Unprotected: Abuse, neglect in senior care homes raise questions about conditions, oversight during pandemic

In some of the worst cases, vulnerable residents were grievously harmed or died.

At the PruittHealth-Shepherd Hills nursing home in LaFayette, an aide changing a resident’s brief in October allegedly forced her to perform oral sex. “Oh that feels good, but we are going to need to practice,” the aide told the resident, according to a state report, adding, “You are not going to tell anyone, are you?”

Within days, the terrified resident reported the attack to another staff member. But the staff was busy dealing with COVID-19. The man kept working at the home until the resident told a family member, who called local police, according to law enforcement and state reports.

At Manchester Court Assisted Living and Memory Care in Conyers, no one noticed during an overnight shift in August when a resident walked into the hallway holding a shower curtain rod, according to state records. In a state of confusion and fear, the person entered another resident’s room and used the rod to severely beat the resident. The 75-year-old victim died, and Conyers police charged the attacker, a 76-year-old woman, with murder.

At Sandy Springs Place, John Furman arrived in March with dementia, but otherwise in good condition, able to walk and feed himself and participate in activities. The facility went into lockdown due to COVID days after Furman moved in, but staff at the memory care facility told the family the 79-year-old was doing fine. Fifty days later, when the family finally saw him, they were shocked and confused by his condition. His body was covered in black and blue bruises and awful bedsores. He died the next day. A thorough police investigation led to the home’s administrator and top nurse being charged with felony elder neglect.

Sitting in the police station in May, hearing troubling details the police had uncovered, Furman’s widow, Elaine, tried to understand what her husband must have gone through in an upscale facility she had trusted. “Now I wished I had taken his hand and walked right back out of that door,” she told detectives, according to police records.

Training standards lowered

The quality of care in senior care homes is closely aligned with how many workers the facilities have, as well as the qualifications of the staff. Having a stable staff with low rates of turnover can help too, studies have found. But many Georgia facilities struggled to find hands-on workers long before anyone had even heard of COVID-19.

Then, the pandemic put an entirely new level of strain on staffing, as outbreaks could sideline dozens of workers at once. No-shows were common too, as COVID-19 took hold. Workers just didn’t want to risk being exposed to the coronavirus.

Nurses and aides had to cover one another’s shifts. The state of Georgia also stepped in and sent staff to some of the hardest-hit facilities. Somehow, many homes lovingly and competently cared for fragile seniors. But throughout the pandemic, almost every home in Georgia desperately needed more workers than it had.

The latest nursing home staffing figures, for the second quarter of 2020, found that Georgia ranked 43rd nationally for average hands-on care staffing at its nursing homes, according to a study by the Long Term Care Community Coalition. The state ranked even lower — 48th — for hands-on RN staffing, according to the report.

To help nursing homes find new workers, the state of Georgia authorized an emergency Temporary Nurse Aide program allowing homes to hire those without the usual training requirements. More than 4,800 nurse aides have been trained and employed in 277 nursing homes since the program was approved in March, according to the Department of Community Health.

That’s how Henrii Reynoso got a job at the PruittHealth-Shepherd Hills in LaFayette, a small town in the northwestern corner of the state. Reynoso was the temporary aide accused in the sexual assault case.

Credit: Photo provided by LaFayette Police

Credit: Photo provided by LaFayette Police

When the victim told another aide about the assault, the aide told a nurse what had happened. But “it was very chaotic” at the facility, the nurse later told an inspector. The home was in the midst of an outbreak that would leave about a third of its residents testing positive for COVID-19 in a single week, according to an AJC review of state records. The nurse told the aide to switch assignments with Reynoso so he wouldn’t care for the resident who reported him. The staff did not report the allegation to the victim’s family or police.

Several days after the assault, Reynoso “smiled and winked at her,” the resident reported. She later told inspectors she was afraid but couldn’t leave and said “it has been as if no one here cared what happened to her.”

After a family member called police and the investigation began, other residents came forward with allegations. Reynoso was charged with aggravated sodomy, and two PruittHealth employees were charged for failing to report the abuse. Reynoso fled the area and is still at large.

PruittHealth, one of Georgia’s largest nursing home chains, said it is “deeply affected and saddened by this occurrence” and called it unacceptable. The company said it is working with the victim and cooperating with authorities and state agencies.

Inspectors swooped in and cited the facility at the highest level. But it’s clear that a system that relies on care facilities to self-report violations can fail, especially during a pandemic.

“If it hadn’t been for a family member, we wouldn’t have known about it,“ said LaFayette Police Detective Heath Owens.

Inspections backlogged

State inspectors retreated from long-term care facilities when the pandemic hit, citing PPE shortages at a time when even hospitals couldn’t find masks or gowns.

For months, inspectors were doing checks by phone, focused only on infection-control and serious complaints alleging harm. Rarely did inspectors enter homes for inspections.

States weren’t told to resume normal inspections of nursing homes, meant to be a thorough check of safety and procedures, until mid-August. The state now has a backlog of inspections to complete. And it was already behind almost every other state in completing inspections on time, federal statistics show.

About 59% of the state’s nursing homes — 212 facilities — have not undergone a comprehensive inspection for at least 18 months.

The situation in assisted living and personal care homes may be worse. Georgia has far fewer inspectors, per facility, for those homes when compared to its team of surveyors dedicated to nursing homes.

Meanwhile, emergency orders bar advocates and family members from in-person visits.

Some cases came to light only because police became involved. At Manchester Court in Conyers, the police had to be called this summer when a bloody crime scene was discovered.

In the wee hours of Aug. 7, only two workers were on duty at the Manchester Court assisted living to care for 57 residents, many with dementia and incontinence, according to a state inspection report. That’s a staffing level that doesn’t meet the state’s requirements. A third worker ducked out during the shift, inspectors found. That’s when the attack happened.

According to inspection reports and police accounts, a 76-year-old, who was known to be confused and wander at night, apparently believed that someone was in the facility shooting a gun. In this state, she got the shower curtain rod and beat a frail, 75-year-old resident, who died later that day.

One staff member was in the memory care unit during the attack, while the other was in the kitchen preparing ice and juices for breakfast, the state later found. No one noticed the beating until a staff member checking residents found the victim bloodied in her bed. By the time police arrived, the attacker was seen talking to someone who was not there. She advised a nurse to leave the facility, saying “There’s shooting going on right now. Don’t you see they’re shooting?” according to a police report.

Conyers police charged the woman with murder, according to police records. Prosecutors will have to consider the woman’s competency and decide how to proceed.

The state conducted an investigation of the August incident during a survey process between Sept. 23 and Oct. 6. It found seven serious violations, including the home’s failure to have enough staff and provide appropriate care and watchful oversight.

Raj Shah, the owner of Manchester Court, said the state’s investigation was not an accurate depiction of the event. “This was not a result of any staffing issues, this was not a result of any training issues,” he said. “This was not a result of anything that was lacking in our community.”

He said there was nothing in the attacker’s history to suggest violence and described the incident as “tragic” and an “unfortunate event.” He also said it’s not reasonable to expect the overnight staff to be monitoring every part of the building at all times.

DCH officials said last week that they could not comment or release information on any proposed sanctions related to the incident because “there is a pending hearing.”

When asked if it was concerned about a possible uptick in abuse and neglect in addition to the threats of COVID-19, DCH said it is “always committed to the health and safety of residents in long term care facilities.” Asked what it’s doing in response, the department said it is prioritizing oversight of the homes and has conducted “over 3,000 surveys of these facilities since the onset of the pandemic” and issued “numerous” citations against homes.

‘Huge neglect case’

Some of the worst cases of neglect are just beginning to come to light as state inspection reports are slowly becoming public and as families learn of deplorable conditions inside homes they had trusted but couldn’t visit during the lockdown

Police started investigating Sandy Springs Place after John Furman died and his daughter sent them photos showing injuries he had suffered.

The facility is part of the Chicago-based Enlivant chain that operates under the re-assuring motto: “Where Senior Living Thrives.” The facility’s website says it offers “compassionate personal care,” with one of the complex’s two buildings dedicated completely to memory care. Pictures on the website show a game room, a movie theater, and a lobby that looks like a fancy hotel.

An ugly portrait of the home began to emerge, though, as police looked into Furman’s death.

Police interviews with people who worked at Sandy Springs Place revealed a dysfunctional care home where the supervisors covered up problems, kept families in the dark and failed to arrange the care residents needed.

One former worker told police that residents sat in soiled diapers until they overflowed with feces and would go two to three weeks without a bath. Residents developed sores on their bottoms because they weren’t kept clean, and they wouldn’t be checked on for hours, she said.

The former employee told police the home’s director, Jeffery Smith, avoided testing anyone for COVID-19, while its top nurse, an LPN named Katrina Perkins, usually stayed in her office.

In Furman’s case, the family had been told he was doing well, according to police records, and pictures sent to the family showed him smiling with a thumbs up, painting and happily eating ice cream with no visible injuries.

But the police investigation discovered that Furman suffered a bad fall in late April that his family and doctor weren’t told about. Later, they were called about another fall and told it was minor. But a nurse called in by the facility to care for Furman’s wounds sent the family the pictures showing his condition. The family immediately made plans to get him out of the facility. Furman died the day after he got home.

Caity Barsin, a victim advocate at the police department, was shocked by the photos showing giant, dark bruises across Furman’s face and forehead and covering his arms and hands. He had pressure sores on his heel and across his bottom.

Upon seeing the images, Barsin said, ”I realized that this was huge — this was a huge neglect case.”

Police exhumed the body and an autopsy found yet another sign of improper care that ended up being deadly. Furman was given a doughnut on his last day at the home, a risky move given his fragile condition. The medical examiner found a piece of soft, tan food lodged in his throat. The official cause of death: asphyxia due to choking.

Police concluded that Furman left the facility and arrived at his home under hospice care with the bolus of food in his throat. “Victim Furman died because he choked on the donut that he was given by Katrina Perkins,” the police account concludes.

Credit: Christina Matacotta

Credit: Christina Matacotta

Police charged Smith and Perkins with felony elder neglect in the case. Attorneys representing them did not respond to calls from the AJC seeking comment.

It isn’t clear what the Enlivant company was doing to make sure the facility was properly caring for residents. The company declined to be interviewed. Louis Kievet, a spokesman, emailed a statement saying the company cooperated with the investigations, terminated employees, hired a new management team and trained staff.

“We remain committed to our goal of providing quality care to all our residents and their families,” Kievet said.

State inspectors opened their own case after they heard what the police were learning. The state investigation led to the home being cited with 10 violations — three of them at the highest level, reserved for infractions that cause a death, serious harm or imminent threat of harm to a resident.

The state’s punishment? A fine of $1,803 — or $601 for each of the serious violations and a requirement that the home correct its deficiencies.

Sandy Springs Place paid the fine and remains open for business.

Data specialist Jennifer Peebles contributed to this report.