Nursing Home News

In addition to the prosecution of these individuals on criminal charges, the Attorney Generals office has filed a civil lawsuit against the corporations that control one of the nursing homes. The investigation against the other continues.

In a related action, the Attorney General released a comprehensive report that will help consumers better assess the relationship between patient care and staffing levels at nursing homes in communities across the state.

"The residents of our states nursing homes are among our most vulnerable citizens," Spitzer said. "My office is committed to doing all it can to protect these individuals, who are sometimes without friends and family to protect their interests. With these cases we are trying to send a message that law enforcement is watching to ensure that appropriate standards of care are met."

The first case involves the Jennifer Matthew Nursing Home in Rochester. Critical evidence in this case was developed through the use of secretly-recorded videotapes of a bedridden patient, referred to in the court filings as "Patient A."

Patient As family permitted the Attorney Generals Medicaid Fraud Control Unit to install a hidden camera to monitor interaction with nursing home staff.

The complaint describes what the camera recorded -- clear evidence that Jennifer Matthews staff had neglected Patient A. The complaint also describes how Patient A and other residents were not turned and repositioned to avoid the risk of pressure sores and were often left for hours to lie in their own urine and feces, and that medications and treatment were not provided as prescribed.

The court papers also describe how a minimal level of attention from management would have detected these problems.

The facility was sufficiently small that walking into every patient room in the home would have taken a few minutes, and a supervisor would readily be able to determine that residents were not receiving appropriate attention.

Instead, the court filing describes how the staff would move call bells away from patients and stop doing their rounds so that they could socialize, watch movies, sleep, or even leave the building.

Staff members are also accused of falsely claiming in required paperwork that proper care had been provided to the patients.

To date, eight former licensed or certified Jennifer Matthew professionals have pleaded guilty in connection with the neglect and record falsification. An additional former employee was arrested on December 6, 2005, and five more were arrested on criminal complaints yesterday.

Among those charged civilly was the primary owner and operator of the facility, Anthony Salerno, and a consulting company he owns known as Healthcare Associates (HCA).

The second matter involves the Northwoods Nursing Home in Cortland. As with the Rochester nursing home, the family of a resident consented to the installation of a hidden video camera.

According to criminal complaints filed in the cases, the secret camera revealed that licensed professionals at Northwoods repeatedly failed to provide care or treatment to that resident, and then falsified his care records to report that proper care had been administered.

Five employees have been charged with Falsifying Business Records in the First Degree, a class "E" felony, and misdemeanor neglect and endangerment in the Northwoods matter.

These and other patient neglect cases were the catalyst for a report prepared by the Attorney Generals office that details staffing levels at nursing homes throughout the state.

In releasing the data, the Attorney General cautioned that consumers should use staffing levels as just one of many indicators in choosing a home.

The report urges consumers to visit homes, actively monitor the level of care being delivered to their loved ones, talk to others with family members or friends in the home, and consult with knowledgeable professionals.

Getting into a quality substitute for home is just the beginning. Once Mom or Dad checks in, you'll assume a new role: elder advocate. Many older people aren't terribly assertive about getting their due, whether it's dietary changes, extra therapy or a seat on that field trip bus. And when it's a matter of both health and happiness, someone needs to be pushing for the full package.

Of course, residential facilities are often understaffed and residents can be needy. As a consumer, you've got federal (and sometimes state) law on your side to insist that Mom or Dad get the quality of care they deserve. The Code of Federal Regulations (CFR) and your state law contain many protections.

Here are a few eye-openers from the Code of Federal Regulations:

• Care Plan Each nursing home resident is entitled to a personalized "care plan," based on their needs. Such a plan must offer services that allow a person to maintain her highest practicable physical, mental and psychosocial wellbeing. This means that, for example, if Dad wants to sleep until 10:00 am instead of rising at the official 6:00 am call, he is allowed to do so. On a practical note, some families hire a part-time aide or appear themselves to ensure that a request is honored.

• Visiting Hours "Family members can only visit during visiting hours." Not so! 42 CFR 483.10(j) allows immediate family the right to visit at any time. And it may be to your advantage to visit during off-hours, to see what things are like when visitors aren't expected.

• Who Decides "The care-taking staff determines the level of care Mom or Dad will receive." Not so! In reality, the mandatory care plan drives the level of care and type of services a resident should get. Federal law requires that a facility do a full assessment of a resident's condition within 14 days of admission, and at least every 12 months after that. A care plan should include measurable objectives and timetables.

• Making Progress You may hear that if Mom or Dad isn't making progress, the home need not offer therapy. Assuming that the resident needs "skilled nursing services" or "skilled rehabilitation services," a facility is charged with trying to maintain his condition. Any facility needs to make sure that a person's ability to carry out activities of daily living doesn't deteriorate. The only exception: if the person's clinical condition makes deterioration unavoidable.

• Feeding Tubes They can be used only if absolutely necessary, not if a resident eats slowly or needs extra help cutting or eating food. The facility must provide whatever help a resident needs to eat normally.

• Wandering Relatives In the bad old days, staff sometimes tied residents into chairs or administered calming drugs to prevent wandering, especially among Alzheimer's patients. Now, nursing homes cannot use convenience or discipline as an excuse for restraining residents. The only legitimate purpose for restraint is to treat a person's medical symptoms.

• One Doctor Fits All "Mom must use the physician assigned to the facility." Not so! In reality, the "free choice" legal requirements include the right to choose one's own personal attending physician.

Financial Matters

• Guarantor "You must sign admission forms as a guarantor or responsible party." Not so! There is no such requirement. 42 CFR 483.12(d) prohibits a facility from forcing a third party to be a guarantor for the tab. You are only obliged to apply Mom or Dad's funds to the bill, not your own.

• Custodial Care "Since your relative needs custodial care only, Medicare won't reimburse the home." Not so! In reality, Medicare can pay for up to 100 days, provided a resident either is a) hospitalized for at least 3 nights, or b) needs skilled nursing or skilled rehabilitation. (As of this year, days 21-100 have a daily co-payment of $114.) Even if the facility nixes the need for skilled nursing care, a resident can appeal.

• Non-Medicare Beds "Once Dad is no longer eligible for Medicare reimbursement, we can transfer him to a non-Medicare-certified bed." No! A "Medicare certified" bed can be used for patients paying privately or through Medicaid, and a resident asked to move against his will can refuse.

• Fixed Fees "Extra charges are set by the facility, and are not negotiable. You have to pay extra for services like bath soap, denture cleaner or hospital gowns." Wrong! A facility's admission agreement should include covered and exempt or "private pay" charges, which are laid out in federal law. See 42 CFR 483.10 ("Resident rights") for details.

• Bed Holds Say your parent/relative leaves the nursing home for a hospital stay and the facility claims that his "bed hold" has expired when you try to have him readmitted. Although Medicaid and Medicare won't pay for "bed holds" in many states, private payment is allowed. And even if a "bed hold" expires, a facility must readmit a resident eligible for Medicaid reimbursement from the hospital if that facility has an available bed.

These are just a few of the misconceptions about nursing home and assisted living facility obligations.

Savvy consumers are aware that about 80% of nursing home residents enter from a hospital and hospitals are legally required to provide a discharge plan to any patient needing or requesting one. Your physician can also request one. Often, a well-thought-out discharge plan will set the stage for more focused, organized nursing home care.

More Info

For more information, see:

• www.medicare.gov/NHCompare, which compares nursing homes within a given geographical area;

• AARP's checklist on what to look for in a nursing home, available at www.aarp.org/bulletin/longterm.

• The Legal Information Institute at Cornell University Law School, an excellent resource for federal and local law. See www.law.cornell.edu.

The author is an attorney in Fairfax County, Virginia

Attorney General Lisa Madigan said the indictments charge Forest Park, L.L.C., and Care Centers, Inc., doing business as The Pavillion of Forest Park nursing home, and Jason Garti, M.D., former medical director and wound care doctor at Pavillion, with multiple charges of Gross Neglect of a Long Term Care Facility Resident.

Forest Park, L.L.C., and Care Centers, Inc., were indicted as the licensee and owner of Pavillion, respectively.

The charges are the result of an investigation by the Illinois State Police Medicaid Fraud Control Unit. The investigation began after emergency room personnel at Loyola Medical Center contacted the Department of Public Health.

According to the indictments, on September 11, 2002, a resident at Pavillion was transported by ambulance to the emergency room at Loyola Hospital, where it was discovered the patient had a large area of decubitus ulcers commonly known as bedsores.

The indictments charge Garti with two counts of Gross Neglect of a Long Term Care Facility Resident, a Class 4 felony, punishable by one to three years in the Illinois Department of Corrections (IDOC).

The two entities, Forest Park L.L.C., and Care Centers, Inc., were each charged with multiple counts of Gross Neglect of a Long Term Care Facility Resident. If convicted, the charges may result in the closure of the nursing home.

Rodney Kenney, 72, died at a Chicago hospital where he was treated for burns. Inspectors say the Alzheimers patient was severely burned May 26 when his clothing caught fire as he sat in a wheel chair. Authorities say they found a cigarette lighter near Kenney, but that he was not a smoker. In fact, state law prohibits smoking in nursing homes and patients are not allowed to possess smoking materials.

In their report, inspectors concluded that the staff at Regency Place failed to properly supervise Kenney. In addition, they said they found numerous other problems:

• A nursing home staff member designated as a medication aide mixed up two residents medications one day, leaving one woman sick and dizzy for two days;
• Regency Place didnt adequately screen two new employees;
• the nursing home wasnt adequately staffed.

In fact, the report said that when inspectors arrived the morning of May 28, they were told there was no one in charge. Inspectors also said residents asking for help from staff members were ignored.

A state health department spokeswoman said Regency Place faces possible denial of Medicare and Medicaid payment for new admissions after Aug. 19, along with a fine.

A spokesman for the nursing home said the company has filed a plan of correction with the state is confident we will resolve these matters to the states satisfaction in the near future.

Department officials say an on-site monitoring visit determined that an emergency existed requiring immediate action to protect the health, safety and welfare of the residents of the home based on widespread infestation of rodents and insects.

Inspectors say they found rodent droppings, urine-soaked kitchen plates and insects crawling all over residents' clothing and bedding.

Noble Residential Care Home housed 34 residents. A separate, unlicensed building housed eight additional residents. An interagency relocation team from the OSDH, Department of Human Services, and the Department of Mental Health and Substance Abuse Services coordinated the relocation of the residents, working with the residents, their families and guardians to find new homes and make the transition as smooth as possible.

James Joslin, assistant chief of Long Term Care Services at the OSDH, reported all residents were out of the building within 24 hours.

"It is a credit to the assisting agencies as well as the receiving facilities that we were able to get these people moved so quickly. We regret the sudden disruption to the residents' lives but the living conditions in this facility fell well below the standards we expect of a licensed residential care home," Joslin stated.

The facility has ten days to request a hearing on the decision to relocate the residents.

"We take our responsibility to protect the residents of these facilities very seriously and we will continue our inspections to ensure the residents are receiving quality care and the operators are meeting state regulations. The residents continue to be our primary concern," said State Health Commissioner Dr. Michael Crutcher.

The action included notice to the facility of the Department's plans to file a petition to not renew the facility's license.

According to an investigation by the Detroit News, many of the deaths occur because residents either don't eat enough food or drink enough liquids.

Nationwide, malnutrition and dehydration killed at least 13,890 nursing home residents between 1999 and 2002, the most recent year for which numbers are available, federal health records show. Those conditions contributed to the deaths of about 68,000 others.

While some of those deaths probably would not have been prevented even with the best of care, analysis of medical records and government inspection reports suggest many could have been, and it's leading to calls for Congressional action. Sen. Ron Wyden, D-OR, a long-term care advocate who sits on the Senate committee on aging, says there's no reason any nursing home resident should die because of diet.

"America is at ground zero in its fight against [nursing home] malnutrition," he said. "Today, we begin an effort that can improve the health and lives of hundreds of thousands of older Americans."

Wyden said it was "morally repugnant" that nursing home residents are malnourished, particularly in a country with abundant wealth and resources.

Nursing home Industry executives maintain that malnutrition and dehydration - and the deaths they cause - are almost always natural progressions of the chronic diseases that put patients in nursing homes in the first place.

"This is an active stage of dying and not necessarily something people should be alarmed with," said Reginald Carter, president and chief executive of the Health Care Association of Michigan, which represents more than 400 long-term care facilities.

But a study by the Commonwealth Fund suggests there's more to it than that. The study says at least a third of the 1.6 million nursing home residents in the United States may suffer from malnutrition or dehydration, conditions that can aggravate or cause more severe medical problems and hasten death. That suggests a more systemic problem. More importantly, the study says the problem can be corrected.

"Much of this problem could be alleviated by increasing the number of overall staff and trained professional nurses at nursing homes so they can make sure residents are getting enough to eat and drink," said Sarah Greene Burger, executive director of the National Citizens' Coalition for Nursing Home Reform and lead author of the study.

Chronic conditions such as depression and cognitive impairment, and the side effects of treatments for these conditions, are also a major factor. Residents suffering from depression, for example, are more likely to experience weight loss, the study says. Another obstacle to good nutrition is that nursing home residents commonly have a limited choice in what they eat, with their cultural and ethnic food preferences frequently ignored. Poor dental health also contributes to inadequate nutritional intake.

"Malnutrition, dehydration, and weight loss in nursing homes constitute one of the largest silent epidemics in this country," said Karen Davis, president of The Commonwealth Fund. "As this report suggests, we can address this problem by promoting changes in public policy, seeking creative solutions from providers and professionals, undertaking further research on key issues, and enforcing existing standards."

Inflation may be under control, but nursing home costs continue to skyrocket. A major insurance company says the average daily cost of a private room in a nursing home in the United States is $70,080 per year, or $192 per day.

The highest rates were reported in the state of Alaska where the cost is $204,765 per year or $561 per day on average. The lowest rates were found in Shreveport, Louisiana at $36,135 per year or $99 per day.

The average length of stay in a nursing home for current residents is 2.4 years, which makes the average cost of a nursing home stay approximately $168,192. The data is contained in the 2004 MetLife Market Survey of Nursing Home and Home Care Costs.

The study also found that the cost of a home health care aide averaged $18 per hour nationally. Home health care is most expensive in Hartford, Connecticut at $28 per hour and least expensive in Shreveport, Louisiana and Jackson, Mississippi where rates are $13 per hour on average.

According to the 2003 MetLife Market Survey of Nursing Home and Home Care Costs the average daily rate for a private room in a nursing home was $181 per day or $66,065 annually. The hourly rate in 2003 for a home health aide was $18.

"The cost of long-term care continues to rise," said Sandra Timmermann, Ed.D., director of the MetLife Mature Market Institute. "Whether one chooses care at home or care in a nursing home, the costs can be exorbitant. As people prepare for their retirement and assess their asset and income requirements, it is also essential that they plan for the possibility that they will need assistance with day-to-day living. Unanticipated long-term care costs can derail an individual's financial plan; long-term care insurance may be a solution," said Timmermann.

People are living longer, but long life may not be accompanied by good health. In 1940, a 65-year-old woman could expect to live an additional 14.7 years; by 2000 a 65-year-old woman could expect to live another 19.5 years, and by 2040 women are expected to live an additional 22 years.

Chances increase that as people age they will develop a chronic condition or physical or cognitive disability for which they will require assistance. For example, almost 38% of people aged 65 and over are diagnosed with a severe disability, and 47% of those aged 85 and older have Alzheimer's Disease or another form of dementia.

Approximately 1.6 million people reside in 18,000 nursing homes in the United States with just under 10% of the residents people aged less than 65 years old and 46.5% aged 85 years and over, according to the National Center for Health Statistics. Most residents (72%) are women and three-quarters require assistance with three or more activities of daily living.

More than 1.3 million patients received home health care services from 7,200 agencies in 2000, with more than half receiving help with at least one activity of daily living. Seven in ten patients were ages 65 and older, and 65% were women, according to the National Center for Health Statistics.

The list, published annually by the independent non-profit organization, uses state records and public complaints to compile a list of homes in states across the U.S. at which consumers should be particularly vigilant.

To compile the Consumer Reports list, researchers looked at five criteria: high-severity deficiencies; substandard quality of care deficiencies; high numbers of repeat deficiencies; high numbers of total deficiencies; and citations for failing to provide access to the survey results.

In a report on the Ensign Group released in August, California-based Nursing Home Watch also exposed resident care problems at several of the company's facilities. The report, "Condition Critical: How Care for Seniors Suffers in California's Ensign Group Nursing Homes," outlined alarming patient care concerns including gangrenous bed sores, repeated falls, unexpected weight loss, medication errors and other problems that threaten seniors at these nursing homes.

Facilities currently operated by Ensign named in Consumer Reports' 2004 Nursing Home Watch List include:

California

• Arroyo Vista Nursing Center*, San Diego
• Brookside Healthcare Center, Redlands
• Cloverdale Healthcare Center, Cloverdale
• Park View Gardens at Montgomery, Santa Rosa
• Sonoma Healthcare Center, Sonoma
• Victoria Care Center, Ventura
• Vista Knoll Specialized Care, Vista

• Northern Oaks Living & Rehab, Abilene, TX

• Sabino Canyon Nursing & Rehab, Tucson, AZ

Hospitals rely on skilled nursing facilities to provide rehabilitation for patients, and regularly refer patients to nursing homes. For information on local hospitals that refer patients to Ensign homes on this watch list, see www.EnsignWatch.com.

Consumer Reports' Nursing Home Watch List can be found on their Web site: www.consumerreports.org.

Nursing Home Watch is a coalition of senior advocates, nursing home staff, nursing home residents and family members, the Service Employees International Union and community supporters who have united to improve the safety and quality of care in California's nursing homes.

Under the terms of the settlement, Advocat will spend $600,000 to install sprinkler systems in Arkansas nursing homes. In addition, Advocat will pay $400,000 into the Arkansas Medicaid Program Trust Fund over the next two years. The settlement also includes $300,000 that Advocat is spending on improving staff training and patient care in its Arkansas facilities.

Beebe filed lawsuits earlier this year alleging mistreatment and neglect of patients at Advocat nursing homes in Conway, Hot Springs (2 facilities), Malvern, Sheridan and Eureka Springs. Additional investigations were also conducted regarding practices at nursing homes in Camden, Newport, Pocahontas, Des Arc, Mena, Walnut Ridge and Ash Flat.

The resulting allegations included failure to provide necessary care, rehabilitation, treatment, supervision and medical services. The state also alleged that nursing-home staff members failed to carry out prescribed treatment plans and failed to report health problems or to report them in a timely fashion. No individual staff members were named in the lawsuits.

"These lawsuits were not meant to financially damage Advocat; they were meant to improve the nursing-home care they provide to Arkansas residents," Beebe said. "The last thing we need is fewer nursing homes operating in our state. What we do need is to ensure quality care from the centers we already have."

In addition to allegations of mistreatment and neglect, the state lawsuits also alleged that some facilities submitted fraudulent billings to the Arkansas Medicaid Program for care that was either inadequate or never provided. Advocat does not admit or acknowledge any violations in their Arkansas nursing-home facilities.

The low staffing levels contributed to more than two-thirds of the staff in California's nursing homes leaving their jobs in 2002. Low staffing and high turnover rates were important contributing factors to poor quality care and a 38 percent increase in complaints between 2000 and 2002.

The CHCF report found that the most common clinical measures of poor quality -- weight loss, time spent in bed, and use of physical restraints -- continued to be serious problems in 2002.

"Low staffing led to 78 percent of nursing homes not complying with federal care and safety regulations during mandatory inspections," said the report's author, Charlene Harrington, Ph.D., School of Nursing, University of California, San Francisco. "An additional 11 percent of the nursing facilities were cited for very serious quality of care problems."

State monitoring by the Department of Health Services resulted in 43 percent of nursing homes receiving deficiencies (warnings for minor problems) and 26 percent receiving citations, which include fines and are indications of more serious violations.

Other findings in the report include:

• The number of facilities with inadequate staffing (according to state requirements) decreased from 46 to 37 percent between 2001 and 2002;
• 93 percent of nursing homes did not meet staffing ratio guidelines of 4.1 hours per resident, per day, recommended in a report to the Centers for Medicare and Medicaid Services; Annual nursing staff turnover rates ranged from 5 to 304 percent. The majority are nursing assistants who earn an average of $10.35 per hour;
• In 2002, 10 percent of nursing home residents experienced substantial weight loss; 9 percent were in bed all or most of the time, and 17 percent were placed in physical restraints;
• Nearly half of the state's nursing homes reported either no profit or a net loss in 2002, and 160 were in bankruptcy between 1999 and 2002;
•Among freestanding nursing homes that receive Medi-Cal reimbursement, the proportion of those that broke even or lost money grew by an average of 26 percent.

Non-profit nursing homes, representing just 18 percent of the state's total, faired better than for-profit facilities, which had:

• An average of 3.3 nursing hours per resident per day compared with 4.1 for nonprofits;
• Staff turnover rates of 70 percent, compared to 49 percent for nonprofits;
• 37 percent more violations than nonprofits.

The report found that in spite of an aging population (the number of residents aged 85 and over is expected to double by 2030) there is ample capacity in the state's 1,400 nursing homes. Occupancy has declined from 85.9 percent in 1991 to 80.9 percent in 2001.

"Nursing homes must do a better job of caring for the 110,000 Californians currently in their facilities, not to mention preparing for a rising tide of elderly citizens who deserve more," said Mark Smith, M.D., CHCF president and CEO.

"Nursing homes face difficult challenges -- low-paid staff, high turnover rates, low margins, and declining reimbursement from government agencies-but seniors deserve quality care and their families must have confidence that loved ones are in a safe environment."

Detailed information on every nursing home in the state-including quality ratings, staffing levels, and results of complaint and inspection visits-can be found at www.calnhs.org. The data is current as of May 2004.

David Arnold, of Athens, Pennsylvania, and his corporation, Heritage Nursing Home, Inc., were convicted after a two-week bench trial this past January of one count of Grand Larceny in the First Degree and three counts of Grand Larceny in the Second Degree.

Appearing before Acting Albany County Court Judge Stephen Sirkin, Arnold was sentenced to 4 to 12 years in prison on the charge of Grand Larceny in the First Degree and concurrent terms of three to nine years on each count of Grand Larceny in the Second Degree. He was also ordered to make $1 million in restitution to the Medicaid program.

Heritage Nursing Home, Inc., was sentenced to an unconditional discharge and fined $10,000.

We have a special responsibility to protect our more defenseless citizens from the greed of unscrupulous nursing home owners who callously fail to deliver needed health services, said New York Attorney General Eliot Spitzer. The sentence imposed today sends a clear message: nursing home owners who abandon and neglect their patients for personal gain will go to jail.

An overwhelming majority of the Heritage residents are New York patients. The evidence at trial established that, from 1991 through 2000, Arnold and Heritage Nursing Home failed to deliver needed services to hundreds of New York Medicaid recipients who resided in the home. These services included basic dental treatment and occupational and speech therapies for which Arnold and the Home billed the New York State Medicaid program millions of dollars.

Evidence introduced at trial established that patients were jeopardized by Arnolds conduct. The evidence showed that:

• hundreds of patients never saw a dentist during their time at Heritage, even though New York paid Heritage to deliver routine dental care to patients.
• patients with swallowing problems were fed with a turkey-baster-like syringe because it was quicker than feeding them with a spoon.
• numerous patients with swallowing problems that went untreated developed serious conditions, including aspiration pneumonia, which may have been preventable had Heritage delivered the speech therapy that New York paid the Home to deliver.
• other patients developed contractures, a stiffening of joints and muscles that is properly addressed with occupational therapy. These contractures became so severe that residents lost the ability to feed and dress themselves because they could not move their hands.
• between 1991 and 1997, no speech or occupational therapists were on staff at Heritage or on contract. Between 1991 and 2000, there was no dentist providing any routine examinations or care at the Home.

The case is part of the Attorney Generals statewide Nursing Home Initiative, which continues to examine the responsibility of nursing home owners and executives for conditions leading to poor patient care and abuse. The Initiative includes the investigation of out-of-state nursing homes that provide care to New York residents.

"Operation Guardians is helping ensure that the 250,000 elderly and dependent adults who reside in the state's 1,400 skilled nursing homes are receiving the care they deserve," Lockyer said. "This program is succeeding in preventing loss, injury and death by identifying health and fire hazards, theft of patients' trust account funds and failures to provide adequate medical services to these vulnerable citizens before they can escalate into life-threatening problems."

Established in April 2000 by Lockyer as a pre-emptive, pro-active program, Operation Guardians uses multi-agency teams to conduct unannounced inspections of facilities and identify problems that threaten the dignity, safety, welfare and quality-of-life of the residents. Operation Guardians operates and inspected facilities in 16 counties: Alameda, Contra Costa, Fresno, Humboldt, Los Angeles, Monterey, Napa, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Santa Barbara, Santa Clara, Sonoma and Ventura. Additional inspections were conducted at the request of three counties: Marin, San Mateo and Yolo.

"Elder abuse and neglect are very serious problems in California's nursing homes," said Patricia McGinness, executive director of the California Advocates for Nursing Home Reform, California's largest nursing home watchdog group. "Attorney General Lockyer's Operation Guardians program provides the scrutiny needed to protect the residents of the state's nursing homes."

"When we entrust the care of a loved one to a nursing home, we expect them to receive the best possible care in a clean, safe and caring environment," said Tom Porter, state director of AARP, the nation's largest elder advocacy organization. "Operation Guardians creates a strong incentive for nursing homes to maintain the quality of their staff and facilities and ensure patients receive the best care possible."

Lockyer said most of the nursing homes inspected during the past two years quickly responded by making improvements in the facilities and the medical and health care provided. The most prevalent problems identified were failure to meet the state's minimum staffing requirements of 3.2 nursing care hours per day, ensure that nurse assistants possess valid certification, document tuberculosis tests of employees and prevent and document the loss of residents' property.

The inspections showed performance levels ranged from near compliance with federal and state standards of care to situations which required referrals to law enforcement, regulatory or licensing agencies. The inspections resulted in two felony convictions. In one, a licensed vocational nurse was convicted of stealing narcotic pain medication intended for residents in an Oxnard facility. In another, an administrator-in-training at a Napa facility was sentenced to three years in state prison for stealing $49,000 from facility residents and their families, and using threats and intimidation to discourage them from reporting the theft.

"Although the goal of Operation Guardians is to prevent injury by identifying even the smallest of problems that, if left unchecked, could grow into dangerous situations for residents," Lockyer said, "we also are there to root out criminal activities that then can be prosecuted."

Of the 38 facilities statewide that underwent follow-up inspections, more than half either had corrected or were in the process of correcting the problems identified. All of the 328 fire safety-related violations discovered were corrected or in the process of being corrected. Three physicians were referred to the California Medical Board for investigation; two were sanctioned and one is still under investigation. At least 34 facilities have received Department of Health Services-issued deficiencies substantiating Operation Guardians' findings, and in several cases in which the loss or theft of residents' property was identified, the residents have received compensation.

Deficiencies discovered during the Operation Guardians inspections were divided into five general categories:

1. Environmental Non-Compliance, ranging from foul odors emanating from urine and fecal matter, to loose handrails and improperly stored food items.
2. Resident Care Non-Compliance, ranging from failure to adequately document patient care, implement medical staff orders, safely store controlled substances and medical instruments, to over-medicating patients and failing to report alleged abuse to appropriate authorities.
3. Administrative Non-Compliance, which includes failure to maintain proper personnel files of medical staff, protect patients' personal items or document required tuberculosis (TB) tests.
4. Fire Safety Violations, which include inoperable fire extinguishers or fire alarms, obstructed fire exits, exposed wires and unsafe chemical storage.
5. Staffing Level Non-Compliance. Of the 116 facilities in which staffing levels could be inspected, 79, or 68%, failed to meet state laws requiring a minimum of 3.2 hours of nursing care per resident per day. Nursing care does not include services provided by housekeeping, maintenance, kitchen, clerical or non-clerical staff.

Headed by the Attorney General's Bureau of Medi-Cal Fraud and Elder Abuse (BMFEA), Operation Guardians includes local elder abuse ombudsmen, fire departments, prosecutors, police and the University of Southern California School of Medicine. The inspections complement regular inspections conducted no less than every 15 months by the Department of Health Services, which is responsible for licensing and regulating the state's skilled nursing facilities.

The program illustrates the Attorney General's commitment to combating elder abuse, both through prevention efforts and aggressive prosecution. Since Lockyer began his first term as Attorney General in 1999, the Attorney General's BMFEA has increased criminal prosecutions of elder abuse in the state's skilled nursing homes by 749 percent, and convictions by 574 percent.

Bill Thomas, M.D., is co-founder of the Eden Alternative, a replacement for the institutional nursing home. Thomas discussed the concept in an interview with the PBS televison special, And Thou Shalt Honor.

Dr. Bill Thomas: American society views its elders as left-over products, I'm sorry to say. Our elders primarily are seen as a burden in our society and not as a gift. And the work of caring for our elders is seen as a drag on our economy and not as a gift to us as a people. As a geriatrician it's very clear to me that once an older person moves past the jolly period of barefoot water skiing and telling fun stories to the grandkids, and needs some real care and maybe is struggling with some real disability, they are regarded as a burden in our society.

It's a great loss to all of us when we adopt the idea that elders are only worth what they can do and not what they can be.

What is the state of nursing home care in our country today?

I'll put the American nursing home on the critical list. It's not going to make it. In fact my work, my whole passion and my whole work is pulling the plug on the American nursing home. It's really an institution, not just from the 20th century but really from the 19th century. It's a relic. It's a left-over vestige of a factory, assembly-line approach to care that is just not going to meet the needs of elders in the 21st century. And in fact, I'll do everything that I can to see that, as we move forward, nursing homes cease to exist.

Why do you think nursing homes have to be unplugged?

In America there are almost 300 million horror stories that people can tell about nursing homes. Everyone's got a story to tell. And the reason there are all these stories to be told is because the nursing home is a relic. The nursing home is supposedly a place for care, but it really becomes a factory of service, where people are provided with services and the art, the gentle art of caring is set aside. And that's a real tragedy for millions of American families.

When you're looking at the American elderly population, the population that needs care, what percentage of those are now in nursing homes? And how should that change?

Right now in America there are about 1.7 million people living in a nursing home. And any adult American who reaches the age of 65 has a 50% chance of spending time, significant time, in a nursing home. That's a vast proportion of our society. Let me give you an example. The only other segment of our society that is more likely to be institutionalized are convicted criminals. We have about 2 million people living in prisons. So here we have a society that uses an institutional pattern for convicted and violent felons and our frail mothers and fathers. And that, that is, that is a losing proposition in the 21st century.

What has to be done? What does our society have to do to change that paradigm?

The first thing we've got to do is to get away from the idea that there is a long-term care industry. Just the words "long-term care industry" make me want to throw up. Long-term caring for our elders is not an industry. And making it an industry perverts the real value in this. So, first thing we got to do is move decisively away from care as a big business, as a business opportunity.

And I think we can do that by moving away from the idea that care for frail elders has to be localized in buildings we call nursing homes. I think what we're going to see going forward is care for elders being diffused through the community in different places, in different communities, in different ways.

Will the boomers change it?

Let me say this, the baby boomer generation is coming. And the irresistible force of the baby boomers is about to collide with the unmovable object of the nursing home. And there's going to be explosive change that comes from this collision. The boomers will not leave one stone upon another. They will completely wipe out the nursing home we remember from the 20th century.

What will be in its place? Well, best way I think of understanding this is, when the baby boomers were kids there were three flavors of ice cream, and that was it. And when they got done with ice cream, there's a thousand flavors of ice cream. Well, right now there's just a few flavors of long-term care for the elderly. When they get done, there will be a thousand flavors. And that's the way it should be.

How long is it going to take for this kind of thing to happen?

Well, you know what, a nice way of thinking about what's going to happen to long-term care ... look at child birth. Look at what the boomers did to child birth. When they came along, cigar-chomping obstetricians used to strap women down with leather restraints and pull the baby out. When the boomers got done with 'em, 15 years, 20 years, family birthing centers, jacuzzis, lactation consultants ... Poof! The whole thing was different. So I actually foresee a revolution that's going to be ramping up in the next 2, 3 years and then over the next 10 to 15 years will radically change the approach to elder care in America.

You say that you have co-founded this Eden Alternative thing. What is the Eden Alternative? Why do we even need to know about it?

Well, in the early 1990's I took a job, I'm a physician, I took a job working at a nursing home, and I took that job because I thought that it would be a break from my real work as a ER doctor. And I fell in love with the work. And I fell in love with the people. And I came to detest the environment in which that care was being provided.

The nursing home takes good, good, loving, caring people and plugs them into an institutional factory-like arrangement. And it's no good. So what I want is an alternative to the nursing home, an alternative to the institution. And the best alternative I can think of is a garden. I believe that every elder should have a chance to live in a garden. I believe that, when we make a place that's worthy of our elders, we make a place that enriches all of our lives, caregiver, family member and elder alike. So the answer the Eden Alternative provides is a reinterpretation of the environment elders live in, from an institution to a garden. That's why we call it the Eden Alternative.

What are the other components, what are the other criteria of the Eden Alternative?

Number one, the organization begins to treat the staff they way they want the staff to treat the elders. Very important. Long-term care has a bad history of treating its staff one way, not so nice, and expecting the staff to treat the elders a different way.

Number two, the organization brings decision making back to the elders and to the people around the elders, so that they have a voice in their, in their daily routine and their life. Crucial, crucial to re-injecting meaning into peoples' lives.

Third, they've taken real steps to make the place where people live rich in plants and animals and children. I want the people to be confused when they walk through the door. What kind of place is this? I mean, there's kids running around and playing and there's dogs and there's cats and there's birds, and there's gardens and plants and ... I want them to be confused. This can't be a nursing home. Right. It's an alternative to the nursing home.

And finally, there has to be a commitment to ongoing growth. We believe in the Eden Alternative that even the frailest, most demented, most feeble elder can grow. And that the young person who maybe has a difficult home life or is living on the edge of poverty, they can grow. That the organization commits itself to human growth. And those words, human growth, nursing home, they've never gone together before and with Eden Alternative they can.

We need to change the way we think about and care for our elders, because by not honoring our elders we damage ourselves. We damage the very fabric of our communities and our society and our families. We do damage to people of all ages when we fail to honor and care for the frailest and chronic, most chronically ill among us. It's a bad habit which leads to bad things in other parts of our society.

We need to be concrete about it. If we want to improve life for everybody in our society, one of the very best places to begin is changing how we think about, care for and honor our elders. That thread, if you trace it all the way back, is woven through the whole context of our, our social life, our families, our churches, our communities. If we can master the art of caring for our elders, we can make a better society for everybody to live in.