Theodore and Dorothy Archer retired to sleepy Hernando County in 1981, but never really settled down. For the next 20 years, the Archers did the Lords 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 Alzheimers disease that finally slowed Dorothy Archer.
Unable to cope with his wifes forgetfulness and agitation, Theodore Archer moved her to a nearby assisted-living facility called Edwinola Manor in late 2008. There, he thought, she would get the care and service she had given so selflessly as a church outreach worker.
Instead, nurses failed to treat a gaping pressure sore on her lower back that 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 the case for the state Department of Children & Families.
Archer, 90, was not the first Edwinola resident to fall victim to shoddy care.
In April 2008, Carmen DeArmas was hospitalized with a rotting, oozing foot, requiring immediate surgery. Family members told investigators the injury was so bad, the 79-year-old womans 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 residents health had deteriorated.
But in October that year more problems emerged: AHCA found the home had failed to keep records on three more residents whose health had deteriorated including one whose pressure sore was severe enough to force a hospital stay.
Once again, Edwinola administrators submitted a detailed plan for doing better.
The plan had just been put in place when Dorothy Archer was admitted to the retirement home, diagnosed with acute psychosis the result of a quickly progressing case of dementia.
The Archers had been inseparable for 37 years, living in the Philippines, Hawaii, South Africa, Panama, Virginia and a host of other places where Theodores second career as a combustion engineer took him.
We were always together, Theodore Archer said. Everywhere I went, she was with me.
The couple had planned to grow old together and die together.
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 wifes Alzheimers.
Confused and agitated, Archer had been hospitalized under Floridas involuntary commitment law when a neighbor suggested Edwinola, a 170-bed home in Dade City, just north of Tampa Bay. Archer said he visited his wife every day usually more than once.
Medical notes suggest Archer was faring well in the facility until March, when nurses feared a raspy cough might be the first signs of pneumonia.
When Archer was sent to a nearby hospital for treatment, the homes notes documented only a small skin lesion, described two days earlier as a red area on her lower back.
But doctors immediately said the homes 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.