A newly uncovered video of a resident at an assisted living facility in Florida mercilessly beating another resident raises new questions about the safety of the elderly in places meant to protect and care for them.
In the video, obtained last week, a 52-year-old resident is seen punching an 86-year-old resident with dementia more than 50 times as the older man lay curled up on the floor.
The younger resident accused the older resident of eating his cupcake, according to law enforcement.
The video was taken by the facility's closed circuit surveillance system in October and later turned over to the police, who shared it with CNN.
The facility -- the Good Samaritan Retirement Home in Williston -- had a history of violations, and more sanctions in the past five years than any other assisted living facility in Florida. In December, two administrators were arrested in connection with separate incidents on charges of neglect of the elderly.
The beating, which was first reported by the Gainesville Sun, lasted on and off for nearly 2 minutes. It occurred in a common area of a secured unit within the facility while other residents ate and watched television mere feet away.
At the time the beating took place, there was no staff member attending to residents in the unit, and no one had been assigned to monitor the unit's video surveillance, according to official reports.
By the time staff arrived, the beating was over. The elderly resident was hospitalized with bruising and swelling to his face, as well as hip pain, according to the police report.
A month after the beating, another resident hit her head at the facility and was not immediately taken to the hospital. She later died.
One of the facility's administrators, Nenita Alfonso Sudeall, later broke down and cried as she told police she was "overwhelmed" at the facility, which she said was short-staffed and had poorly trained employees, according to a police report.
A number of other recent reports and incidents have called into question the safety of residents of nursing homes and assisted living facilities across the country.
Sometimes, as in the case in Florida, the threats come from fellow residents. Other times, it's from staff.
According to a 2016 study of 10 New York nursing homes, in a given month, one out of five residents suffers mistreatment at the hands of another resident. In September, residents of a Florida nursing home died after Hurricane Irma knocked out the facility's air conditioning. According to the Hollywood Police Department, Broward County Chief Medical Examiner Dr. Craig Mallak classified 12 deaths as homicides from heat exposure, as staff at the Rehabilitation Center at Hollywood Hills failed to evacuate residents amid sweltering temperatures in the days following the storm.
Also earlier this year, a CNN report found that the federal government has cited more than 1,000 nursing homes for mishandling or failing to prevent alleged cases of rape, sexual assault and sexual abuse at their facilities between 2013 and 2016.
"There are far too many cases of abuse and neglect happening in nursing homes and assisted living facilities," said Brian Lee, executive director of Families for Better Care, a national advocacy organization for residents and their families. "We've been seeing cases for decades. This one incident in Florida shows how bad the problem can be."
A spokeswoman for the association that represents many of Florida's long-term care providers said the October beating at Good Samaritan and the national report about nursing home rapes are "disturbing." The association does not represent Good Samaritan.
"We extend our heartfelt thoughts and sympathies to all residents and families involved," Kristen Knapp, the spokeswoman for the Florida Health Care Association, wrote in an email to CNN.
"Cases of abuse are appalling and deeply troubling, and actions that jeopardize the privacy, dignity and safety of the elderly should be condemned and prosecuted to the fullest degree possible," she added.
Fifty-six punches in two minutes
The beating occurred October 3 in a secure unit of Good Samaritan, a 45-bed assisted living facility.
The 86-year-old man was punched 56 times, according to law enforcement reports. Two other residents futilely attempted to help. Staff members arrived at the scene roughly 30 seconds after the beating ended.
The resident seen doing the beating had previously suffered a traumatic brain injury, according to police.
Clay Connolly, Williston's deputy police chief, said the man, whose name was not released, has been arrested several times in the past for assault and battery. Connolly said the man was never prosecuted because he was declared mentally incapacitated. According to a police report, he wasn't arrested for the October beating because of his "limited capacity."
Staff at Good Samaritan told police the man had shown no signs of aggression since coming to the facility in 2015, according to police reports. After beating the other resident, he was removed from the facility temporarily for evaluation, but was later allowed to return to Good Samaritan.
After his return, he was supervised one-on-one by facility staff, according to a report by the state's Agency for Health Care Administration. The report goes on to say that "there was no evidence that the staff had been trained on the scope of such responsibilities."
According to the Florida Health Care Association, which represents some of the state's long-term care providers, nursing homes and assisted living facilities have mandatory staff training programs that address prevention and recognition of abuse, including abuse committed by residents.
CNN attempted to contact the owners and administrators of Good Samaritan by phone and email, and attempted to reach the owners on Facebook, as well. Court records do not yet indicate the names of the administrators' lawyers.
A long history of violations
Over the past five years, the state Agency for Health Care Administration has sanctioned Good Samaritan 17 times -- more than any other assisted living facility in Florida. The agency has also hit Good Samaritan with $73,750 in fines over the same time period -- again, more than any other facility in Florida.
CNN obtained these numbers from the agency's website last week, before the facility was listed as closed.
Over the last five years, there were changes in ownership at the facility. The most recent owners, Helen Romero and Jhoana Paz, appear on ownership documents dating back to August 2015, according to the agency. CNN was unable to determine if their roles at the facility go back further.
In the year before the beating, the state agency reported that the facility had problems with documentation for medications given to residents, failing "to provide a decent living environment," and failing "to provide appropriate supervision for a resident in need of medical services."
State Sen. Lauren Book became involved after receiving a phone call from Lee, the advocate who is also Florida's former long-term care ombudsman. She questioned why Good Samaritan wasn't closed down after the beating in early October, especially given the facility's long track record of infractions.
"Why are residents being left in these facilities that clearly aren't safe?" Book asked.
A resident death
The Florida Department of Children and Families was informed of the October beating the day it happened, police records show.
One month later, on November 1, a 72-year-old female resident fell and hit her head. Staff did not take her to the hospital or inform her daughter or health care provider about the fall.
According to the police report, Sudeall, the facility administrator who complained of being overwhelmed, told police that the elderly woman had fallen in the parking lot and did not wish to be transported to the hospital for treatment. Sudeall told the police she had followed established protocol since "the wound was not actively bleeding and she was conscious and responsive, she was permitted to make the decision as to medical treatment."
Sudeall told the police she placed the elderly woman in the "memory ward," a special unit within the facility, to better monitor her condition and keep her from wandering outside. The woman was reportedly monitored on an hourly basis by staff, according to the police report.
About six hours after she fell, the resident was found unresponsive in bed and 911 was called, according to the police report. Police found the woman, her face turned toward the pillow, occasionally gasping for air and with dried blood on her head and hands.
Sudeall, the facility administrator, told police she delivered first aid to the woman. When police asked what that entailed, Sudeall said she cleaned the blood off her face and hands, according to a law enforcement report. In an incident report, staff also recorded they had given her an ice compress and that she "refused to go to the hospital," according to an agency survey.
The woman was taken to the hospital, where she later died.
The fatal injury was first reported in the Gainesville Sun.
Connolly, the police deputy chief, said he and his colleagues became frustrated that the Agency for Health Care Administration wasn't doing enough to protect the residents.
"The whole thing was atrocious. We have people being killed and injured. We were anxious. We were beside ourselves," Connolly said. "There was a huge amount of frustration in my office because regulatory agencies weren't regulating."
On November 22, nearly three weeks after the woman's death, the Agency for Health Care Administration put a moratorium on new admissions to Good Samaritan.
Connolly says that wasn't enough.
"That just meant they could only kill the people they had left," he said. "We asked, 'What are you planning to do with the people who are there?' We never got a good answer."
According to a statement from a spokeswoman, the state agency took "swift action to hold this facility accountable. ... The health and safety of residents is our top priority, which is why (the agency) has and will hold any facility who fails to protect residents fully accountable."
Two weeks later, there was another incident -- one that resulted in the arrest of a facility administrator.
On Thursday, December 7, a resident underwent a medical procedure. A nurse instructed Rhaimley Yap Romero, an administrator who police said was the co-owner's son, to closely monitor the resident over the weekend and alert her immediately if there were any changes in the resident's condition, according to a press release by the Williston police.
Over the weekend, the patient's condition did deteriorate, and the facility staff contacted Romero twice, but Romero did not contact the nurse and gave no care instructions to the staff, according to police.
On December 11, police arrested Romero, 31, on charges of neglect of the elderly. Sudeall was taken into custody days later on the same charge involving the death of the resident who had hit her head. Neither has entered a plea.
Still, the facility was not immediately shut down.
'Why did it take seven weeks to shut this facility?'
On December 19, the Agency for Health Care Administration filed a report about the facility. It noted many problems, including that some patients had been given the wrong dosages of medications, and other patients were given medications even though there was no documentation of a physician's order. In another case, the medication record reflected that a medication wasn't given to a resident until 11 days after it was prescribed.
The agency also reported that the facility's administrator "lacks requisite qualifications" and that the "current administrator and shareholder both candidly admit a lack of knowledge of Facility operations."
The report continues to say that most of the staff were not English speakers, while most of the residents spoke only English.
"The majority of (Good Samaritan's) staff is unable to communicate with the resident population due to language barriers," according to the report.
"No resident need be subject to the rudderless management and operations which exist" at Good Samaritan, the report continued.
On December 19, Deputy Chief Connolly and others expressed their frustration during a conference call with officials from the state agency. Book, the state senator, said she contacted the agency the same day.
The state filed an emergency suspension order of the facility's license that day.
"We have taken aggressive action to ensure the Good Samaritan facility will no longer be responsible for any residents, and this facility will be shut down by this Saturday, December 23," Mallory McManus, a spokeswoman for the agency, said in a statement on December 21. "We will continue to work with our partners, and with families to quickly and safely relocate all residents."
Book says that while she's glad the facility will no longer operate, she looks back and wonders why it wasn't closed back in October when the beating occurred, or nearly two months ago, after the other resident died.
"There are some questions the secretary (of the Agency for Health Care Administration) and I are going to have to go over," she said. "Why did it take seven weeks to shut this facility?"
Incidents and arrests at Florida assisted living facility led to it being shut down
Reports raised concerns about resident safety at nursing homes and assisted living facilities