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Florida Moves to Shut Down For-Profit Residence After Finding Horrific Abuse and Neglect

| April 20, 2018

carlton palms educational center for profit abuse

Safer staying out.

After another patient died under suspicious circumstances and reports surfaced of more instances of abuse and neglect, Florida regulators moved this week to shutter a for-profit school and residential campus for children and adults with severe developmental disabilities.


The action Tuesday by Florida’s Agency for Persons with Disabilities came after years of complaints that patients at the Carlton Palms Educational Center were violently mistreated by staff and subjected to physical restraints known as “wrap mats,” which resemble full-body straitjackets.

Carlton Palms and its owner’s other facilities were the subject of a ProPublica investigation two years ago that chronicled the deaths of threeteenaged patients, patterns of abuse and neglect, and company executives’ often-successful efforts to stave off regulation.

After our coverage, state officials said they would work to transfer all residents from Carlton Palms by 2019. The center’s parent company, AdvoServ, also changed its name in 2017 to Bellwether Behavioral Health.

But the new name and new executives brought in to lead the company, which is owned by a New York private equity firm, Wellspring Capital Management, didn’t end the troubles at Carlton Palms.

Florida’s Agency for Persons with Disabilities, or APD, filed an administrative complaint with the state Tuesday seeking to revoke the facility’s license, fine it $10,000 — the maximum allowed by law — and remove its remaining patients.

“We are actively working to close Carlton Palms as soon as possible,” said APD Director Barbara Palmer in a press release. “We will not tolerate any type of abuse or neglect at any of our APD licensed facilities.”

The agency said Wednesday that 108 residents remain at Carlton Palms. Another 52 residents have already been moved. The relocations have been complicated by the intense needs of Carlton Palms’ patients, many of whom face behavioral challenges such as compulsions to injure themselves.

Bellwether has 21 days to respond to the state’s complaint and request a hearing. Representatives for the company and for Wellspring did not respond Wednesday to a request for comment. On its website, Bellwether says it serves more than 600 people in Florida, Delaware and New Jersey.

The state’s complaint says staff at Carlton Palms repeatedly taunted and abused a man before he died unexpectedly after an incident there on March 1. The complaint did not name the individual. But resident William James Lamson died there that day, according to news reports. Lamson, 26, had autism, was prone to harming himself, and died of wounds he sustained at the center.

The complaint said the resident was also hospitalized in April 2017 after receiving unexplained injuries on his neck, chest and the back of his head. The injuries “were believed to be burns,” the complaint said, and Carlton Palms officials did not explain how he was hurt.

Two months later, the resident was “verbally and physically abused” by staff and denied access to a bathroom, causing him to soil himself. A worker knocked him out of a chair and dragged him to a bathroom, hitting and shoving him.

On the day Lamson died, a staff member ripped a helmet off the resident’s head after he stood up from a chair and began to walk away. The resident tried to retrieve the helmet, which he needed to protect his face from injuries he inflicted on himself that had previously left him partly blind in his right eye. The staff member didn’t return the helmet when the man began slapping his face, at one point holding “the helmet out in a taunting manner,” the complaint said. When the patient reached for it, the staff member pulled the helmet away.

The worker and the man went into his bedroom, and about 13 minutes later the staff member came out of the bedroom and called for a nurse — saying the man had banged his head and was having trouble breathing. An ambulance was called. The resident was pronounced dead at the hospital.

The Orlando Sentinel has reported that when was Lamson found, he did not have head injuries, and that sheriff’s deputies did not find blood.

Disability advocates have accused Carlton Palms of making incomplete and misleading reports about alleged abuse and neglect. This week’s state complaint highlights incidents where information the facility provided to officials was not accurate.

The state also details more incidents in which patients were hurt by staff or were left alone and experienced harm; in one instance, a patient was raped; in another, several residents went missing. In November, a staff member shoved a patient from behind, causing the patient to fall and suffer a head injury.

In addition, nurses visiting the campus last month at the agency’s request found buildings “dirty and in disrepair,” with holes in walls throughout the facility and a strong urine smell in a bathroom. Patients received inadequate amounts of food for lunch, the complaint said, and nurses found numerous errors related to medications patients were given.

The complaint was also remarkable for its critique of how the center cared for patients. The state said that training was inadequate for workers and that patients were given “woefully generic” behavior plans, leading to treatment that failed to address their unique challenges. Staffing ratios at times fell far short of state standards, with one behavior analyst, who was also the center’s clinical director, being assigned 70 clients instead of 20 or fewer as required.

–Heather Vogell, ProPublica

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6 Responses for “Florida Moves to Shut Down For-Profit Residence After Finding Horrific Abuse and Neglect”

  1. Just the truth says:

    I feel there needs to be more inspections done on these residential (private home) nursing homes within Palm Coast.
    This story is horrible and those involved need to do jail time.

  2. Mark says:

    Two years? It would take me one day! These regulations that require you to dot every i and cross every t costs lives. They tie the cops hands and cause a multitude of additional problems. What ever happened to common sense. If some one dies under suspicious circumstances put a lock on the door until the 2 year investigation is complete. If someone sees abuse, send in a decoy and lock the door immediately if it’s there.

  3. Duncan says:

    Unbelievable! I hope those responsible serve prison time! If you don’t have the temperament to care for these unfortunate souls respectfully, then find another line of work! To abuse them is unacceptable and state shares responsible for letting this facility operate i such a fashion! To little to late State of Florida!

    Bellwether Behavioral Health. should be shuttered in all states they operate in and the prospective state attorney generals notified of the abuses!

  4. Richard says:

    It should be mandatory to have tamper-proof security cameras covering every square inch of these facilities with security personnel watching everyone’s movement.

  5. Anonymous says:

    I agree about the security cameras–not only to document staff on patient abuses but also patient on patient abuses.

  6. Victim of Injustice says:

    Florida is lax when it comes to investigating complaints of facilities and home care personal. Every agency blames the other and the complaints goes nowhere. Two years after the abuse was exposed and the facility is still in operation? Who will take accountability for that—and another death.

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