That may be why the director cut a break to Landon Terrel when he didn’t show up on time for his first day of training. It may explain why Terrel kept his job after one resident said she was afraid of him. Sunrise stuck by him even after a co-worker reported that he told her, stone-faced, “I’m going to kill you,” because he was frustrated that he couldn’t find her when he needed help with a resident.
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» MORE: The 'Unprotected' investigative series
“My gut feeling is that he really needs to be out of this building today,” the worker told a Sunrise manager, according to a sworn statement. “There’s something off.”
Another manager told the Sunrise facility’s director there were too many “red flags” around Terrel. “I really think we need to get rid of him, you know, before it’s too late,” she told the boss, according to testimony. But the director, who other managers said was failing to act on concerns, kept Terrel on staff.
While these problems and conflicts were playing out during night shifts and inside meeting rooms, they were not apparent to Christine Houk, who had just moved her dad into what she thought was a top-of-the-line assisted living facility.
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The Sunrise home was only a few minutes from her house in the Cobb County suburbs, so she’d be able to visit all the time. She wanted the absolute best for her dad, and Sunrise offered chef-prepared meals and a building designed to look like a Victorian-style mansion. But having a caring staff to help her father, around the clock, with whatever he needed was now what mattered most.
At 91, Adam Bennett, a World War II veteran and retired businessman, was no longer steady on his feet. Once a gregarious outdoorsman who loved family trips and sailing, he now needed help with almost every event of the day: getting up and dressed, going for meals, showering and getting to the bathroom.
Sunrise welcomed Bennett, saying he could move into the home’s “Reminiscence Neighborhood,” which catered to seniors with dementia. Bennett had some memory issues, but his biggest challenge was his failing body. Houk heard that this unit was set up to help with that, too.
“They said they had more staff, qualified staff and the memory unit was the place that offered more care,” Houk said.
With a plan that would cost $6,800 every month on top of a $1,250 move-in fee, Houk said Sunrise assured her that her father would get everything he needed.
“And I believed them,” Houk said.
On the night of Aug. 14, 2017, Landon Terrel reported to work for his overnight shift on the memory care unit. He was put in charge of Adam Bennett’s care. That night would change everything for Bennett and his entire family. It would change everything for Terrel, too.
Chandeliers and fireplaces
As the Greatest Generation reaches its twilight and 10,000 baby boomers turn 65 each day, many sons and daughters face the same dilemma that Houk did. A parent loses a spouse and is living alone. The stairs get to be too much. Cooking and shopping become difficult, and everyone but dad thinks it’s time to give up the car keys. Balance issues turn into dangerous falls. A simple shower becomes hazardous without help. Often, a parent can’t keep track of medications, or memory issues turn into full-blown dementia.
Luckily, for this generation and its boomer kids, there’s a solution that feels good: high-end, private-pay senior care homes.
These facilities often have spacious lobbies with giant fireplaces and impressive chandeliers. They offer restaurant-style menus served in dining rooms with tablecloths. They have field trips, bridge clubs and walking trails around landscaped campuses. The private suites feel like an apartment, not a nursing home or hospital ward. Families are told that caregivers will always be available to keep close watch.
Some are national assisted living chains like Sunrise, while others are locally owned with just one or two facilities. With owners watching demographic trends and hoping to capitalize on the needs of an aging America, scores of new senior care homes have popped up in recent years all over the state. In Georgia, these facilities are licensed as assisted living facilities or personal care homes, depending on the level of care provided. They are a solution that rests between senior living complexes for active retirees and skilled nursing homes that offer 24-hour medical care.
» CONSUMER GUIDE: Resources for finding and evaluating a senior care facility
» DEEPER FINDINGS: 20 deaths linked to violations at Georgia senior care homes
For those who can afford the country club prices, the facilities can seem like a godsend. Indeed, many are. They keep their promises and allow frail and forgetful seniors to age comfortably and safely in a homelike setting with their dignity intact.
But more often than most families would imagine, these homes fail not only when it comes to providing the lavish care that the homes promised. Over and over again, a significant share of these facilities failed to provide even the minimal level of care that state regulations require, resulting in injuries, discomfort, humiliation and even deaths, an Atlanta Journal-Constitution investigation has found.
Short staffing, lapses in training and constant turnover among both top managers and front-line staff led to the worst problems, the AJC found, with incidents playing out in dozens of facilities.
Two staff workers at a home in Savannah had to care for 28 residents during the day. They were so busy changing adult diapers and helping residents lie down for naps that they couldn’t properly monitor two residents on special diets. One resident, previously hospitalized for aspirating food, fell asleep while eating, head down on the table. The other resident tried to get help during lunch, but staff repeatedly walked by even though the resident was never supposed to be alone while eating.
At a home in Canton, a resident who was supposed to get a two-person assist fell and suffered two fractures when a worker tried to single-handedly move the resident to a wheelchair. The worker explained that with slim staffing, there just wasn’t time to read the plan for the resident’s care.
» ABOUT THIS PROJECT: AJC investigative team examines thousands of public records
» EDITOR KEVIN RILEY: What it took to investigate Ga’s senior care industry
In Dunwoody, a facility had just four workers to care for 98 residents during a 3 p.m. to 11 p.m. shift. When a resident fell while on the commode and suffered a head injury, one caregiver found the resident on the floor but couldn’t lift the person alone. The resident was on the floor for an hour before another resident called someone from outside to get the resident up and into a wheelchair.
Many families learn the hard way, the AJC found, that it doesn’t matter that the lobby is gorgeous and the food is five-star if nobody comes when a frail person presses the call button for help.
Scant training required
Sunrise at East Cobb’s website offers a confident message about what families should expect at its facility. “Like all Sunrise communities,” the site says, “it is the caliber of our caregivers that really sets us apart.” Sunrise says its “highly trained team” is available around the clock, and that personalized plans make sure that each resident’s “unique needs and preferences” are met.
When Houk moved her dad into Sunrise in June 2017, he was sleeping a lot and was incontinent. He’d fallen a couple of times, too. But Houk thought it was going OK at Sunrise. When she was visiting during the day, she said, workers would give her reports on her dad and pop in to take care of his needs. “They were respectful,” she said. “I liked the people I met. I thought they were doing a good job.”
Check the marketing materials of almost any senior care facility, and most will rave about their care staff. The common buzzwords: compassionate, dedicated, person-centered, highly skilled.
But in truth, no degrees or credentials are needed to get hired as a front-line caregiver.
Georgia just requires on-the-job training in a few areas, such as CPR, infection control and the special needs of residents with dementia. Even then, the AJC found that many facilities in Georgia do not comply. Over the past four years, more than 2 in 5 homes have been cited for failing to meet at least one part of the state’s minimal training requirements. Some have been cited multiple times.
In spite of the meager requirements, facilities often struggle to fill the jobs that typically pay front-line care staff $10 to $12 an hour.
For that, caregivers have jobs that can be impossibly demanding. Between 30% and 60% of residents in assisted living facilities have some level of cognitive impairment, and staffers are often tasked not just with bathing, dressing and changing adult diapers, but also doing laundry and housekeeping, said Catherine Hawes, Regents Professor Emeritus at the Texas A&M Health Science Center and a nationally recognized expert on long-term care.
Yet Georgia only requires homes to have a minimum of one care staffer for every 15 residents during the day, and one for every 25 residents at night. The state says facilities must exceed that if needed to meet their residents’ needs.
“One to 15 is just a cruel ratio. It’s cruel to the staff, and it’s cruel for the residents. They’re not going to come when you ring the call bell,” Hawes said.
The nighttime ratio is even riskier, she said.
“One to 25 is crazy,” Hawes said. “If you had a fire at night, people would die.”
State inspectors have cited nearly 20% of Georgia homes for failing to have enough qualified staff on duty.
It’s so hard to find qualified workers that some homes hire whomever they can get, even those whose employment history doesn’t appear to be ideal. Some homes have hired workers with felony criminal records, even though the state forbids it.
Landon Terrel’s employment record before he came to Sunrise was blemished, although Sunrise didn’t know how bad it was when he was hired. In March 2016, a home health company wrote him up for falling asleep twice on the job. He was fired from another job for sleeping at work. Another senior home fired Terrel after a resident’s son reported that Terrel had left his dad in a soiled adult diaper for five hours.
He’s not exactly the type of caregiver Sunrise bragged about on its website.
Frantic phone calls
Adam Bennett made it through the Great Depression as a child. Then he survived World War II, serving in the U.S. Army Air Forces. He went on to live the American Dream. He earned a business degree at Michigan State, got a good job and met Nancy, the woman with whom he would spend his life. They had a daughter, and then two sons, and they eventually settled in upstate New York, outside of Ithaca.
Their family life was classic Americana: The sons were active in Boy Scouts, so Bennett became Scoutmaster. They sailed as a family on local lakes on the weekends, and Bennett planned family vacations that revolved around camping. When he retired from his career as a purchasing agent, he and Nancy relished living in a community where they had lots of friends and a local college that offered plenty for active seniors to do. But things changed in 2008, when Nancy died. Bennett was on his own in a big house. His kids were spread out, in Georgia, Florida and Colorado. Ithaca was a long flight away.
Eventually, after prodding and pestering, they wore him down. He agreed to move to Atlanta, where his daughter lived.
For several years after that, when Bennett was still in good shape, everything was great. He moved into an independent living section of a retirement community near Christine Houk’s home. At the Parc at Piedmont, he had a dog, made good friends, went on bus trips and took advantage of exercise classes. He was a poster child for all the positives of life in a senior living community. He was frequently with Houk’s family, too, and was able to catch nearly every one of his grandson’s high school baseball games.
“He loved people and seldom met people he didn’t like,” Houk said. “Everybody got a handshake. He was easy to be with and easy to get along with.”
Four years in, though, Bennett was approaching 90 and starting to need assistance with the basics. He moved into the community’s personal care wing so he could get help with showers and meals. Eventually, the facility told the family he needed a place that could offer more care. Houk and her brothers decided on an upscale assisted living home called Elmcroft. But within just a few months, Elmcroft told the family it couldn’t give Bennett the care the facility felt he needed. He had to move again, and the family was given 30 days to find his next home.
That’s what prompted Houk’s urgent search and led her to Sunrise. She was relieved when Sunrise promised its staff could provide the care he needed.
"I'm dying. Hurry. Hurry. Hurry. ... I'm dying right here" —Adam Bennett, in voicemail messages to his daughter
Bennett had been at the home for a month and half when Landon Terrel arrived for his overnight shift. Houk had visited with her dad that afternoon. He was fine.
Then in the dark of night, Bennett made frantic phone calls to his daughter. “I’m dying” and “need help,” he said in the first message, left at 3:54 a.m. Panic was clear in his voice.
He called back two minutes later saying, “I’m dying. Hurry. Hurry. Hurry.” He called again just before 5 a.m., once again telling her to hurry. “I’m dying right here,” he said.
These were Adam Bennett’s last words to his daughter.
Sunrise called Houk the next morning and told her it had called 911. Houk’s phone was off overnight, and she hadn’t heard the messages. Houk raced to the facility, arriving as her father was being loaded into an ambulance. “I said, ‘Hey, Dad! Hey, Dad! It’s Chris!’” Her father didn’t respond, but he raised his hand. “That was his way of saying, ‘OK! I hear you,’” Houk thought.
At the hospital, doctors discovered all sorts of physical damage. His face was bruised in several places. He had broken ribs, a punctured lung and a damaged kidney. He wasn’t able to speak again. Three days later, Adam Bennett was dead.
Houk had learned after arriving at the hospital what her father told his morning caregivers. “He punched me,” he had said, pointing to three places on his body. Houk was horrified when she saw not only the bruises on his face, but the wide bruise that ran all the way down the side of his body.
Cobb’s medical examiner ruled Adam Bennett’s death a homicide, finding the injuries were consistent with a beating.
Landon Terrel repeatedly talked to police, giving them an elaborate story that they didn’t think added up. Terrel was charged with elder abuse and elder neglect — and murder.
Only about a month before the incident, inspectors from the Georgia Department of Community Health had visited the Sunrise facility to investigate four complaints. The nature of the complaints is confidential. But DCH reported that its inspectors found nothing wrong.
After Bennett’s death, with a homicide investigation underway, DCH came back. This time, its review found a host of serious violations.
Sunrise kept residents who were far too sick to be there. It didn’t protect residents from abuse, inspectors said, citing Bennett’s case and an allegation of sexual assault. The facility failed to report serious events to the state as required. And, citing multiple resident injuries, the state said Sunrise didn’t have enough staff to provide residents with the oversight they needed.
That inspection report cited the case of the resident found on the floor with a head injury and “serious bleeding.” The staff didn’t know when it happened, or how, or how long the resident waited on the floor, helpless. The report also said that a resident told a caregiver that another staff member was rough, and the resident made hand motions indicating a sexual assault. “Fingers big,” the resident said, according to the report. The state said the home failed to report that incident as required.
The types of violations the state found at Sunrise are not uncommon. About 40% of the state’s homes have been cited for violating their residents’ rights, the AJC found, and about 30% have been busted for failing to report serious incidents as required. Keeping residents who are too infirm to be at an assisted living facility or large personal care home is especially risky. But it’s not rare. About a third of homes have been cited for it, the AJC found.
A jury decides
For a week in July, a Cobb County jury heard emotional and contradictory testimony about what happened to Adam Bennett at Sunrise. The jury listened to the frantic voicemails Bennett left on his daughter’s phone. Houk sobbed as she recounted what it was like to see the giant bruises as he was clinging to life.
But in the end, no one but Landon Terrel and Adam Bennett witnessed what happened that night. There’s no video. The handful of other workers at Sunrise that night said in court they didn’t hear or see anything. Though the Cobb County medical examiner saw violence and homicide in the physical evidence, a medical expert for the defense said Bennett’s injuries more likely resulted from a fall and argued that Bennett was an old man with memory issues whose “he punched me!” account was not reliable.
Landon Terrel told police that Bennett was combative the night he came into Bennett’s room repeatedly to change his adult diaper. He described in his police interview what seemed far-fetched: that he caught Bennett’s 6-foot-3, 200-pound frame as he fell out of bed, just inches from the floor. But he didn’t hit him, he told police. In the police interview, he mimicked Bennett’s voice and described how Bennett told him repeatedly that he was in pain. Terrel admitted he did nothing in response.
Jason Marbutt, the Cobb County senior assistant district attorney who prosecuted the case, told jurors in his closing arguments that it was clear Terrel’s version of events wasn’t plausible. He replayed the voicemails Bennett left for his daughter the night Terrel was supposed to be caring for him. The jurors heard Bennett pleading for help.
“This is about a 91-year-old man,” Marbutt told the jury. “He spoke to you. The state is asking you to listen.”
Aaron Henrickson, the attorney defending Terrel, knew it wasn’t a pretty picture. “I’m not suggesting to you that Landon was the greatest caregiver,” he said. Terrel was underqualified and in way over his head, Henrickson said, and yet he was in charge of single-handedly caring for an entire wing of delicate, elderly people with memory issues.
“I’m very scared about becoming 90 years old right now,” the attorney said to the jury in his closing arguments, referring to testimony during the trial about shortcomings at Sunrise. “It should terrify all of us because that’s a horrible way to live, and we have got to be able to do better than that.”
Jurors found Terrel guilty on just one count: elder neglect. One juror explained that a whole cast of characters at Sunrise, not just Terrel, seemed responsible for what happened. Terrel was sentenced to five years behind bars.
Adam Bennett’s daughter and sons still struggle with their father’s death. They couldn’t stop thinking about how afraid he must have been, how much pain he must have endured. This was not how their father’s long life was supposed to end.
“They made us promises,” Houk said. “They told us there were people to care for him. And that’s not the truth.”
Sunrise declined to be interviewed for this story, but it sent the AJC a statement saying it had made changes at its East Cobb home since Bennett’s death, including hiring new staff and retraining workers on abuse and neglect and reporting requirements and implementing audits to see if workers are following Sunrise protocols.
“This situation still weighs heavily on all of us here in Atlanta. We have some of the most compassionate, dedicated team members in the industry and this tragic situation is not representative of our larger team’s values,” said Michelle Minor, the vice president of operations for Sunrise Senior Living.
Sunrise at East Cobb settled a civil lawsuit filed by Bennett’s family. On its website, it doesn’t mention what happened in 2017. But it does say it got a “deficiency-free” state inspection in 2019.
“This accomplishment,” its website said, “recognizes our community’s commitment to and reputation for providing quality care — going above and beyond the standards to champion quality of life for all seniors.”
—AJC data specialists Jennifer Peebles and Nick Thieme contributed to this report.