Caretakers at the Beckett Lake Lodge assisted living facility struggled to keep track of Walter Stowman Cox.
The 75-year-old man with dementia was once found in a bank lobby after wandering from his Pinellas County ALF. Months later, he wandered into a nearby condo complex and had to be escorted back.
But the last time he left Beckett Lake Lodge his home for more than a year he never returned.
The former Episcopal priest and social worker was found a week later floating face down in a thatch of cattails in a nearby lake, his body ripped apart by alligators.
His gruesome death in 2004 led to an investigation by the Agency for Health Care Administration, which turned up several violations, including a citation for failing to keep track of Coxs whereabouts. But in the end, no fines were imposed and no penalties issued in the death of the elderly grandfather.
AHCA said the home committed a minor infraction that didnt call for a penalty. But records show AHCA initially slapped the home with a serious violation for putting Cox in danger punishable by a $5,000 fine. The agency later agreed to lower the severity of the violation.
In the year before Cox died, records show he was growing confused, with a psychologist noting the Air Force veteran was suffering from memory impairment and in need of an anti-anxiety drug. Though Beckett Lake Lodge had a section for people with dementia where residents are more closely monitored Cox was never placed in the ward.
The homes director of care, Audrey Malin, later said in a deposition she didnt think he should have been allowed to leave the facility because I would already have known that there were risks.
Home administrator Michael Payne declined to talk about the death.
Cox had wandered at least three times, but his daughter, Sharon Sandoval, said no one from the home told her including one episode seven months before he died when police had to conduct a nighttime search for him. Had she known, she said, she would have asked he be placed in the more secure setting.
The day before Cox wandered into the woods for the last time, he was found confused outside a nearby development. The next day, when he wanted to go for a walk, the home sent an aide to watch him. But Cox soon bolted into the woods, and the aide, who wasnt carrying a cellphone, didnt follow, returning to the facility before calling rescue workers.
After a week of searching, law enforcement officers on an airboat found Coxs partially clothed body in four feet of water on the edge of Harbor Lake, his upper torso ripped by alligator bites and both arms missing.
In the year before his death, regulators cited the home twice for not keeping key medical records, including doctors orders detailing the specific care each resident was supposed to receive. In fact, the home didnt complete those documents for Cox until hed been missing four days, records show.
After initially finding the home had lost track of Cox when he ran into the woods, AHCA reversed its decision, saying workers at the home were aware of the whereabouts, said Shelisha Coleman, an agency spokesperson. But records show no one knew where Cox was until police pulled his badly mauled body from the water seven days later.
Sandoval, 52, whose family recently settled a lawsuit with the home for an undisclosed amount, said she was haunted by whether her father was still alive when his body was attacked by the alligator.
I kept going around and around in my head all the different possibilities, she said. I was just driving myself crazy. Finally, I just came to the conclusion that I will never know.