Ninety-three year old Michael Gruen lived at Homewood Residence at Delray Beach and suffered from advanced Alzheimer’s disease. Gruen was found standing over a dishwasher detergent container on December 28, 2009. He apparently got into the kitchen early in the morning that day while staff members were caring for another resident. Gruen could not tell staff members if he had drank the sodium hydroxide solution and staff called paramedics. Gruen died 18 hours later from severe burns to his esophagus and the neglect of the nursing home staff.

Despite a state health care warning during a March 2008 inspection that certain areas of the dementia unit were improperly secured and residents could access chemical products and other potentially dangerous items, Holly Botsford, public relations manager for Brookdale Senior Living, says there was no way to anticipate what happened to Michael Gruen. According to Botsford, “the device with the dish detergent in it was in a cabinet under the sink and was attached to the dishwasher. The lines of the device ran directly to the dishwasher. It took much maneuvering and manipulation to get to the fluid, including disconnecting the hoses.”