Georgia families in the dark about risks

Kim Ross, with her husband and daughter in June, views a regulatory report filed on incidents at Rosewood Assisted Living. She thinks her mother, Iris Carter, was abused at the Fort Oglethorpe facility, which reported that Carter fell. DCH cited the home for failing to provide protective care and watchful oversight for three residents, including Carter. (BOB ANDRES / BANDRES@AJC.COM)

Credit: Bob Andres

Credit: Bob Andres

Kim Ross, with her husband and daughter in June, views a regulatory report filed on incidents at Rosewood Assisted Living. She thinks her mother, Iris Carter, was abused at the Fort Oglethorpe facility, which reported that Carter fell. DCH cited the home for failing to provide protective care and watchful oversight for three residents, including Carter. (BOB ANDRES / BANDRES@AJC.COM)

Georgia’s regulators and public safety agencies know quite a lot about problems at the state’s private-pay senior care facilities.

Reports of abuse and unexpected deaths and injuries. Fire safety violations. Missing dementia patients. Thefts. Outbreaks of contagious disease. Dirty dining areas.

But even if you are looking for this information, you might not find it. Families facing the gut-wrenching process of placing a loved one in a personal care or assisted living home in Georgia are up against a tremendous disadvantage: a haphazard system of accountability that gives low priority to transparency and informing the public.

“We want people to be savvy consumers, and we want their money to last as long as possible, and we want them to have the best quality of life,” said Melanie McNeil, Georgia’s state long-term care ombudsman, whose office advocates for residents. “You can’t make a responsible choice if you do not have the information you need.”

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The Atlanta Journal-Constitution found that it’s not just caring families who are kept in the dark about serious incidents that would never be noted on a sales tour. The officials in charge of protecting vulnerable residents aren’t always getting critical information they need, either.

Time and again, senior care homes fail to report serious incidents as required. What’s more, state inspectors may never learn about abuse, exploitation and other crimes reported to police.

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These gaps mean few families can rest assured they know what goes on in the facility they’ve chosen.

“You always wonder about what is the true story behind this place,” said Dan Goerke, whose wife, Denise, has early-onset Alzheimer’s disease and has been cared for in two assisted living communities.

Dan Goerke, whose wife, Denise, has early-onset Alzheimer's disease, has been cared for in two assisted living communities. He says, "You always wonder about what is the true story behind this place."

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Families try to find information online but don’t find much beyond reviews, Goerke said. Some try talking to other families before selecting a home, a decision that requires a personal and financial commitment and involves enormous trust, he said.

“You still have that feeling in your stomach,” Goerke said. “Is she going to be safe? Is she going to be taken care of? Are they going to remember to feed her? Are they going to remember to get her to the bathroom regularly? It’s a worry, wondering situation.”

Delayed, missing reports

Georgia’s Department of Community Health (DCH) licenses and inspects the state’s assisted living communities and personal care homes. Its inspection reports can offer consumers crucial information about facilities where things have gone wrong and residents have been harmed. The state reports can also help consumers identify homes with few — if any — violations or complaints.

But these reports can be almost impossible for consumers to find online. Many are outdated or missing. When consumers do find inspection records, they’re often vague, confusing and use technical language.

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The AJC monitored the state’s website for months in 2018 and discovered no information provided at all for dozens of facilities, including Northlake Gardens, an assisted living home in Tucker.

When reports for Northlake Gardens were finally posted this year, they revealed that state inspectors had repeatedly cited the home for serious violations over several years. In one case, the state found the home in 2016 had neglected a resident who fell and complained of pain for several days before being taken to the ER. It turned out the resident had three broken ribs, the report noted. In 2017, state inspectors found residents' medication records were knowingly falsified.

In 2018, the home was cited for an incident of abuse based on a resident’s report of being thrown into bed by a caregiver, resulting in a knee injury.

Frank W. Berry, center, Commissioner of Georgia Department of Community Health (DCH), leaves after a board meeting in Atlanta on Aug. 8. The AJC asked to meet with Berry and others at DCH to discuss cases of abuse, neglect and deaths uncoverered by the newspaper’s investigation. Berry  would only answer questions in writing. Asked to comment on the deaths and injuries, Berry wrote that “The health and wellbeing of Georgians is always our top priority.” (Hyosub Shin /

Credit: Hyosub Shin

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Credit: Hyosub Shin

Northlake’s spokesman declined to comment.

Consumers can find more detailed information on nursing homes because the federal government provides star ratings to summarize their records for quality of care. But state governments, which oversee assisted living communities and personal care homes, do little to help consumers sort the good from the bad, said Charlene Harrington, professor emeritus at the University of California, San Francisco and a nationally recognized expert on long-term care quality.

“They are often reluctant to make that information readily available because they think it will be controversial and the industry will get upset and they will get complaints,” Harrington said.

To try to get consumers better access to inspection reports, The Atlanta Journal-Constitution is launching a new consumer website to provide detailed information compiled about Georgia’s assisted living facilities and large personal care homes. The new site includes warning flags to help consumers spot homes with troubled inspection histories.

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The AJC’s investigation found that 20% of homes had a history of violations that indicate significant shortcomings. Many other facilities had troubling, but more isolated incidents.

Timely information wasn’t available on many homes. DCH says it inspects facilities about every 16 months. When the AJC checked the agency’s website this spring, the latest reports for nearly 100 facilities dated to 2017.

The Department of Community Health’s leadership declined to be interviewed by the AJC. But written responses to the AJC’s questions indicated the agency’s process doesn’t allow for a quick way for consumers to get information. The agency blamed missing reports on a “glitch” last year and said it had no information on how long, on average, it takes for it to finish an inspection report and then make it public.

Melanie Simon said during a presentation in December 2018 that the state needs 28 more surveyors to be able to respond with the “quickness that is required for public safety.” In a written response to AJC questions, however, DCH didn’t say it needed more inspectors to keep closer watch on licensed homes. It said Simon’s comment related to unlicensed personal care homes.  (Hyosub Shin /


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Industry experts said six months to a year is the norm — a lag that even operators find frustrating.

DCH said the delays are sometimes necessary in order to provide facilities with “due process” to respond and contest findings on a report before the public finds out what an inspector discovered.

Georgia lags in transparency

The way Georgia handles complaints is another limit on the public’s ability to evaluate senior care facilities.

State regulators acknowledged they have no required timeline for investigating serious allegations at assisted living communities and personal care homes.

Even under the best of circumstances, complaints may be hard to prove because many residents have dementia and concrete evidence can be elusive. Delays in investigating can mean evidence may be gone by the time an inspector arrives.

Unless complaints are substantiated, Georgia doesn’t disclose information about the nature of the allegations. Some states, however, do more to keep residents and families informed.

California and Oklahoma are among states that tell consumers what was alleged in complaints, even if the complaints ultimately are not substantiated. Florida maintains years of inspections on its website and offers a level of detail that far surpasses what Georgia provides. Ohio surveys facility residents and their families and shares the results online. North Carolina uses inspection information to rate homes using a star system.

Knowing that a facility had a lot of complaints, and at least something about the allegations, could be revealing, McNeil, the ombudsman, said.

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“We need more accountability of facilities and more transparency so that residents and families know what is going on in facilities, even if [the state] doesn’t substantiate the complaints,” she said.

Another information gap: Homes frequently don’t report serious incidents to the state or police as required. About 30% of homes were caught failing to report after regulators later learned of incidents.

And then there are gaps caused when one government agency doesn’t share crucial information with another. Law enforcement agencies are not required to report incidents to facility regulators.

AJC found cases of abuse, exploitation and theft in police reports that weren’t reflected in DCH inspections.

For example, in June 2018 at Bentley Assisted Living at Northminster in Jefferson, police arrested three employees after a Snapchat video showed them laughing, making obscene gestures and screaming obscenities while in the room of a 76-year-old resident who was suffering a stroke and later died. One employee was smoking a vape pen in the video they titled "The End."

The facility did not respond to AJC requests for comment.

It’s unclear whether DCH has investigated the case. The agency’s website has no public report on the incident.

State Rep. Sharon Cooper, R-Marietta, said DCH should get reports from police and public health officials to ensure it knows of anything that may suggest systemic problems.

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The gaps are concerning to state Rep. Sharon Cooper, R-Marietta.

Cooper, who chairs the House Health and Human Services Committee, said DCH needs to get reports from police and public health officials to make sure the agency knows about everything from assaults to scabies outbreaks that might suggest systemic problems.

In a written statement to the AJC, the state health agency said it doesn’t view the lack of required reporting by police as a gap in the system.

“DCH disagrees with your conclusion that there is a gap in reporting,” the statement says. “Our focus is always on whether or not the facility has complied with state rules and regulations relating to the health care services being provided. Law enforcement has a public safety mission that takes precedence over regulatory matters.”

Advocates for residents say the agency has an obligation to provide more complete information.

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Most families searching for a facility are in a crisis and have little time to do research, said Mike Prieto, an attorney who represents families of people harmed in senior care homes. It’s impossible, he said, for families to search criminal records to vet a facility’s employees before selecting a home.

“It is imperative that the state agencies who are funded by our tax dollars and are charged with inspecting and posting of information about facilities do so accurately and timely,” Prieto said. “In essence, if DCH does not do its job, our elderly pay the price.”

Bleeding on the floor

Without easy access to reports, consumers often rely on information that may not give them the full picture.

Consumers checking out Rosewood Assisted Living might feel assured by a statement on the home's website: "State Survey 100% Deficiency Free."

While it’s true that the home had no violations during its most recent public inspection, it was cited in 2016 and 2017 for acts that were abusive and neglectful. State inspectors found the home failed to investigate what had gone wrong inside its own facility. Rosewood also didn’t report injuries and allegations of abuse as required.

Rosewood Assisted Living in Fort Oglethorpe had no violations in its most recent public inspection but was cited in 2016 and 2017 for acts that were abusive and neglectful. State inspectors found the home failed to investigate what had gone wrong inside its own facility. (BOB ANDRES / BANDRES@AJC.COM)

Credit: Bob Andres

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Credit: Bob Andres

In one case, an aide at Rosewood posted a video on social media showing a resident in Rosewood’s hallway wearing only an adult diaper. Although the facility was required to report the abuse immediately, it waited two weeks before notifying the family, police and the state.

In another case, a night aide at Rosewood discovered Iris Carter bleeding on the floor of her room in the memory care unit. The facility sent her to the ER.

“When I saw her, it was awful,” said Carter’s daughter Kim Ross, who went to the hospital. “Honestly, I almost passed out.”

Though the facility said the injuries were the result of a fall, Ross saw that her mother had deep bruising on her face and what appeared to be finger marks and bruises on her legs and pelvic area. A social worker at the hospital found the marks suspicious, records show. A doctor encouraged Fort Oglethorpe police to investigate, saying the bruises on her pelvic area weren’t consistent with a fall.

Iris Carter's family provided this photo of her taken after an incident at Rosewood Assisted Living facility in Fort Oglethorpe. Carter had Alzheimer's disease and wasn't able to say what had happened. (Family photo)

Credit: Family photo

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Credit: Family photo

Carter had Alzheimer’s disease and wasn’t able to tell anyone what had happened to her. Police investigated, but without a witness they couldn’t make a case. DCH cited the home for failing to provide protective care and watchful oversight for three residents, including Carter.

Carter died about seven months after she was injured.

Ross wishes she had known about the other problems at the facility.

“If you know somebody has been abused, that’s the last place on earth that you would put your loved one,” she said.

Experts say even the best facilities will have occasional incidents, including some where residents get hurt. But well-run homes report serious incidents to families, the state or the cops.

Randy Holcombe, the CEO of Regency Senior Living, which owns Rosewood and six other homes, said any past issues have been cleared up with the state. He said there’s no excuse for not meeting state rules, including failure to report incidents. He said Rosewood’s overall record is strong and families often express gratitude for the care the home provides.

“We do everything we can to ensure no one falls,” he said. “But we can’t have one-on-one care all day. In an assisted living setting it’s not realistic.”

Consumers hit dead ends

Patti Pennington tried to exercise due diligence before selecting an assisted living home for herself and her husband,who has dementia.

Web searches didn’t unearth any state inspection records. So she had little to go on beyond online reviews, marketing materials, sales tours and no-fee referral agencies that she later learned were being paid commissions by the facilities.

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The Penningtons left their first upscale facility disappointed. They moved into another that had been highly recommended by a referral agency.

“I had no way of knowing how bad it would be,” Pennington said.

The food was horrible, residents were verbally abused, there were thefts and staff didn’t come when residents pressed call buttons for help, she said.

So the couple moved again and are now in their third facility.

It turned out that the second home had been cited repeatedly by the state before they moved in, but neither the agency nor the sales staff revealed any problems.

Pennington has learned that a sales tour will never reveal the realities, and unflattering information about a facility can be difficult to obtain.

“They’re not going to give you that information,” she said.

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