Peer into the files of Pennsylvania's assisted-living industry and confront a catalog of horrors.

Betty Trainer, 81 and suffering from dementia, died of heat exhaustion in 2005 after wandering off from her Bucks County care home during a fire drill. They found her body near her husband's grave.

June Loth, 74, who raised her family in Levittown, succumbed to complications from when she was raped in 2004, authorities say, by a live-in handyman in a home outside Pittsburgh.

In December, John Lambert, 95, tumbled down an unsecured basement stairwell at a sparkling Main Line complex and broke his neck. At the same home a few years before, a resident killed another resident.

Since 2000, at least 55 assisted-living residents have died across the state under circumstances that raise questions about whether they were cared for properly and whether their deaths could have been prevented, an eight-month Inquirer investigation has found.

Uncounted others were beaten or neglected at the state-regulated facilities, which are also known as personal-care homes. At least five were raped.

The Inquirer's examination of Pennsylvania's assisted-living industry - based on thousands of pages of public records and hundreds of interviews - found a long list of health and safety violations, a history of substandard care, and a system of state oversight that, until recently, often allowed deficient operators to violate safety rules with virtual impunity.

While most personal-care homes appear to provide reasonably good care, a significant segment of the industry has been so problem-ridden for so long - and the regulation of it has been so lax - that elder-care experts call it one of Harrisburg's worst failures.

"The situation with personal-care homes really is the shame of the state," said Sue Walther, executive director of the Mental Health Association of Pennsylvania and chairwoman of a state coalition of personal-home advocates.

The shameful state of assisted living in Pennsylvania has been well-chronicled for decades: in audits, in newspaper accounts, in a 2002 grand jury report after a Bucks County murder.

Yet state politicians have placed more emphasis on satisfying the concerns of the industry than on protecting vulnerable residents, The Inquirer found.

When the state set out in the late 1990s to overhaul health and safety rules for personal-care homes, lobbyists and legislators dragged out the debate for years - and significantly diluted key provisions of the original proposals, according to public records and interviews.

Top Rendell administration officials at the agency in charge of protecting assisted-living residents - the Department of Public Welfare - acknowledge that regulation was inadequate for many years, including two years under their watch.

They say they inherited a broken regulatory system when Gov. Rendell took office in January 2003 and have made substantial progress toward fixing it.

But they concede they did not begin to turn the agency around until the spring of 2005, when a new top regulator took over - Rendell's third.

"I wish I could have made more drastic change sooner," Welfare Secretary Estelle Richman said last week.

That regulator, Karen Kroh, has replaced half her staff, boosted enforcement actions by 55 percent, and revoked the licenses of 75 facilities.

But in an interview, she acknowledged that her tiny complement of inspectors - 31 for nearly 51,000 Pennsylvanians in 1,590 homes - was overwhelmed. While trying to keep up with investigating complaints, they have fallen badly behind on inspections, she said.

"This program has so many systemic problems that have gone unnoticed, unchecked and unregulated for a decade," Kroh said. "I don't have enough staff to fix it.

"By the time we get out to them, many homes are in so much trouble that they can't fix the problems - or somebody's already been harmed."

Regulators continue to find shockingly unsafe conditions, Kroh said, "and I'm sure there are many more to be found."

The department's record-keeping has been so poor that Kroh is unable to say how many people died of unnatural causes in the homes before 2005. Nor is she able to say how many homes were cited with serious safety violations before that year.

Using documents from the welfare department, the courts, and the Philadelphia medical examiner, The Inquirer identified 55 deaths in the last seven years that pointed to possible failures in care and supervision at assisted-living homes.

In many death cases before 2005, the welfare department did not investigate or took little meaningful action. Since Kroh took over, homes have been sanctioned - and some closed - after deaths linked to inadequate care.

The Inquirer's review of welfare department records involving more than 80 facilities, dating back to 2000, found missing documents, superficial investigations, and a tolerance for repeated violations. For example:

At the James-Marie Personal Care Home in Germantown, Elmo Johnson, 75, was found slumped over a radiator with third-degree burns in 2003. He had been there for four hours, according to a medical examiner's report, which said Johnson had died of "thermal injury." The state cannot find any record that the death was investigated. The owners say they did nothing improper, and say a state inspector cleared them - after telling them to get better radiator covers.

At Hill House Manor in Bensalem - part of the Independence Blue Cross subsidiary NewSeasons - six people had wandered away before Trainer's death in 2005, police records show. The facility - sanctioned for "gross incompetence" after her death - had previously been cited for failing to properly supervise residents with dementia. A lawyer for the home said it was not at fault in Trainer's death, and disputed the notion that Hill House residents were not well-supervised.

At Arden Courts in suburban Pittsburgh, an employee was charged with raping an 84-year-old Alzheimer's patient in 2005 - three years after a resident with a history of violent behavior beat another resident to death. Regulators, who repeatedly found that the home had insufficient staff, took no action after the rape and, in a settlement, collected a $780 fine after the killing. Officials from Arden Courts, part of the national HCR ManorCare chain, said in a statement that they had acted appropriately and had substantially improved operations since 2002.

At Country Living Personal Care outside Scranton, regulators did nothing after learning that the home admitted a convicted sex offender who later raped an 84-year-old resident in 2002. The owner, who acknowledged mistakes during court testimony, declined to comment and hung up on a reporter.

All of the homes are still open, though Hill House has been sold.

Noting that those cases had happened before she took over, Kroh said she could not defend the department's past actions. Investigations often had been inadequate, she said.

"I think we've started to fix the program, but there's still a lot to do," she said.

Kroh said record-keeping and the quality of investigations in the Philadelphia region had been particularly poor.

"We found all kinds of things stuffed in the wrong files," she said. "I suspect there were also many deaths that were not properly investigated and cited."

Asked why she hadn't moved to fix such basic failings when she took office in early 2003, Richman said she had been busy with other pressing priorities in her sprawling multibillion-dollar agency.

"People were dying there, but people were dying in a lot of places," she said in an interview last week.

Richman promised to add more assisted-living inspectors.

Rendell declined to be interviewed about personal-care homes. Asked about his record during a public appearance last week, he said:

"We moved faster than any other administration in the history of Pennsylvania, and we put more money into dealing with that than any administration in history."

A Rendell spokeswoman later added: "The problems with licensing and enforcement of personal-care homes go back over 20 years," and Rendell has made "steady progress" in fixing them.

William A. Gannon, who led the welfare department office that regulated personal-care homes from 1995 to 2003, acknowledged that "the program has been a mess for a lot more than a decade."

There never have been enough inspectors, he said, and the department had "a history of not being aggressive enough in pursuing complaints."

But Gannon, now a senior official in the state labor department, disputed the criticism by Rendell's administrators that enforcement had been abysmal under his tenure.

"I take exception to that. I think a lot of people busted their buns to try to do what they could" in the face of a "pathetic" set of regulations, he said.

Quick growth,

looser oversight

The personal-care industry mushroomed after state mental institutions began closing in the 1970s. Small homes sprung up as housing of last resort for many with mental illness.

Then, after scandals beset nursing homes in the 1980s, corporate-run assisted living came to be seen as a more humane alternative.

Assisted-living residents tend to be elderly, disabled, mentally ill, or some combination of the three - a population extremely vulnerable to abuse, neglect and exploitation.

These residents live in a gray area: They are infirm enough to need help with daily living, but legally they are not supposed to be sick enough to qualify for more elaborate and expensive nursing-home care.

Unlike nursing homes, which are subject to federal regulations, assisted living operates under less stringent state-by-state rules. For years, Pennsylvania had some of the country's weakest regulations. A recent update put the state in the middle of the pack, experts say.

In 1999, a federal study of assisted living in four other states - California, Florida, Ohio and Oregon - found that state regulators had cited more than a quarter of the facilities for five or more serious deficiencies, including poor care, understaffing and medication errors.

But the sheer magnitude of the problem in Pennsylvania stands out, experts say - along with Harrisburg's long-standing failure to do much of anything about it.

The welfare department office that licenses and inspects the homes "was always a stepchild," Kroh said.

Industry representatives acknowledge that there are bad operators, but say the horror stories obscure a largely good record in most facilities.

"Bad operators taint everyone," said Michael Leader, president and chief executive officer of Country Meadows Retirement Communities in Hershey, a company that runs nine assisted-living communities and two nursing homes.

"It's horrible. The assumption is that others must also be that way" when, in fact, most operators do a good job, he said.

Rich homes,

poor homes

Pennsylvania's personal-care facilities run the gamut from ramshackle family-run boarding homes to sleek, corporate-owned institutions.

Some of the worst incidents, predictably, have occurred at boarding homes that cater to low-income people, giving them a place to live in exchange for monthly Social Security checks of $1,062.

One such home was St. James Place in Chester, where a resident's facial wound was allowed to fester for so long last year that emergency-room doctors removed 50 maggots from it.

Regulators closed that home in the fall. They had taken no action in response to a death there in 2004; an advocacy group in a letter to state regulators complained that the dead woman had been found "nearly naked, filthy, and lying upside-down in her bed with her head lying in a bedpan containing dried urine."

Two weeks ago, the state Attorney General's Office filed criminal neglect charges against three former St. James employees in connection with the maggots case.

James-Marie, where Johnson cooked to death on a radiator, does not have a history of serious regulatory violations.

State officials could find no records on the Johnson case.

"Without evidence and documentation, I have to assume the department did not properly investigate," Kroh said of the Johnson death.

The home's owners, Albert and Rhonda Edwards, said in an interview that the state had looked into the matter - and cleared them. They said that Johnson had been sick and unsteady on his feet, and that they had urged their staff to check on him at night.

The night he died, they believe, a staff member found the bathroom door locked and took no further action, Albert Edwards said. They called the death an unavoidable tragedy.

Owners of facilities that cater to poor people say delivering the best possible care for $1,062 per month is extremely difficult. Advocates for the poor agree that the state should contribute more.

"The problem is that we're talking about a fringe element of society. . . . They have no money. They have no status. They have no political clout," said Bob Meek, managing attorney of the Philadelphia office of the Disabilities Law Project.

"Regular middle-class people are just as happy not to know about them. They don't want to hear about it, and they certainly don't want to pay for it."

But the poor represent only about a fifth of the state's assisted-living population. The Inquirer's review also turned up problems at well-heeled suburban facilities that command $5,000 or more a month.

At some, an upscale appearance can mask weaknesses in care or supervision.

When former Main Line resident Julian Michaelson, suffering from mental illness, wandered from the Willow Lake home in Willow Grove in January 2006, "staff and managers were untrained and unable to handle emergencies" and never did a coordinated search, according to a state inspection report.

Michaelson drowned in the lake. His death was ruled a suicide.

Afterward, the state cited the home for a raft of violations, including failure to comply with rules about medication, safety, resident rights and training.

A spokesman for the Florida company that owns Willow Lake, Al McKinney, declined to comment on the case's specifics but said: "Our sympathies, of course, go out to the family of the resident. We always strive to provide a safe and healthy environment. . . . Unfortunately those things happen, and everybody feels terribly sad."

Two other high-end facilities, owned by the former Alterra Healthcare Inc., were host to some of Pennsylvania's most serious known cases of harm. Before its 2003 bankruptcy, Alterra was the nation's largest assisted-living chain.

Bucks County resident William Neff, 83, was murdered by an Alterra employee in 2000. And three residents of a State College home run by Alterra died of complications from severe bedsores in 1999 that weren't properly treated, according to court records. (The company disputed that.)

Alterra's homes are now part of Brookdale Senior Living. In a statement, that company's CEO said he could not discuss cases that happened before it took over, but he said Brookdale "does not condone any action that compromises our high standards."

Scenery Heights, the home in Elizabeth where authorities say Loth was raped, was neither a luxury facility nor a low-end one. The family was paying about $2,000 a month for Loth to live there, said her daughter, Colleen Buglar.

Loth, who once relished trips to Disney World with her grandchildren, by then was suffering from dementia. Her 5-foot-1 frame had shrunk to 65 pounds, according to court testimony.

Buglar said she believed the home was providing wonderful care, right up until the day in August 2004 when a part-time, live-in staff person allegedly was caught raping her mother. The man, Dwight Hill, 44, is in jail awaiting trial on homicide and sexual-assault charges.

Regulators cited the facility for failing to obtain a criminal background check on Hill, and for failing to prevent the assault. One inspector noted that the home's "licensing history includes multiple citations for not obtaining criminal background checks and in 2003 for having staff smelling of alcohol." The home was allowed to remain open.

Representatives of the owners, Chester Niedzwiecki Enterprises, did not respond to repeated calls and a letter seeking comment.

In addition to stepping up enforcement, Pennsylvania last year implemented tougher regulations that nearly everyone agrees will better protect assisted-living residents.

But The Inquirer's investigation found that the new rules were weakened significantly after pressure from owners of personal-care homes and their allies in Harrisburg.

When the industry was unsatisfied with the welfare department's first proposal, industry lobbyist Gwen Bower said, "we went to our friends in the legislature" to change it.

That pressure continues: Kroh said the welfare department routinely fielded calls from lawmakers complaining about enforcement actions against homes in their districts.

And Richman said two state senators recently had asked her to meet with home operators concerned about the new regulations. She declined to name the senators.

In that political climate, the welfare department has been unable to do what experts say is most needed: substantially boost the small cadre of regulators who inspect facilities, investigate complaints and enforce the law.

"I couldn't do it all in one fell swoop," Richman said.

The state's 31 field inspectors must cover 51 homes each, on average. By contrast, the state Department of Health, which inspects nursing homes, has four times the inspectors and about half the homes.

New Jersey has six inspectors for 204 assisted-living facilities, or 34 per inspector. (Unlike Pennsylvania, New Jersey regulates assisted-living facilities separately from other types of boarding homes.)

Even leaders in the personal-care-home industry say Pennsylvania's enforcement efforts have been lacking.

"I think there are some significant problems within this industry, and . . . for whatever reason, things have not always been enforced consistently in the past," said Bower, a lobbyist for the Pennsylvania Healthcare Association, which represents larger facilities. She said enforcement had markedly improved.

"I wish they could add more inspectors, because it would also help to ensure that the level of service is where we want it to be," said Leader, the assisted-living executive.

Kroh agreed. Since she took over, she said, the licensing division spends more than 50 percent of its time on enforcement actions, up from 10 percent. As a result, it has fallen far behind in inspections, which are required each year for license renewals. Also, regulators don't have time to analyze the incident reports that homes must file.

"We can't get out to homes frequently enough," Kroh said. "If problems could be identified early, it could prevent some of the very tragic deaths and injuries and accidents. And that's my problem: I don't have enough staff to do both."

Kroh said her analysis suggested she needed 38 more people.

The current staffing, she said, means the welfare department depends on the homes to report serious incidents honestly.

"She's not going to get 38," Richman said. "But she will get more staff."

Richman said personal-care homes were one area competing for scarce dollars in a welfare budget that had been reduced in recent years.

Reforming a deeply troubled government program takes time, she said.

"We went through, in essence, three different directors in that program in two years," she said. "That tells you that I am aware of what's going on and I am not satisfied with what I am getting."

Years of appeals

When the welfare department does take enforcement action, it often finds itself stymied by a glacial appeals process.

The case of the Cedarwood personal-care homes outside Pittsburgh is a telling example.

In August 2004, sometime before 7 a.m., Anna Mae Edwards, 90, suffered a stroke in her room. She had fallen on the floor and hit her head. No staff member was on hand to help her.

The owner, Judith Reynolds, had gone to Harrisburg early that morning, leaving eight frail and elderly residents alone. An employee was due in at 7 a.m., Reynolds said in an interview, but showed up an hour late.

Resident Anna Latronico, 100, walked outside to get help, fell and hurt herself.

Edwards died in a hospital three days later. Allegheny County prosecutors charged Reynolds with two counts of neglect of a care-dependent person, a misdemeanor.

Prosecutors later dropped the one count related to the death, saying they could not prove Reynolds' absence caused it. On the charge of neglecting Latronico, Reynolds entered a program that allowed her to avoid a criminal conviction if she completed 24 months of probation.

After Edwards died, the state moved to revoke Reynolds' licenses for all five of her personal-care homes on the grounds of "gross incompetence, negligence and/or misconduct."

She appealed. Later, inspectors found she was supervising residents alone, defying an order to have another caregiver present at all times.

Reynolds, a registered nurse who lives in one of the homes, said she kept her residents safe. She acknowledged ignoring the order, but said she couldn't afford to have a staffer on duty overnight.

She called Edwards' death a "tragedy" that could not have been prevented. "God chose to end her life," she said.

In December, after nearly two years of state efforts, a judge ordered Cedarwood's five homes closed.

Much of the delay was attributable to the welfare department's Bureau of Hearings Appeals, Kroh said. Homes have a right to a hearing on closure actions, which can take months or years to complete.

"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.

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/assistEndText

Contributing to this report were Inquirer staff writers Nancy Phillips, Craig R. McCoy and Mario F. Cattabiani.
Contact Phillips at 215-854-2254