An Atlanta Journal-Constitution investigation uncovered cases in which seniors were left in urine-soaked briefs, emergency calls for help went unanswered for hours, and residents with dementia wandered away unnoticed. Others fell repeatedly, suffering bruises, bloody faces and broken bones. Some suffered in pain for days without treatment.

Caregivers have slapped, pinched and pushed down residents in their care. They’ve belittled residents who move too slowly or wet their beds. Some sexually abused those under their watch.

In many cases, the worst offenses garnered nothing more from the state than a $601 fine.

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Many of the roughly 400 large facilities across Georgia offer quality service with dedicated caregivers. But the AJC investigation identified more than 600 allegations involving neglect and 90 of abuse by caregivers in the past four years, pointing to pervasive problems across a booming industry that operates with inadequate state oversight.

“I’m appalled,” said Rep. Sharon Cooper, R-Marietta, who chairs the House Health and Human Services Committee. “I’m saddened for the people that were injured, and I’m appalled for humanity in general that our elders would be treated this way. Certainly, as a state, we need to intervene.”

Breakdowns in care were often rooted in facility staffing shortages, poor training or efforts to cut corners, the AJC determined after examining thousands of regulatory citations, police reports and lawsuits and interviewing dozens of people.

The drama that unfolded involving a resident at Summer Breeze Senior Living in Savannah three years ago echoes problems across Georgia. The upscale assisted living facility sells itself as a "Taj Mahal" compared with nursing homes. (HYOSUB SHIN / HYOSUB.SHIN@AJC.COM) Credit: Hyosub Shin Credit: Hyosub Shin

The drama that unfolded at Summer Breeze Senior Living in Savannah three years ago echoes problems across Georgia. The upscale assisted living facility sells itself as a "Taj Mahal" compared with nursing homes. It charges residents several thousand dollars a month and vows to offer a superior experience.

Shortly before midnight on March 8, 2016, a diabetic resident with high blood pressure hit the room’s emergency call button. Facility logs show it took 26 minutes before an aide responded. By that time, the resident was unconscious, state records show.

An additional 19 minutes elapsed before anyone called 911. When the ambulance made it to the hospital, the resident was pronounced dead, records show.

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“Imagine his terror for all that time, hoping someone and expecting someone to come and help him, and nobody showed,” said Georgia’s Long-Term Care Ombudsman Melanie McNeil, whose office advocates for thousands of residents of senior care facilities.

Patty Dixon, Summer Breeze’s current executive director, declined to discuss the case but said the state’s account didn’t provide a full picture of what happened. State regulators interviewed a worker who claimed the check was done sooner than 26 minutes, but facility logs didn’t show that, and the state cited the facility for failing to take action.

At least 19 more residents died and more than 100 suffered injuries after other homes failed to provide care as required, the AJC found in examining reports issued by the Department of Community Health, which licenses and inspects long-term care facilities and investigates complaints. The toll could be much higher. In interviews with the AJC and in lawsuits, families have tied other deaths and injuries to improper care.

"I'm appalled. ... Certainly, as a state, we need to intervene." —Rep. Sharon Cooper, R-Marietta, who chairs the House Health and Human Services Committee

Top officials at the state agency refused repeated requests over several months to meet with the AJC. After the newspaper provided its findings to DCH, a spokesman again declined an interview, saying it wasn’t in their “best interest.” The agency would only answer questions the AJC submitted in writing.

Though officials didn’t directly address some AJC questions, DCH Commissioner Frank W. Berry said the agency manages a heavy workload and is always seeking ways to improve and carry out its mission.

“The health and well-being of Georgians is always our top priority,” Berry wrote.

Those in the industry say these facilities are a much-needed, high-quality lifeline for thousands who want their loved ones to live out their days in comfortable settings that feel more like home.

In years past, Georgia had only two main options for seniors looking for care outside their own homes. Personal care homes served those who needed prepared meals and medication reminders, and perhaps help with bathing, going to the toilet or dressing. Nursing homes were for those whose frail bodies or failing minds required intense assistance.

A 2011 state law gave seniors another option: a new type of personal care home dubbed assisted living community. This new type of facility allowed a higher level of care from staff who could administer medication and assist residents who need help moving around.

Advocates for seniors heralded the law, which helped fuel the rapid expansion of Georgia’s senior care industry.

State Rep. John LaHood, R-Valdosta, whose family has been in the senior care business for decades, said the industry overall is doing great and its growth reflects aging Georgians’ desire to spend their final years in a setting of their choice. LaHood said “family after family” has touted the care loved ones received while dealing with the realities of aging bodies or incurable dementia.

“A good provider walks that journey with the family, with that resident, and makes it as pleasant and easy as possible,” said LaHood, who is president/CEO of Fellowship Senior Living, which operates five facilities in Georgia that rarely have been cited for violations.

Yet the new law and the rapid graying of the population have led to facilities taking in more residents who are in their 80s and 90s and have chronic care needs. Though facilities market an active lifestyle, some have residents who can’t move their own wheelchairs or who need assistance to get out of bed. Dementia has robbed others of the ability to dress or feed themselves or to speak.

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That creates more pressure on caregivers who have less training and get less oversight than those at nursing homes. Assisted living and personal care homes aren’t required to have nurses, even though some residents have complex health and medication needs. In the past four years, the state cited facilities 238 times for admitting residents with conditions and illnesses that staff could not handle.

At the same time, the for-profit companies that dominate the industry have incentives to keep their costs low, which translates to minimal staffing, said Catherine Hawes, Regents Professor Emeritus at the Texas A&M Health Science Center and a nationally recognized expert on long-term care.

“It’s like: Let me sit down and write a prescription for disaster,” she said. “You’re writing a prescription for abuse and neglect.”

‘Neglect’ rarely used term

Neglect is a curious word across Georgia’s assisted living and personal care system.

It’s rarely used in public regulatory reports by DCH. In thousands of citations reviewed, the AJC found just four instances in which the agency specifically cited a facility for neglect.

Yet hundreds of cases the AJC identified fit the definition used by federal long-term care authorities for nursing homes.

Some of the most common breakdowns in care included medication errors; residents wandering away from facilities; and general safety violations, such as the more than two dozen citations for water so hot that it risked burning seniors in minutes. At a Savannah home, a resident who was supposed to have help while bathing was found one morning in the shower lethargic, with water running and burns on a leg, state records show. The resident was taken to a hospital’s burn unit but died six days later.

Residents, at times, suffered in isolation when they pushed call buttons to try to summon help, and no one came. At one facility when no one responded, a resident called 911 for help.

At a Cobb facility a state inspector cited the home for delays of up to six hours in responding to residents’ calls for help. One resident said it took 30 minutes before anyone came to offer help getting to the bathroom. “It makes me feel like I don’t matter,” the resident told the inspector.

The chief protector of these vulnerable residents is the Healthcare Facility Regulation division of DCH, which also regulates thousands of other Georgia health care facilities. The division reported last December that it was understaffed, with fewer than half the surveyors needed to cover the state. Its technology is so outdated that officials have trouble tracking whether fines and license fees have been paid.

In recent years, the agency has had to cancel or delay inspections of licensed facilities as the state has cracked down on small unlicensed personal care homes. It can be 16 months or longer between regular inspections of licensed assisted living and large personal care facilities. Too often, DCH seems unaware of troubling allegations of harm.

It wasn't until March that the state investigated the October 2018 death of a 92-year-old woman repeatedly bitten by ants at Somerby Sandy Springs. The upscale facility failed to eradicate the insects that had been reported in her room a week earlier. Then, over two consecutive days, ants attacked the woman in bed.

An ant infestation at Somerby Senior Living left 92-year-old Betty Perloe covered in bites, according to a lawsuit by her family. She died a week after ants attacked her in bed for a second time in two days. She was a retired nurse who was known for caring for elderly relatives and friends. (FAMILY PHOTO) Credit: Family photo Credit: Family photo

Betty Perloe, a retired nurse who had once cared for elderly family and friends, suffered in her final days and needed heavy doses of morphine to help ease the pain, a lawsuit alleges.

“She didn’t deserve — because somebody didn’t follow protocol — to die a miserable, horrible, painful death,” said her son Ross Perloe.

Falls are an especially pervasive and deadly risk across the system. They were linked to more than half of the 20 cases in which a facility was issued a violation related to a death.

In 67 cases, DCH cited facilities for failing to take appropriate measures to safeguard residents at risk of falls or failing to provide proper care after residents fell, the AJC found. A resident at a Conyers home fell 29 times over a four-month period in 2017. A resident at a south Fulton facility had one unwitnessed fall in December 2015, then 10 more in January 2016. That resident suffered injuries that included a concussion, a bruised foot, a broken ankle and a broken toe. Eventually, the resident died of a cerebral hemorrhage. DCH said the home shouldn’t have retained a person whose needs it couldn’t meet.

Because many cases of serious falls go unreported to state regulators, no one knows the scope of the problem. In dozens of cases, the state found out about the falls well after the fact and cited the homes for not reporting the incident.

Mountain View Personal Care Home near Decatur was cited for failing to take appropriate care after resident Lorna Reckord fell and broke a hip. (Hyosub Shin / Hyosub.Shin@ajc.com)

The failure to report at Mountain View personal care home in DeKalb carried a heavy cost for Lorna Reckord, a retired paralegal. When the 71-year-old arrived at the facility three years ago, it already had a history of not documenting harm.

All told, regulators cited the home for 11 violations the year before Reckord arrived. A resident spent a week in the hospital after falling in April 2015, but the facility failed to document the incident or report it to state regulators.

Reckord’s only daughter, Annette Coleman, knew nothing of the problems when she moved her mom to the home.

“I don’t know what I expected,” Coleman said. “I feel bad that I made that decision.”

Reckord had dementia, was blind due to cataracts and had trouble speaking, records show. She had a history of falls when she arrived in early August 2016. Three weeks later, Coleman grew alarmed when Reckord seemed to be in agony. At one point, Reckord was in bed screaming in pain.

Coleman said when she pressed the staff to do something, she was told her mother had a urinary tract infection. It took more than a week of her insisting something else was wrong before an X-ray was taken.

It revealed a broken hip. Reckord was taken to DeKalb Medical Center and a few days later had surgery.

She died three months after the fall. Complications from her broken right hip contributed to her death, records show.

Annette Coleman said that her mother, Lorna Reckord, suffered for days with a broken hip before caregivers at a personal care home sought medical care. (Hyosub Shin / Hyosub.Shin@ajc.com)

State records indicate Mountain View may have been less than forthright with Coleman. A hospice nurse reported being told on Aug. 22 that Reckord had fallen, but the facility staff and an administrator denied that it had happened.

The state cited the facility for failing to give proper care and failing to take appropriate action when Reckord’s condition changed.

Coleman is still anguished at the thought of her mother’s suffering.

“Nine days — they let her sit with a fractured hip for nine days,” said attorney Mike Prieto, who is representing Coleman in a lawsuit against Mountain View. “Had it not been for the action (Coleman has) taken, this whole thing would have been covered up.”

Mountain View officials declined to comment when contacted by phone. In court papers, the facility denied negligence or wrongdoing in its care of Reckord.

Dozens of reports of abuse

While abuse is less common than neglect, the cases demonstrate disturbing breakdowns, with caregivers robbing vulnerable residents of their dignity and subjecting some to physical or sexual assaults.

More than 100 residents were reportedly abused by workers of assisted living and large personal care homes over the past four years, the AJC found in examining police and DCH reports.

At a home near Athens, a worker in 2017 hit an 86-year-old woman with dementia who tried to leave the facility, bloodying the elderly person’s nose and bruising a cheek. At the same time, an 84-year-old resident at the home would not listen to the worker, who then pulled the woman’s hair and hit her, records show.

At a home in Columbus three years ago, a worker was arrested after he faced allegations that he abused two residents with dementia. He was accused of slapping one in the face and pushing another in the back, records show.

Patricia Reed suffered a broken arm while she was a resident at Arbor Terrace Decatur. Reed told police a caregiver dragged her by the arm late one night after Reed asked her to not make so much noise. Reed is seen here at the DeKalb Medical Center. (DEKALB COUNTY POLICE DEPARTMENT) Credit: DeKalb County Police Dept Credit: DeKalb County Police Dept

Arbor Terrace in Decatur received a state citation in March 2018 after an aide was accused of abusing a resident late at night. Nine months earlier, a separate allegation of abuse involving two other employees surfaced on the night shift.

Police were called to the memory care unit after an 82-year-old resident with dementia said an employee broke her arm. Resident Patricia Reed, a retired Agnes Scott English professor, told police that after she confronted the worker about making too much noise late at night, the woman twisted her arm, and she fell to the floor.

“I was on the floor, and she just dragged me up to my room,” Reed told police. “She didn’t try to pick me up at all. It broke my arm.”

Natasha Lewis was an Arbor Terrace of Decatur med tech accused of breaking resident Patricia Reed's arm. Lewis denied hurting Reed but said she took a plea deal to avoid the risk of prison. (DEKALB COUNTY JAIL) Credit: DeKalb County Jail Credit: DeKalb County Jail

Police arrested med tech Natasha Lewis and accused her of abuse. Also arrested was another aide, Mary Harvey, who police say witnessed the abuse and failed to report it. Both women denied harming Reed, but they said they entered plea deals last year to avoid the possibility of time in prison.

Harvey told the AJC that Arbor Terrace was in turmoil at the time of the alleged incident and she felt railroaded by its management. She said she still regrets pleading to a misdemeanor and not fighting the charges in court.

“I was a scapegoat,” Harvey said. “It was much bigger than me.”

The Atlanta-based company did not directly address questions the AJC submitted regarding the June 2017 case, including how the company hired Lewis even though she had been convicted of robbery with a firearm in Florida in 2000. A company spokeswoman said employee background checks and employment guidelines “meet and exceed” the standards set by state law.

Mary Harvey, who worked as a caregiver at Arbor Terrace in Decatur, said the facility was in turmoil during the period that resident Patricia Reed suffered a broken arm. Harvey was accused of witnessing alleged abuse and not reporting it. She denies any abuse occurred but said she pleaded guilty to a misdemeanor to avoid the risk of prison. Bob Andres / robert.andres@ajc.com

“We’re proud that we are able to offer our residents improved quality of life,” the facility said in a statement.

There’s no public record indicating that regulators issued a citation to Arbor Terrace or conducted an investigation. The AJC found other allegations of abuse in police reports that aren’t in public DCH citations.

At a home in Albany, for example, in 2016 a caregiver was accused by a fellow employee of cursing one resident, and cursing and striking another resident who had Alzheimer’s. The worker denied the allegations. Police records say the state was investigating, but there’s no DCH public record that mentions the alleged incidents.

More needs to be done to protect seniors and to hold those who abuse and neglect accountable, say prosecutors and advocates.

“No one who has lived their life and reached 70, 80, 90 years of age, raised a family, contributed to society — they should never be left to rot in a bed or be bashed in the face or have all of the money that goes to their care squandered,” said Will Johnson, the elder abuse prosecutor with the Prosecuting Attorneys’ Council of Georgia. “That’s just not acceptable in our society, in our state, anywhere.”

—AJC data specialists Jennifer Peebles and Nick Thieme contributed to this report.

ABOUT THE REPORTERS

Brad Schrade is an Atlanta native who first worked at The Atlanta Journal-Constitution in the 1990s before moving to Nashville to join The Tennessean newspaper. He rejoined the AJC in 2013 as an investigative reporter. He has received numerous journalism honors, including a 2013 Pulitzer Prize for work as part of a team at the Minneapolis Star Tribune that uncovered safety breakdowns and deaths in the state's child care system. He was lead reporter on the AJC's investigation into police shootings that helped prompt legislative reform of the state's grand jury system in 2016.

A graduate of University of Georgia, Schrade grew up in Roswell and is married to AJC journalist Rose French. He enjoys coaching their two sons in baseball, basketball and soccer.

Carrie Teegardin is a veteran Atlanta Journal-Constitution investigative reporter.

In 30 years at the AJC, Teegardin has written articles on a wide range of topics from health care to consumer affairs to criminal justice.

She has won numerous state and national awards and in 2009 was named the Atlanta Press Club’s Journalist of the Year.

She was a lead reporter on the newspaper’s “Doctors and Sex Abuse” series in 2016 that was a finalist for the Pulitzer Prize in national reporting and that won several other national awards, including the Scripps Howard Award for investigative reporting.

A graduate of Duke University, Teegardin grew up in Circleville, Ohio. She is the mother of two teenagers and lives in Atlanta’s Grant Park Historic District.