Neglected to Death

Part III | At homes for the mentally ill, a sweeping breakdown in care

For the residents of Hillandale, punishment was swift and painful: violent takedowns, powerful tranquilizers that made them stumble and drool, and staffers who would scream and tackle them when they misbehaved.

The worst was the closet — a cramped room at the end of a hallway where the residents who were deemed unruly were locked, sometimes for hours.

“It’s like you’re in jail,” said Karen Westfall, who lived at Hillandale for five years.

And like a jail, the Pasco County assisted-living facility sometimes prevented residents from leaving, records show.

Last April, the staff protested the removal of a 47-year-old man — frail and mentally retarded — who said he wanted to move, while residents shouted and blocked the path of state workers trying to safely escort him from the home.

In the end, regulators were forced to bring in sheriff’s deputies to clear a path and break up the crowd gathered behind the gates of the facility.

The dramatic rescue highlights the problems that have turned a special subset of assisted-living facilities into Florida’s most dangerous.

While most ALFs are designed to care for the elderly — providing help with everyday tasks — Florida licenses facilities like Hillandale to also care for people with severe mental illness.

Created a generation ago, the special homes were the state’s answer to providing housing for thousands left in the streets after the historic closings of Florida’s psychiatric institutions.

But The Miami Herald found dozens of the homes are so poorly run that residents are forced to languish without crucial needs — including medication and psychiatric help — leaving their care to police and rescue workers.

Ranging from small cottages in suburban neighborhoods to 350-bed complexes, the homes represent a third of ALFs in the state, but account for some of the most egregious cases of abuse.

“It’s a cheap, easy, unregulated system of care,” said Miami-Dade Mental Health Court Judge Steve Leifman, who refuses to send people in his program to some of the homes because of dangerous and decrepit conditions.

While The Herald found sweeping breakdowns in the state’s oversight of standard ALFs, the lack of controls in ALFs for mentally ill residents have created even more problems for some of the state’s most vulnerable residents.

Complaints to the Agency for Health Care Administration — the state entity entrusted with overseeing the facilities — are routinely ignored, leaving residents at the mercy of shoddy operators.

Even when the agency found enough violations to close facilities, which frequently mix elderly and mentally ill residents, regulators rarely act under state law.

The Herald’s examination of Florida’s 1,083 homes for people with mental illness, including a review of state inspection reports, police investigations, court records and interviews with mental health experts, found:

Twice, residents at Tampa’s Escondido Palms were forced to call police when fellow residents were dying — one from a drug overdose, after the lone caretaker had locked the office door and fallen asleep.

It wasn’t until a third resident died in 2007 after caretakers failed to perform CPR — leaving the task to another resident — that AHCA asked the facility’s owner to sell the home.

A criminal moves in

When Darryl McGee moved into the Munne Center in 2007, he was supposed to get psychiatric care and medication at the sprawling facility in Miami-Dade.

Instead, caretakers gave him a bed in the home’s locked Alzheimer’s ward with people twice his age and never arranged for care, state reports show.

During the next four months, the burly man with a criminal past became a 214-pound nightmare, beating the elderly residents at least four times before he brutally raped a 71-year-old woman in her bedroom.

The 33-year-old man, diagnosed with bipolar disorder and schizophrenia, was like thousands who flooded into ALFs during the past decade — a younger generation that would now be housed with older people with dementia.

Though residents who move into the specially licensed facilities are supposed to receive psychiatric intervention and care — paid for by state dollars — The Herald found that hundreds of homes are failing to provide those critical services.

In at least 555 cases during the past decade, state agents caught homes failing to make sure residents got medications, psychological care and the supervision needed to spot drastic changes in behavior.

One of those was the Munne Center. The facility had been warned in 2006 it was not delivering the services to its residents, but the following year, it was still not complying with the law.

For four months in 2007, McGee terrorized the home’s elderly residents during drunken rages, beating elderly men and women.

After citing the home for a host of violations in the aftermath of the rape, inspectors returned months later — only to find the Munne Center was still not providing care and treatment.

State agents concluded the home was an “unsafe environment to live” and eventually slapped it with a $19,000 fine — later reducing it to $2,000. Then in 2010, it happened again: AHCA found the home had placed another resident with severe mental illness in the Alzheimer’s ward, leading to an assault on an elderly resident.

“They give them chance after chance after chance,” said Brian Lee, former head of the state Department of Elder Affairs ombudsman program. “Their residents were being abused.’’

Home administrator Olga Munoz referred questions to Sean Ellsworth, an attorney for the home, who said the facility is now “under a microscope” and “has been inspected frequently.”

McGee, who had been arrested 11 times before the rape on charges ranging from simple assault and vandalism to cocaine possession, was found incompetent to stand trial.

The incidents at the Munne Center underscore a wider problem in Florida ALFs that care for people with mental illnesses: Homes are allowed to stay open despite histories of violence that jeopardize the safety of residents.

Twice the rate of abuse

Year after year, regulators found people inside the homes suffering twice the rate of abuse — including beatings, sexual abuse and intimidation — than at standard facilities, a Herald analysis shows.

A manager at Arlington House in Palatka was found sexually abusing at least three different men with severe mental illnesses in 2008, but it wasn’t until the local fire inspector found a broken sprinkler system the next year that the facility was closed.

At Nueva Vida, a cluster of cottages in Miami-Dade, police were called 38 times in 2008, and investigated six assaults and a brutal murder in which a 29-year-old man with a violent criminal past smashed a brick into the head of his 52-year-old roommate, nearly severing his ear. The next year, the violence continued, with residents routinely beating one another, police reports show. Though the home was required to report the incidents to AHCA, inspectors found it hadn’t — and the agency never imposed sanctions allowed by state law.

In an analysis of facilities in Miami-Dade, where the majority of the special homes are located, The Herald found the homes cited for inadequate supervision are also far more likely to draw police and emergency calls.

The violence does more than disrupt residents’ treatment: It leaves them in serious danger.

“Even a person without a mental illness would have a difficult time,” said Alan Lipton, Florida’s former chief of psychiatric services. “It’s unacceptable.”

In Lauderhill, a special enclave set aside for a group of ALFs catering to people with mental illness draws police or rescue calls an average of every four hours — 10,703 in the past five years. Police have gone on so many calls to the area known as “Cannon Point” that Lauderhill officers now receive special training in crisis intervention.

The rise in violence comes as advocates and Florida’s Department of Elder Affairs are pressing for increasing the minimum qualifications of people running the facilities and ramping up training for their employees.

Lee, former chief of the Elder Affairs ombudsman program, said as the homes become the primary residences for people with mental disorders, they are failing to provide the professional care to take on that role.

To open a home for people with mental illness, administrators need only a high school diploma and four days of training — far less than other major states, including Ohio, Pennsylvania, California and Texas.

“You’re talking about people with mental challenges — complex — and you got a cook in there supervising,” Lee said. “Talk about warehousing.”

In fact, The Herald found that more than two-thirds of the homes have been caught by state agents with untrained workers or dangerously low staff levels since 2002 — and in some cases, no employees at all.

At Tampa’s Escondido Palms, staff never helped as two residents died in separate incidents — one from a drug overdose, the other from neglect.

For an entire day, Jason Thomas Wright, a 28-year-old recovering addict, was stumbling, slurring his words and falling asleep outside the home. Though caretakers were alerted to his drastic change in behavior and struggles with drug abuse, they never called a doctor.

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 hadn’t 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 doctor’s 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 County’s Hillandale.

Known as the time-out room, it became a symbol of the home’s 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. Can’t 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 home’s 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 don’t 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 didn’t 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, sheriff’s 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 woman’s blouse and mismatched shoes — so overmedicated he was drooling and couldn’t 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, sheriff’s deputies were called to protect the two inspectors and put an end to the disturbance.

After the incident, one agency criticized the home’s 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.”