the stray cats and the black handprints marring the walls, and she tried to picture her father there.
"He was really weak from being sick," the daughter said. "I honestly feel like him being there killed him, because it kind of just broke his spirit."
Times researchers Caryn Baird and John Martin contributed to this report.