That night, as Wright gasped for breath, his roommate pounded on the office door to get the lone caretaker to call 911. But no one answered, forcing the roommate to run to a payphone at a nearby Food Town store.
When paramedics arrived, Wright was dead killed by an overdose of painkillers. Regulators later discovered the caretaker hadnt come to the door because he, too, had taken painkillers and fallen asleep.
When state agents cited the home for the death in 2005, it was the fifth time in two years the facility was slapped with staffing violations. Former owner Avelino Garcia did not return repeated phone calls seeking comment.
While many homes were allowed to stay open by paying fines, another problem was emerging that would have a direct impact on the safety of residents.
In home after home, regulators were catching caretakers resorting to a wide range of illegal restraints to control disturbed residents clear violations of state law and residents rights.
Since 2002, AHCA has cited homes 508 times for actions ranging from feeding tranquilizers to residents without doctors orders to strapping disabled people to wheelchairs and beds.
In fact, The Herald found at least 96 homes were repeatedly cited for the same violations actions that could have drawn sanctions ranging from suspensions to bans on new residents.
Caretakers were caught 14 times in one month tackling residents and forcing them into a locked isolation closet at Pasco Countys Hillandale.
Known as the time-out room, it became a symbol of the homes excesses: a cramped chamber with a metal door magnetically locked from the outside.
They split her head
Residents suffering from mental retardation, hearing impairment and other disabilities were left in the room for sometimes hours, said Karen Westfall, a resident who recalled one incident in which a friend was thrown in the closet. They split her head open, she said. All I could hear was a big, loud thud.
Former resident Tommy Drinnenberg, 45, described the room through a sign-language interpreter. Dark. Cant see, said the deaf man. Hated that Bad.
A former office manager who phoned in a complaint to AHCA about the room told The Herald she kept a log of what she saw, including scratch marks around the door frame where residents tried to claw their way out and footprints on the walls.
Ellen Rothermel said her notes from February 2005 also say she heard screams, and remembers one incident in which a female resident was ordered to remove her clothes before being dragged into the room by the homes administrator.
Though ordered by AHCA to stop using the room which was linked to a spate of injuries Hillandale administrator John Ross was defiant: I dont care how many times they cite me for this, state agents quoted him in a report.
In an interview, Ross said he no longer uses the room, but feels it was the best solution for dealing with people with severe mental illness who were acting out.
I defend it to this day, he said. You just put them in a room and let them chill down.
At the same time, regulators found the home was also overdosing its residents on tranquilizers.
In 2007, a psychiatrist working for the state found people at the home were so overmedicated one resident was on at least 18 mind-altering drugs that they drooled and slept most of the day. The doctor said the drugs placed residents at significant risk, and appeared to be an attempt to chemically restrain them.
I knew I didnt need all that medication, said Westfall, who said she spent a year detoxifying after she left the facility.
No end to problems
Though AHCA slapped sanctions on Hillandale including a temporary ban on new admissions the problems continued: In just 18 months, sheriffs deputies were called to the home 174 times to investigate assaults, thefts and missing persons, records show.
When a 50-year-old man living at the home tripped the exit alarm before dawn in 2007, the lone caretaker shut off the device and did nothing until police called an hour later asking if anyone was missing.
It took two more hours before staff members learned Co Dang who suffered from paranoid schizophrenia was dead, struck by a car as he walked along the road nearly two miles away, his spine severed.
Again, AHCA cited the home for failing to safeguard its residents Co had been found wandering by police more than a dozen times but in the end, never imposed a penalty.
During the next three years, state agents turned up more problems, including residents abusing other residents.
In April 2010, a disabilities advocate visiting the home found a 47-year-old man clad in a womans blouse and mismatched shoes so overmedicated he was drooling and couldnt hold up his head.
State workers agreed to remove him after he asked to leave, but their efforts sparked a near riot at the facility. It had been the fourth time in 18 months that agents had encountered trouble while trying to move residents, state records show.
Shortly after two AHCA agents came to whisk him away, angry residents began to circle the agents when they were told by a Hillandale staff worker to stall the removal of their fellow resident, a state report said.
The men and women formed an unruly mob that cursed at the two AHCA workers, blocking their path to a state van.
Finally, sheriffs deputies were called to protect the two inspectors and put an end to the disturbance.
After the incident, one agency criticized the homes oversight of its residents, saying clients were visibly overmedicated and the home lacked proper supervision, noted Ken Winn, a behavior specialist for the Agency for Persons with Disabilities. This represents an escalating pattern.
But AHCA the lone state agency with regulatory authority took no action, saying it did not find rules or laws were being violated.