While the incident would be distressing on its own, its timing adds a layer of alarm. The assault took place two months after the state sent Savannah Court of Lake Oconee a notice that it planned to revoke its license. And while such an action should imply serious safety concerns, the department’s efforts to move the process along and ensure residents are free from harm have lacked urgency. Even after the assault, a closure hearing set for Nov. 1 was postponed because the facility and the state were discussing a potential settlement agreement. A new court hearing is scheduled for today, Jan. 3.

The sequence of events underscores persistent shortcomings, and a seemingly unhurried approach, in the state’s oversight of assisted living and large personal care facilities. Court documents and inspection reports reviewed by The Atlanta-Journal Constitution show that, since 2021, Savannah Court of Lake Oconee has accrued over 70 state violations, including two incidents where residents died. In that same period, DCH entered into two settlement agreements with the facility. Those agreements softened penalties by breaking up fines into monthly payments.

These patterns, coupled with DCH’s recent consideration of a third settlement agreement, raise questions about the state’s commitment, as well as its ability, to follow through with its promise to hold its 1,686 assisted living and personal care facilities accountable. An alarming problem considering Georgia touts a robust enforcement system. In 2020 following an Atlanta Journal-Constitution investigative series documenting similar inadequacies and accountability issues, the state passed a reform package to increase its fines and requirements of senior care facilities.

DCH would not comment on the status of the settlement talks, citing the pending litigation with the facility. Savannah Court of Lake Oconee did not respond to questions sent by The AJC.

Their operator, Senior Living Management, a Florida-based organization with senior housing communities in Florida, Louisiana and Georgia, did not answer specific questions but provided a statement stressing that the industry is heavily regulated and inspections are common.

“The Community is committed to the safety and well-being of its residents. These core principles are and will remain the Community’s top priority and focus,” a spokesperson for Senior Living Management wrote.

Richard Mollot, executive director of the Long Term Care Community Coalition, a New York-based nonprofit, said the AJC’s findings are not surprising.

“It’s the Wild West,” he said about the sector, which lacks the federal oversight — and teeth — that nursing homes have, despite increasingly caring for the same populations.

While nursing homes have historically been branded as medical facilities, and assisted living facilities as social facilities with support services, over the years the lines between the two demographics have blurred, he said, adding that there is little incentive for operators, many of which are for-profit businesses, to recommend these at-risk residents to more regulated and appropriate facilities.

“If you have someone whose needs are greater, heaven help you,” said Mollot. “There’s just not that oversight. there’s not the monitoring.”

Cascading violations

When Gov. Brian Kemp signed House Bill 987 into law in June 2020, there was optimism about the accountability to come. Elder care advocates and families navigating the senior care system cheered what seemed to be a significant shift in the state’s approach to dealing with assisted living and large personal care homes.

Under the reform package, facilities would have to pass a test to be licensed. Memory care units would have to be certified. Nurses would be required in assisted living and memory care, and overall staffing and training requirements would increase. Finally, fines would increase. While previously fines maxed out at $601, under the bill the state would be required to fine facilities at least $5,000 for infractions that caused a resident to be seriously harmed or to die.

Rep. Sharon Cooper, R-Marietta, led the reform effort over three years ago as chair of the House Health and Human Services committee. She said her bill tried to address an urgent need in the state to improve senior care, but she finds the trajectory of events both heartbreaking and frustrating. She said she was concerned to hear about the AJC’s findings at Savannah Court and the state’s oversight of the home.

“You knock yourself out to try to get a good bill to improve the system so that our elderly can get the respectful, quality care they deserve, and then you find that the bureaucracy at some point slows things down,” she said. “And always, in the end, it’s the seniors that are at risk.”

In the 3½ years since the bill passed, Savannah Court of Lake Oconee has been inspected at least 16 times with 76 violations flagged, not including the most recent sexual assault. Violations range from smaller-scale infractions like a lack of nutritious snacks and failure to properly store cleaning supplies, to mid-size issues like a failure to properly staff nurses in the memory care unit and for failing to admit and retain only ambulatory residents, to finally serious and imminent threats.

A July 2022 inspection report, for example, documented two deaths in which DCH found the facility failed to adhere to state protocols.

In one incident, the state found that Savannah Court failed to provide CPR when it was clear that an individual was facing a cardiac or respiratory arrest. According to the report, a resident on April 17 of that year pressed their assistance pendant nine times at 3:20 p.m. and nine times at 6:46 p.m., and no one responded. When the individual was eventually checked on, after a family member called worried, the resident was found sitting by a fan complaining of being hot and not being able to breathe. The staffer left to call 911, and when another staff member entered the room, the individual was supine on the floor, not breathing. While waiting for the first responders, no one on staff attempted to resuscitate the individual, records show.

In a second incident, just 10 days later on April 27, a resident died of diabetes complications. The state noted in its report that the facility failed to “asses, monitor and seek treatment in a timely manner.” The resident pressed their assistance pendant nine times in the middle of the night, with no response from staff, despite the individual’s extremely elevated blood sugar levels coming up as a serious concern the day prior, according to the report. It wasn’t until 6 a.m. — when a staffer was doing a routine check and noticed the individual had vomited and it was an unusual color — that the resident’s blood sugar level was checked again and EMS was called. The resident had two cardiac arrests in the ambulance and died in the ER that morning, records show.

Reports also detailed a recurring issue of vulnerable residents being unsupervised and running away.

In February 2022, a resident with Alzheimer’s gained access to a staffer’s car when the employee had left it on and unattended, a state report shows. The resident, who had been trying to elope all morning, drove off and was found at a hospital 41 miles away. That December a resident with vascular dementia and Parkinson’s disease wandered out of the building in the early hours of the morning, a state report shows. The resident, who fell and broke their femur, was found on the ground, scantily dressed in near-freezing weather. The March 2023 inspection report noted that, while the resident was taken to the hospital, Savannah Court of Lake Oconee never reported the incident to the state, as is required by law.

A review of the state records reveals a cascading pattern: Inspectors find violations; DCH sends a notice of intent to fine to the operator; the operator then has 10 days to contest and request a hearing, which they always do; then as the parties wait for that hearing, a new inspection occurs, and new violations are found. The cycle begins again, with settlement agreements occasionally used when fines pile up.

On two occasions — July 2021 and March 2023 — DCH created such agreements. While fines were still imposed, the facility was allowed to pay in more manageable monthly installments, an action that cushioned the impact of a penalty.

The July 2021 settlement agreement, for example, was based on six violations in 2020 with fines totaling $2,402. Under the agreement, Savannah Court of Lake Oconee could pay in four monthly installments of $600.50. The March 2023 agreement bundled 26 violations that were cited in three reports from 2022, which included the two deaths and the resident who drove off in the car. Under the agreement, the facility agreed to pay $9,503 in fines. Roughly 25% was due within a week of signing. The rest could be paid in four monthly installments.

A stalled revocation

Despite the state’s overtures last spring, something changed by the summer. In August, one month after the last tranche of fines was due, the state sent Savannah Court a notice to revoke its permit.

The Aug. 17 letter explained the decision was based on inspections made in July and August. Seven violations had been found, including an episode where a resident went to the hospital with an open sore on their shin and was sent back to the home with a wound vac to treat the leg that was never plugged in, causing the wound to get worse.

While the incidents detailed in the two summer reports are troubling it is unclear what finally triggered the revocation notice after three years of similar, and repeated, offenses.

When asked, Fiona Roberts a spokesperson with DCH said the department couldn’t comment on pending litigation.

And despite the revocation notice suggesting serious and dangerous issues within the facility, a resolution has been drawn out.

A hearing was scheduled for Nov. 1, but on Oct. 24 — two weeks after the sexual assault — Savannah Court of Lake Oconee requested that the court push back the revocation hearing again because a possible new settlement agreement was in the works.

“Counsel for the parties have conferred several times regarding the possible resolution of this matter without the need for a hearing,” the facility’s motion explained, adding that “party resources and energies will be best utilized by continuing to focus on a possible settlement without the additional, concurrent burdens of preparing for a hearing.”

When asked what a facility needs to show for a settlement agreement to become an option, Roberts wrote the “decisions hinge primarily on the adequacy of the facility’s implementation of an acceptable plan of correction.”

Questioned if the state has done enough to hold Savannah Court of Lake Oconee accountable over the years, Roberts wrote back “Yes” in an email.

Fines

Savannah Court of Lake Oconee is not the only facility Senior Living Management operates that has run afoul of Georgia’s regulators. And the company has successfully used the state’s court appeal process to limit its penalties.

In 2020, DCH found that a staff member at Savannah Court of Milledgeville slapped a resident and another stole over $20,000 from a resident’s bank account over a three-month period. In a letter sent that September, DCH explained that a total of four serious violations were found which they deemed “Category I Violations.” Those are the most serious type of violation, which is defined as an infraction that causes death, serious physical or emotional harm, or poses a threat that could lead to such an outcome. The total fine was $2,404.

The administrative law judge who oversaw the hearing, however, decided none of the violations warranted that level of punishment. The total ultimate fine imposed was $301. While DCH appealed the court’s decision in 2021, they were unsuccessful.

“The ALJ determined that while the evidence showed serious threats, there was insufficient evidence that such threats were not also imminent,” a Superior Court judge wrote, adding that, while certain events or continued employment could be “upsetting,” it doesn’t mean physical or emotional health and safety of individuals “were imminent and seriously threatened.”

The case highlights the uphill battle still occurring around accountability in the sector.

Melanie McNeil, Georgia’s Long-Term Care Ombudsman, said the senior care industry is a powerful player at the state capitol. A fact that she says impedes Georgia’s ability to really go after bad actors in the sector, or raise penalties and requirements to the levels she sees as necessary.

“If you asked any of us representatives whether facilities are sanctioned as they should be, and whether facilities correct the problems as they should, most of the time they don’t,” said McNeil.

McNeil said she couldn’t answer why the state has participated in so many settlement agreements with Savannah Court of Lake Oconee, but points out the complexity of a closure: It’s not just the facility that gets punished. People must find new homes.

Back at Savannah Court of Lake Oconee, business appears to be continuing as usual.

On a brisk afternoon in December residents milled around the lobby watching television, and community volunteers stopped by to drop off poinsettia holiday gifts. There was little indication that the facility was facing potential trouble with the state.

In fact, on Dec. 18, the facility posted a job listing for a new Med Tech.

Credit: Miguel Martinez

Credit: Miguel Martinez

Residents had not been told about the sexual assault, which Greene County Sheriff’s Office is currently investigating. Nor were they officially informed about the possible closure, according to Suzy Smith, 76, who has been at Oconee for a year and a half living in one of the facility’s independent-living villas.

The former Marietta resident, with a penchant for sewing holiday pillows and painting landscapes, was unsure if the possible closure of the personal care facility would impact her and others in the facility’s independent living units. And it scared her.

While Smith likes to complain on Facebook about problems at the facility — calling out the dirty tables in the kitchen and the lack of enrichment opportunities — Savannah Court of Lake Oconee is also home.

It is affordable. She has friends. She has a community. The violations were disturbing but not her day-to-day. Why, she wanted to know, could she not stay in her home, but have it run better?

“I’m working around the stress. It’s there definitely,” she wrote in a text last week. “But I have a very strong faith. Without it, I would not exist.”

This story has has been updated to accurately reflect Suzy Smith’s age.