Assisted living facilities increasingly accept and care for elderly residents who are too sick, too aggressive or require more care than the centers are able to provide.
Nearly 1 in 10 facilities inspected in two years by regulators in Florida and Arizona, two major retirement states, were cited for violations that involved accepting or keeping residents who should have been cared for elsewhere, according to a USA TODAY review of state inspection records.
Nationwide, seniors and their families try to balance cost, convenience and independence with proper long-term care. As more opt for assisted living as an alternative to nursing homes, they also face risk of illness, injury or worse:
* Claude Trice, a 91-year-old Alabama retiree with Alzheimer's disease, in December 1999 was accepted by Wellington Place at Hampton Cove, a hotel-style brick facility in Huntsville where visitors at the time were greeted by the homey view of a chandelier, a grandfather clock and a china cabinet. The facility accepted him even though it wasn't licensed to care for residents with dementia, said Rick Harris, the state's chief assisted living regulator. Weeks later, the retired machinery operator climbed out the window of his room on a night when the temperature dipped to 26 degrees. He was found dead of exposure.
* Chester Kelly, 84, a retired Minnesota sign painter, moved into Epoch Senior Living, a Minnetonka facility with wall-to-wall carpeting, private apartments and other costly amenities in July 2000.
His daughter, Kathy Ervin, said administrators told her the facility had opened a heavily staffed unit capable of caring for Kelly, who had Alzheimer's disease, needed a special diet and was at risk for skin ulcers. But one month later he was hospitalized with bedsores and signs of malnutrition. The sores started ''the events leading to his death'' two months later, the state reported in a conclusion disputed by the facility.
Although assisted living facilities typically have fewer medical staff than nursing homes, many states allow them to accept seniors with complex health needs if the resident and his or her doctor and family agree. The policy is aimed at giving residents maximum choice.
''That sounds good, but such a policy essentially abrogates a public responsibility to make sure facilities actually have the capability to provide that health care,'' says Donna Lenhoff, executive director of the National Citizens' Coalition for Nursing Home Reform.
Meeting that need is getting harder. As the population ages, there are more Americans over age 85. Hospitals are discharging elderly patients sooner. And few nursing homes are being built.
Trying to keep occupancy rates and income up, the assisted living industry has shifted its marketing to reach frailer, sicker residents as well as the more active elderly. Suzi James, a former marketing director for a Sunrise Assisted Living facility in Fort Wayne, Ind., says she was pressured to sign up new residents even if they were very ill.
''We were taking people who were real iffy,'' says James, who added that she would not criticize the practice ''if we had the proper staffing.''
State assisted living inspectors have seen the change, said Harris, noting that Alabama inspections routinely find ''people who should be in a nursing home.''
Trice was one. He had already been discharged from one assisted living facility because he needed extra care. Relatives say Wellington Place accepted him because his wife, Wyness, moved in with him and helped staffers with his care.
But she fell sick with a heart ailment and was hospitalized just weeks after the move. The day before he climbed out the window, Trice roamed the facility, muttering about finding his wife, inspection records show. Caregivers noticed the behavior but didn't alert his doctor, family or administrators.
Trice's relatives sued the facility. They later settled the case for an amount ordered sealed in a confidentiality agreement.
Rather than close Wellington Place, state regulators pressed successfully for a transfer to new owners who would correct violations and keep other residents in place.
Officials of The Wellington Group, which owned the facility, did not respond to a written request for comment.
Advocates, government officials and others say states should enact stricter laws that spell out the types of residents assisted living facilities may accept and set standards that specify when residents should move to facilities with more intensive care.
''We're imposing too much on the citizens to have them sit down and figure it all out for themselves,'' says Minnesota Attorney General Mike Hatch, who advocates a ''more regulated'' system.
Such a system might have directed Kelly to a nursing home rather than assisted living, says Hatch, who filed a criminal lawsuit that accused Epoch Senior Living of neglecting the resident, who had to use a wheelchair. The case was later dismissed.
Ervin, Kelly's daughter, says she decided to move her dad into a $4,450-a-month facility only because Epoch representatives promised he would live in a newly created unit staffed by one caregiver for every four residents.
''I thought that was wonderful. You don't get that in a nursing home,'' says Ervin.
She became alarmed when Kelly quickly developed bedsores, dehydration and signs of malnutrition. After her father's death, Ervin sued Epoch. The two sides ultimately settled the case.
Epoch CEO Laurence Gerber said Kelly ''probably should have gone to a skilled nursing facility.'' But, stressing that Kelly was not neglected, he said the decision to accept him as a resident complied with all Minnesota regulations.
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