Bugs, cold water, sexual assault: Florida suspends Cape Coral assisted living facility license

State officials have suspended the license of the Woodlands assisted living facility in Cape Coral for ignoring a sexual assault and other failures, and is requiring all residents be moved, according to state documents.

The license suspension of the 110-bed assisted living facility located at 825 Santa Barbara Blvd. takes effect Nov. 14 at 5 p.m.

It is not immediately clear how many elderly residents are currently living at the Woodlands and must be discharged or moved to other facilities.

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Officials at the Woodlands, owned by Langham Healthcare LLC, could not be immediately reached for comment.

State records show the Woodlands has a history of complaints with the state Agency for Health Care Administration filing administrative complaints and imposing seven fines totaling $26,000 since September 2019.

Langham Healthcare is 100% controlled by Atlantis Senior Living, a for-profit company based in Brooklyn, New York, records show. Officials at Atlantis could not be reached for comment.

In issuing the emergency license suspension, the state agency said the ALF has failed to meet minimum license standards to protect residents against abuse and neglect, and to provide a safe living environment.

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The state agency said the Woodlands “vividly illustrated” a disregard for the health and safety of the residents with the administrator at the helm on multiple occasions not reporting adverse incidents as required or taking action.

The failures range from a resident masturbating on another resident with dementia and not investigating or moving either to new rooms, not fixing ceiling panels from falling due to water damage and mold, and a lack of hot water for most residents.

Another resident fell through a glass window at the lobby and another resident escaped, known as elopement, when the front door was opened and staff did not realize the resident was missing for two hours.

In addition, the Woodlands has not been paying bills that could lead to vendors for food and home health care to halt service to the ALF, according to the state.

"Bed bugs, the lack of hot water, leaking pipes, dysfunctional emergency equipment, and inadequate resident supervision to prevent assaults, falls or elopement all vividly reflect gross failures in administration," the state found.

“In this instance, the facility has demonstrated an inability or unwillingness to comply with the regulatory scheme,” according to the state order.

“These failures include significant shortcomings to the physical plant, the provision of adequate water temperatures to promote resident health and sanitary conditions, the provision of care and services appropriate to residents’ needs, and the prevention of resident abuse or neglect,” the order says.

The administrator is responsible for assuring the center is operating on a sound financial basis and has failed to do so, according to the report.

The state agency said the findings justify an emergency suspension of the license and the state will help get residents discharged and located to other facilities.

The emergency order must be posted at the ALF and the state agency is filing an administrative complaint.

Here are the findings:

• An inspection last month found that on July 24, a resident masturbated on another resident whose shirt had been removed. The victim has dementia and was unable to answer questions.

The Woodlands sole response was to shower the victim and no other medical or mental health assessment was done.

The two residents’ rooms are across from each other in the same hallway and neither were moved to new rooms, the state said.

The ALF did not investigate or notify family members of either resident and did not report what happened to law enforcement.

The Woodlands did note in records in August that the aggressor is known for exposing genitals.

• On Oct. 3, a resident fell through a glass window in the entrance lobby and was sent to the hospital for injuries.

The ALF did not investigate or file an adverse incident report to the state agency as required. The resident had fallen twice on Oct. 6 and had a total of nine falls since July 12, 2023. There is no documentation of the falls.

• On Oct. 3, a resident eloped when staff opened the locked front door at 7 p.m. for a pizza delivery.

The ALF did not realize the resident was missing until 9 p.m.; the resident’s family and law enforcement were not immediately notified.

Paramedics found the resident 1.4 miles away near a busy four-lane road. The resident was taken to the hospital. The hospital notified the administrator at the Woodlands at 10 p.m. of the resident’s hospitalization before the ALF staff called the administrator.

The state found the Woodlands did not investigate and no adverse incident report was filed. The sole action was to warn an employee which read; “Will make sure to pay attention at all times who goes in and out.”

• The state found severe neglect with the premises and maintenance with water pipes leaking into residents’ rooms and a hallway. There is evidence of mold above the ceilings because of the leaks.

The maintenance director acknowledged leaks are being repaired when they appear. The ceiling in one room fell due to water damage on Oct. 24 and was patched. The ceiling in an adjacent room shows water stains and signs of mold on ceiling panels.

• There is no hot water on three of five resident hallways or in the laundry. The hot water heater broke Oct. 14, 2023.

The water temperature in one hallway is 139 degrees and 120 degrees in another.

Ninety-eight residents are forced to take cold showers or use communal showers in another hallway. Residents say they forego showers.

A staff member reported showering three residents in cold water and the residents have dementia and unable to answer questions about their care.

The state found the Woodlands has no policy to address the lack of hot water or the health consequence to residents or impact to infection control. Two repair companies were called and one did not offer a quote and the second company provided a repair quote Oct. 24 and the center is waiting for corporate owners to respond, according to the state.

• The ALF was told Sept. 11 that it suffered from a bed bug infestation and was given 30 days to fix the problem. A return inspection Oct. 16 found the ALF had not contracted with a company and instead used over-the-counter pesticide when bed bugs were visible.

Active bed bug infestation was found in 10 resident rooms and in an activity room. Four residents confirmed bed bugs in their rooms and one resident showed bites.

The administrator said two quotes from companies were obtained and forwarded to the corporate office Sept. 28. The ALF said it had not been given the OK for the expense.

• The control panel on the emergency generator on Oct. 25 displayed a “Stopped-Warning Service Schedule A.” The ALF has no procedures to start it manually if it does not start automatically.

The administrator reported not being aware of the warning on the generator.  The state found there is no regular service or monitoring of the generator although it was serviced in August 2023. The only person trained on the generator is the maintenance director.

• The ALF provided an income statement for September and reported room and board income of $179,159 and Medicaid income of $89,859 for total of $269,019. The administrator reports the ALF operates at a loss but documents for the prior six months show net income of $94,770.

Outstanding bills to nine vendors totaled $171,632, the state found. A vendor reported removing a 200-gallon propane tank on Oct. 23 due to nonpayment and had loaned the ALF temporary tanks until a new vendor could be found.

This article originally appeared on Naples Daily News: Cape Coral assisted living facility ignored sex assault, mold: Report