Beth Nakamura

Sydney Vosgien, 28, gets ready to take her step-son Paul to school. She worked at a memory care facility in Florence.



By FEDOR ZARKHIN and LYNNE TERRY



Grueling work. Rampant turnover. Elderly people with dementia, abused and neglected for lack of staff.



The Oregonian/OregonLive asked more than 200 current and former memory care employees what they experienced on the job. Their stunning responses shed light on why memory care too often falls short of its promise of specialized support for people with dementia.



The pay that workers reported didn't reflect the responsibility or the stakes. Hourly wages for caregivers equalled those of Oregon dishwashers, motel clerks and parking lot attendants: $11 and change. On average, the caregivers reported taking on 15 memory care residents at a time.



Confirmed cases of abuse and neglect in senior care are rare, state data show. Yet 70 percent of employees who answered the newsroom's call for comments said they witnessed abuse or neglect. Eight in 10 of those people blamed a shortage of staff.



The candid responses from people on the ground offer a unique viewpoint on memory care, which has more than twice as many confirmed cases of abuse per occupied bed as other forms of assisted living, a newsroom analysis found.



It's the first time an Oregon news organization has built such an extensive database to capture the firsthand experiences of senior care workers in the state.



"When they're trying to sell it, they call it a safe haven," said Jill Faith, a caregiver at an eastern Oregon memory care from 2013 through last year. "I don't think it's safe at all."



READ PART ONE OF THE INVESTIGATION: FALSE COMFORT



In addition to conducting dozens of interviews, The Oregonian/OregonLive sent a questionnaire to Facebook users who listed jobs in caregiving.



The reviews weren't all bad. One caregiver described the management at her facility as "beyond perfect." Another said her employer exclusively hired people with far more training than the law requires.



On the whole, however, the response from such a large group of caregivers painted a disturbing account of problems.



"Caregivers often feel they are personal slaves," wrote one. "We often neglect our own health and families to provide care for less than what fast food workers get paid."



"I think each caregiver should have a maximum of 5 residents so basic needs can be met/exceeded, residents don't feel rushed, helpless, or violated," another wrote.



"The lack of effective training BEFORE being personally responsible for the care of residents is appalling," said a third.

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Oregon has set precise numeric staffing levels for other types of senior care facilities in efforts to ensure residents are treated well. It also requires workers in other facilities to receive state certification or licensing.

But not for memory care.

The industry's main lobbying group, the Oregon Health Care Association, dismissed as "anecdotal" the caregiver responses gathered by the newsroom, pointing to statistics that paint a rosier picture.

The group's lead analyst cited

a survey

, conducted by national experts and the state, that found 95 percent of elderly and physically disabled Oregonians felt safe around their caregivers. The association also pointed to a state ombudsman's report listing only 36 complaints of low staffing in residential care in one year.

But neither source shows that memory care has the right number of workers.

In fact, the survey suggests the opposite: About 25 percent of memory care residents relied mainly on a family member for help rather than someone on staff, compared with 9 percent in ordinary assisted living. And the ombudsman's office gets many complaints that were likely a result of short staffing but weren't identified that way, such as concerns about long wait times or incorrect medications.

MEMORY CARE: WHAT IT TAKES TO DO IT RIGHT

A 2017 report by the

Oregon Long-Term Care Ombudsman

's office found poor care caused by low staffing in memory care facilities. Volunteers took notes on the care they saw when visiting facilities and in many cases found there wasn't enough staff.

Among other problems, inadequate staffing creates a chaotic environment at mealtime, the agency's volunteers found. In more than half of their observations, residents who should've gotten help eating didn't.

"Staffing shortages must be greatly reduced," the office concluded.

The state has ramped up enforcement in recent years, and new laws have expanded its authority to punish bad actors and measure staffing levels.

Surveys

by Portland State University have found that memory care facilities do provide, on average, more total staff time than regular assisted living facilities.

But advocates say there remains little in Oregon law to keep facilities from going far below that level. Frontline workers told the newsroom that, in their experience, they didn't see enough employees to meet the extraordinary needs of dementia patients.

"Every case I've handled that involved abuse in a memory care facility has involved too few staff, which is how for-profit facilities save money," said Erin Olson, a Portland attorney who's represented families in elder abuse cases. "When you have too few staff, you have too little supervision."

***



Defined: Memory care and assisted living

Oregon law recognizes two kinds of large-scale senior centers designed, unlike nursing homes, to support elderly people in a non-clinical setting. Assisted living provides exclusively private apartments, while residential care can offer private or shared rooms. These facilities follow virtually identical state regulations. Either type may add a memory care endorsement. In this story, the term "assisted living" describes both assisted living and residential care.

***

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Beth Nakamura

Sydney Vosgien cares for her friend's father, who is ill, and helps feed her friend's baby.





"You better pray"



Sydney Vosgien knew Elderberry Square was in trouble the day she interviewed to work there in 2016. Its elderly residents were at such risk of harm, state authorities wouldn't allow the facility to accept new ones. Vosgien had an early hint as to why: Waiting to go into the director's office for her interview, she watched as a worker practically ran from resident to resident.



A panel with room numbers lit up, and beeping alarms blared from each room where a resident pushed a call button for help.



"I was getting a headache from the call lights," Vosgien said.



The recently married mother of two took the job at the Florence facility anyway. She wanted to help make the place better.

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Beth Nakamura

Sydney Vosgien holding her daughter Kiley.





In the year and a half that followed, each resident became precious to her, like the man whose hand she held late into the night the week he died, or even the woman who poured orange juice down caregivers' pants .



But no matter how hard she worked, Vosgien could barely meet their needs, she said, because she was often on her own.



"You better pray that nothing comes up and that everything goes smoothly, because anything starts to go wrong, you get behind," said Vosgien, now 28. "And then you're struggling and struggling and struggling to keep up."



Before Elderberry Square, Vosgien sold jewelry at Fred Meyer for about $11 an hour, plus commission, and counted inventory for stores like Safeway and Dollar Tree. She also cared for her grandmother, who died a few months before Vosgien started at Elderberry Square. That experience led her to consider caregiving as a job.



Elderberry Square's website says its memory care units "have environments designed to accommodate people with memory loss allowing freedom, mobility, choice, and independence".



In 2016, the year Vosgien started, investigators confirmed 17 abuse cases at Elderberry Square's memory care and residential care wings. It had eight abuse cases in 2017, state data show.



Robert Zink, one of the facility's owners, declined to talk about Vosgien's experience or the substantiated cases of abuse and neglect at the facility.



"We comply with the law, and we take care of our employees," he said.



FIND A SENIOR CARE FACILITY'S RECORD OF ABUSE, NEGLECT AND POOR CARE



Caring Places Management, which operated Elderberry Square for the owners during Vosgien's last nine months there, disputed her characterizations.



"During the time in question, our staffing pattern met the needs of our residents and the requirements of the state," the company said through its attorney in a written statement.



"Elderberry Square's goal is to provide loving care to all of the residents who call it home."

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Beth Nakamura

Elderberry Square, the combined residential care and memory care facility in Florence where Sydney Vosgien worked from late 2016 to early 2018.





One month after being hired at $10.50 an hour, Vosgien said, she became the sole caregiver on the evening shift at one of Elderberry Square's two memory care buildings. She was responsible for 11 people at a time, she said.



One bed-bound man in her unit weighed 250 pounds, and Vosgien, 5-foot-10 and 125 pounds, wasn't supposed to lift him alone. Whenever the man needed his briefs changed, Vosgien would call for help on her walkie-talkie. She said she would wait up to an hour while the man lay helpless in his filth.



When a resident fell, Vosgien had to wait for someone trained in checking for injuries. Vosgien wasn't allowed to lift people who fell or leave their sides, she said.



Vosgien recalled waiting with a woman who hit her face against a table.



"I'm sitting there, 'OK, come on. Somebody. Give me somebody. Now,'" she said.



Vosgien said turnover and poor training meant her coworkers were often unreliable. Once, she asked a caregiver to help with a Hoyer lift, a machine that required two people to operate.



"The what?" Vosgien said the caregiver asked her.



Vosgien was surprised.



"How are you getting her up?" Vosgien asked.



"I haven't gotten her up," was the reply.



The woman had worked at Elderberry Square for about three weeks.



Caring Places Management, which Vosgien worked under at Elderberry Square, said it trains employees when they're hired and throughout their time at the facility.



Vosgien said she lost almost 10 pounds in her first four months. She would often come home in tears, feeling like she "couldn't do anything right." She thought of quitting. But she worried her departure would make the quality of care even worse, she said.



"I would talk myself out of it," she said.

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Vague requirements



Despite decades of research showing people's health, dignity and well-being suffer when there aren't enough caregivers in a senior center, Oregon lets memory care companies decide how many workers to employ.



It's a dramatic departure from how the state regulates nursing homes, facilities for seniors with specialized medical needs. State data show memory care residents, like people in nursing homes, are more dependent on others for help dressing, bathing, using the bathroom and eating than people in other types of assisted living.



Concerns about nursing homes in the 1980s were similar to the ones about memory care today.



"The complaints of cold food, urine-soaked beds, patients not dressed, etc., can most often be traced back to lack of people to do the job," elder rights advocate Marty Lemke testified at a legislative hearing in Salem in 1981.



Lawmakers were considering a bill to limit how many residents each nursing assistant could care for at a time. The idea was to set a realistic limit, beyond which "it is not possible to give humane care," elder advocate and senior care nurse Barbara Nelson said at the time.



LOOKING FOR SENIOR CARE: WHAT TO ASK



The Department of Human Services agreed that staffing was key to good care in nursing homes. The Oregon Health Care Association lent its support. The bill passed, setting the stage for a series of progressively tighter requirements for nursing home staffing in the decades that followed.



By the 1990s, the standard was 10 residents per nursing assistant on the day shift, 15 on the evening shift, and 25 on the night shift. And that was just a bare minimum. If some residents were especially time-consuming, nursing homes had to hire more nursing assistants to make sure everybody's needs were met.



But the state continued to make the rules stricter still.

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In 2006, a special commission took up concerns from certified nursing assistants who said caregivers were burning out and nursing home residents were suffering. They pleaded for the state to lighten their workload.



In just four meetings, the commission decided the department should cut the number of residents per nursing assistant. The department did as told, phasing in stricter rules over six years to give nursing homes time to hire more workers.



Officials also required facilities to report quarterly on how many residents they have for every nursing assistant, making it easier for regulators to identify the nursing homes that need to hire more people.



Nursing homes today must limit each of their certified nursing assistants to seven residents on days, 9.5 on evenings and 17 on nights.



What's the equivalent requirement in memory care?



The number of caregivers - none of whom have to be certified - must be "sufficient to meet the scheduled and unscheduled needs of residents."



That wording is more or less unchanged from when the standard was created in 1993.

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Beth Nakamura

Three former memory care workers. Left to right: Zernie Harkins, former caregiver; Tara Dueñas, former medication aide and caregiver; Angela Velasquez, former medication aide and caregiver.



Low staff, constant churn



Today, many workers in memory care say they feel unable to do enough for residents.



"You can only change so many residents and shower so many residents at a time," said former caregiver Sara Gibson.



Only 9 percent of memory care employees who shared their experiences with the newsroom said staffing was consistently adequate where they worked.



It's hard to find people to do the work and to keep them.



"They'd get paid more if they worked for Walmart," said Nuala Davies, a former licensed volunteer for Oregon's Long-Term Care Ombudsman.

HOW WE REACHED 215 MEMORY CARE WORKERS



One former memory care worker said he got a job about 15 minutes after walking in the door. People leave just as quickly, others said.



"I've seen plenty of people that thought it was an easy job," said Stephen Sharp, who's worked at multiple facilities in southern Oregon. "They were there for two days, and then they quit. It was too much."



The churn makes caregivers less likely to bond with residents, learn their needs or notice new health problems. It makes the job extremely difficult for those who stick around.



Training gets short shrift, memory care workers said. New hires are often sent into action after watching a brief instructional video or are taught by people who themselves have very little experience, caregivers said.

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Only half of the memory care workers who answered the newsroom's questionnaire said they felt adequately trained in all six of the following areas: preventing falls; preventing ulcers; dealing with aggressive behavior; helping residents with basic needs; recognizing signs of abuse; and knowing how to report abuse to the state.



"There was no one to train me to be a med aide," said Catlyn Enyart, who worked for two months at Royalton Place Memory Care, a facility in Milwaukie. "They basically threw me the keys and said, 'Figure it out.'"



Jason Childers, executive vice president of the company that managed Royalton Place at the time, said he was surprised by Enyart's description.



"I do think it's likely to be inaccurate," he said. "I also feel for the employee."



The failure to hire enough people, train them effectively and pay them an adequate wage has consequences.



Memory care has higher rates of abuse and neglect than other types of assisted living, an analysis of state data shows.



Of the 150 caregivers who told The Oregonian/OregonLive that they witnessed abuse or neglect, 125 blamed a lack of workers.

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Rules remain weak



Discussions of tighter staffing requirements for memory care in Oregon have not gone far.



When the Department of Human Services rewrote the rules for memory care in 2010, it specified the minimum brightness for interior lights and mandated four hours of memory care training a year.



But the rules remained vague about staffing levels.



When the department in 2014 looked into setting specific staffing numbers for both memory care and ordinary assisted living, officials concluded the existing system worked well and staffing ratios were unnecessary, internal emails show.



In 2016, Oregon Rep. Caddy McKeown, D-Coos Bay, introduced a bill to require that workers be certified with the state to work in memory care. McKeown later put aside the idea. She decided the issue needed a more comprehensive approach, she said in an email to The Oregonian/OregonLive.



The bill started a broader effort to address abuse and neglect the following year, which included two proposals backed by McKeown to address staffing.

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One unsuccessful proposal would have capped caregiver workload.



McKeown did succeed in getting passed a bill saying regulators would be allowed to use special software to calculate how many caregivers are needed in a facility. It didn't mandate use of the software across the board as a way to compel facilities to have enough staff, as McKeown had originally proposed.



The move was part of a compromise bill, endorsed by industry lobbyists, that contained other provisions McKeown and others sought: stiffer fines; quality reporting; extra training; and safer medication management in all assisted living facilities.



Rural lawmakers and lobbyists said using software to mandate staffing levels could have unintended consequences. Facilities that couldn't comply might shut down. The group writing the bill decided to drop the idea.



"In an ideal world, best practice should tell you how many people you should have on staff," said the bill's co-sponsor, Rep. Alissa Keny-Guyer.



"I also operate in the real world," the Portland Democrat said.



McKeown said in an email that the legislation as a whole was "historic."



"Though there is certainly still more work to be done, I am proud of what we did here," McKeown wrote.



Those who praise the legislation include the head of the Oregon Long-Term Care Ombudsman's office, Fred Steele. The Oregon Health Care Association, the industry's lobbying group, said "virtually every stakeholder" involved "felt happy about the work we all did."



The association has given $2 million to legislative candidates since the 2010 election cycle, according to the National Institute on Money in State Politics, and it lists a yearly budget of $4 million. Its chief executive, James Carlson, made more than $600,000 in 2015.

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A spokeswoman said the association has taken no position on proposals for staffing minimums in memory care. But the group offered numerous reasons such requirements wouldn't work.



The spokeswoman, Rosie Ward, said in a written statement that even if residents could afford constant, one-on-one care, there could still be accidents that sometimes cause injuries.



Adding just one more caregiver per shift would cost the average Portland memory care resident about $370 per month, according to the association's estimates as of May 2018. Memory care facilities already charge $5,620 a month, on average, according to an industry survey done by Portland State University.



"Mandating dramatically higher staffing levels would make services unaffordable for most Oregonians," said Linda Kirschbaum, senior vice president of quality services for the association, in a written statement.



Facilities might not even be able to find enough workers to fill the newly required positions, Ward said.



And Ward pointed to laws already on the books that let the state require more caregivers at a specific facility if residents are in danger.



"As anyone who has any experience in policymaking knows, rarely do you find simple, easy solutions," Ward said in an email.

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David Berger, Oregon deputy long-term care ombudsman for Multnomah and Columbia counties (Photo: Beth Nakamura).



Officials with the Department of Human Services said they're open to revisiting Oregon's existing standard, which sets the same requirement of "sufficient" staffing at both memory care and ordinary assisted living facilities. But agency officials, in a statement, said the rule makes managers responsible for constantly evaluating their staffing levels to account for changes in their residents' needs.



Bob Blancato, a national advocate and board member for the AARP, sees it differently. He called "sufficient" staffing a "Swiss cheese" term that leaves facilities broad latitude.



Robyn Grant, director of the advocacy group National Consumer Voice for Quality Long-Term Care, said without a legal mandate for profit-driven care operators, "there's no limit to how much you can cut staff."

MEMORY CARE: WAYS TO MAKE IT BETTER



And in Oregon, David Berger, a deputy state ombudsman for senior care, takes a similar view.



Oregon's standard is so vague, he said, that facilities can fall short and get away with it. Violations are hard for state inspectors to prove. And the state only checks on a facility's caregiver workload every two years or if somebody complains, he said.



Berger said memory care companies could absorb some of the added cost of state-imposed minimum staffing. And, he said, facilities could address labor shortages simply by raising wages and treating employees well.



"This is what I want policymakers to ask themselves," Berger said. "'How much would I need to pay you, per hour, to change a dirty diaper on a 250-pound man?'"



"You tell me that," he said, "and then we can have a conversation about what caregivers need to be paid."

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Beth Nakamura

Sydney Vosgien in physical therapy.



Better pay, less stress



The breaking point for Sydney Vosgien, the worker at Elderberry Square, came in March of this year.



Her pay had increased to $12 per hour, but running from room to room had taken its toll, she said. She has a condition that makes her joints sensitive to stress, and her right hip hurt so much she walked with a cane. She had to take two weeks off of work, her doctor wrote in a note she shared with the newsroom.



When Vosgien gave her boss the note and asked for two weeks off, she was told she had nearly exhausted her sick leave. She received a text: "Just because u have a drs note doesnt mean u can just not go to work for two weeks."



The supervisor's text said Vosgien could put in for family medical leave by the end of the next business day or "I can hire someone to take your place."



The company declined to comment on Vosgien's description of events.



Vosgien made the deadline, she said. But she quit the next day and went on to be a private caregiver, working 27 and a half hours a week and making $14.65 an hour.



It was 22 percent more hourly pay for a job that was much less stressful.



"I realized I had more options and I needed to quit killing myself," she said. "I needed to take care of me."





Have a tip about senior care? Contact the reporters:



-- Fedor Zarkhin

fzarkhin@oregonian.com

desk: 503-294-7674|cell: 971-373-2905|@fedorzarkhin



-- Lynne Terry

lynneterry@gmail.com|cell: 503-349--2765|@lynnepdx



Lynne Palombo contributed to this report.