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Part 1: 'Shame of the State'
Troubled facilities and lax state oversight have for years put residents of Pennsylvania's assisted-living homes at risk of assault, neglect - and tragedy.
"It's just way too long to wait," Kroh said. Richman said she was trying to fix what she called a plodding culture in that bureau.
Contributing to this report were Inquirer staff writers Nancy Phillips, Craig R. McCoy and Mario F. Cattabiani.
A tough new approach
In December, a death at a well-appointed facility on the Main Line highlighted continuing problems at assisted living facilities.
It also showed the welfare department's tougher new approach to fixing them.
At NewSeasons Devon on Valley Forge Road, Lambert, who suffered from dementia, was found dead of a broken neck. He had walked through an unlocked door and fallen down a basement stairwell.
In the past, such incidents often provoked little reaction from the welfare department, state records show. For example, when a resident beat another resident to death at the same home in November 2002, the welfare department took no action. The state attorney general launched a criminal inquiry against the home, though no charges were filed.
In this case, welfare regulators swooped into the home and investigated for days.
The resident "was not adequately supervised to protect health safety and welfare to avoid access to hazardous areas," the inspectors concluded, noting that the home had agreed to make sure the resident used his walker.
Regulators found other serious violations, including three unlocked doors that led to stairs. Inspectors also cited the home for fire-safety violations, and for failing to provide medical attention to a resident with a swelling hand.
On Feb. 9, the welfare department notified NewSeasons Devon that it was refusing to renew its annual license.
The home remains open pending appeal. NewSeasons is selling its assisted-living homes to Virginia-based Sunrise Senior Living, one of the nation's largest assisted-living chains, state regulators said. Sunrise will be given a chance to operate the home with a provisional license, Kroh said.
In an interview, NewSeasons CEO Richard Neeson said the facility had fixed all the problems highlighted by regulators.
The door to the basement "should have been locked," he said. "There's no other explanation. . . . It's just one of those unfortunate things. We deeply regret what happened."
The case symbolized a new thoroughness at the welfare department, Kroh said. Previously, she said, when regulators got a complaint about a resident's safety, they stopped investigating when that was no longer an issue.
"Victim's dead . . . end of problem," she said. "That wasn't appropriate."
Read examples from the files of written complaints and reports of violations against Pennsylvania assisted-living facilities at http://go.philly.com/assist
Contributing to this report were Inquirer staff writers Nancy Phillips, Craig R. McCoy and Mario F. Cattabiani.
Contact Phillips at 215-854-2254
