The first 911 call from the Rehabilitation Center at Hollywood Hills didn't sound ominous: A nursing home patient had an abnormal heartbeat.
An hour later, came a second call: a patient had trouble breathing. Then came the third call. A patient had gone into cardiac arrest — and died.
Over the next few hours of Wednesday morning, the dire situation at the Rehabilitation Center for fragile, elderly people would come into clearer view. Three days after Hurricane Irma hit Florida, the center still didn't have air conditioning, and it ultimately became the grimmest tragedy in a state already full of them. Eight people died and 145 patients had to be moved out of the stifling-hot facility, many of them on stretchers or in wheelchairs.
Authorities launched a criminal investigation to figure out what went wrong and who, if anyone, was to blame. Within hours of the tragedy, Gov. Rick Scott and U.S. Sen. Bill Nelson made no effort to hide their anger and frustration that something like this could happen.
On Saturday, Scott ordered the directors of the Agency for Health Care Administration and the Department of Elder Affairs to issue emergency rules to keep residents safe in health care facilities during emergencies.
This requires all assisted living facilities and nursing homes to obtain ample resources, including generators and the appropriate amount of fuel to maintain comfortable temperatures for at least 96-hours following a power outage.
In Hollywood on Wednesday morning, Judy Frum, the chief nursing officer at the air conditioned hospital just across the street from the rehabilitation center, was working in the Irma command center when the emergency room notified her that three patients had been brought in from the nursing home.
"It set off a red flag that something might be going on," said Frum, who grabbed a colleague and hurried across the street.
When they arrived, paramedics were treating a critically ill patient near the entrance. She saw harried staff members trying to get patients into a room where fans were blowing.
The center had some electricity, but not enough to power the air conditioning.
Frum called her facility, Memorial Regional Hospital, to issue a mass casualty alert. As many as 100 hospital employees rushed over to help.
"The scene on site when I got there was chaotic," said Randy Katz, Memorial's emergency services director.
Word of the crisis soon reached relatives. Vendetta Craig searched frantically for her 87-year-old mother for 25 minutes. She finally found her mother, with doctors from Memorial already applying ice and giving her intravenous fluids.
"She opened her eyes — she looked in my eyes— oh my God, that was the best thing that ever came into my soul," Craig said.
The Rehabilitation Center said the hurricane knocked out a transformer that powered the air conditioning. The center said in a detailed timeline of events released Friday that it repeatedly was told by Florida Power and Light that it would fix the transformer, but the utility did not show up until Wednesday morning, hours after the first patients began having emergencies.
The utility refused to answer any specific questions about the nursing home case.
State and local officials said the nursing home had contacted them, but did not request any help for medical needs or emergencies.
Paulburn Bogle, a member of the housekeeping staff, said employees fought the lack of air conditioning with fans, cold towels, ice and cold drinks for patients.
Rosemary Cooper, a licensed practical nurse at the rehabilitation center, defended the staff's work but declined to discuss specifics.
"The people who were working there worked hard to make a good outcome for our patients," she said in a brief interview before hanging up on a reporter. "We cared for them like family."
Certified nursing assistant Natasha Johnson, who left the facility weeks ago for another job, said she didn't understand why the center didn't transfer patients to the hospital sooner. "I'm as shocked as you. I just don't understand it," she said.
Craig, whose mother was sickened at the nursing home, said the center's administrators should "be prosecuted to the full extent that the law allows and then some."
Owner Jack Michel's attorney didn't immediately respond to a request for comment.
State records showed problems with fire and safety standards, as well as more serious issues with generator maintenance and testing, according to February 2016 reports by Florida Agency for Health Care Administration inspectors.
Inspectors also said they didn't see a clean, well-supplied facility, noting peeling paint, chipped and scratched doors and floors and furniture in disrepair. There were overflowing trash bins, rusty air conditioning vents, soiled bathtubs and cracked or missing bathroom floor tiles.
The facility's directors told inspectors that staff needed a refresher course on reporting maintenance and housekeeping issues.
Evangelina Moulder hired an attorney after her 93-year-old mother became severely dehydrated on Wednesday. Moulder's mother was released from the hospital to a new nursing home.
Moulder's attorney, Bill Dean, said Moulder visited her mother on Monday and worried about the heat.
"She said, 'It's very hot in here,' and the staff said, 'Yes, it is,'" Dean said. "She opened her mom's windows, and she said, 'Mom, it's going to be OK.'"
