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>> Tonight on Frontline, assisted living is home to almost a million American seniors, and it's a billion-dollar business.
>> When the baby boomers start hitting, we're looking to service that demand as it continues to grow.
>> Seniors are paying sky-high prices out of their own pockets.
>> You can charge $5,000, $6,000, $7,000 a month.
>> Over the last year, Frontline and ProPublica have been investigating this growing industry.
>> You don't have to worry about federal government rules and regulations like you have to with a nursing home.
>> And the country's largest assisted living company.
>> They did not have the state-required training, they didn't have the Emeritus-required training.
>> And examining the care this for-profit chain provides to tens of thousands of seniors.
>> The biggest thing I always heard was, "We need 100%.
Fill the building, 100%."
>> Correspondent A.C. Thompson interviews insiders who are telling their stories for the first time.
>> Did you worry, "Hey, I've got an impossible task here.
I could do something that leads to somebody's death"?
>> All the time.
>> Tonight on Frontline, "Life and Death in Assisted Living."
>> The head of the state licensing agency told me, "Assisted living is the rock we don't want to look under."
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>> A.C. THOMPSON: So this is 1940, is that right?
>> Yes, this was the championship game.
>> Oh, look, there he is.
>> There he is.
>> Carrying the ball.
That's daddy, number five.
>> Right in the middle, with his curly hair, yeah.
>> THOMPSON: Is that him?
Right there?
>> Yes, he's got the ball right there.
>> There he goes.
>> Yeah, he just intercepted that and now is just running and making his way through and just scored.
>> Scored a touchdown.
>> I believe this is when they scored... the score was 73 to nothing.
>> It was a game that Daddy talked about the most, I think.
>> THOMPSON: George McAfee had a remarkable life.
In the 1940s and 50s, he was the star running back for the Chicago Bears.
He won three NFL championships and was inducted into the Pro Football Hall of Fame.
>> He didn't really talk about that that much.
In fact, our mother wanted to place plaques of his in our den, and the only place he would let her put them was behind this door so that when the door was open, you couldn't see them.
>> THOMPSON: I see all these photos and he seems like he's just loving his later years.
>> He enjoyed being around his family.
He would just light up when he saw the grandkids, the great-grandkids.
>> THOMPSON: But in his 70s, George became one of the more than five million Americans suffering from dementia.
>> I guess we first started noticing that there were some changes in Daddy's behavior.
He would go to the bank and he could get there, but once he got there, he couldn't remember why he was there.
>> THOMPSON: His daughters began searching for a facility that could care for him.
They chose Cypress Court, an assisted living home that charged more than $4,000 a month.
>> When I saw the Court, a couple things impressed me.
The residents were free to access the outside and walk or sit.
I thought we had just struck gold as far as a home for him.
>> THOMPSON: But then the facility was bought by the Emeritus Corporation, a nationwide chain.
The sisters say they began to see changes.
>> His room would be dirty and he would just be unkempt, like he hadn't showered.
>> I know for a fact that his sheets weren't being changed.
His laundry was not being done.
I would come home with his laundry, do his laundry myself.
I would clean his room.
Many times when I would go over, he looked like a dirty old man.
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>> THOMPSON: One night, George left his room and went wandering through the facility.
Records show that for almost half an hour, there was no one on duty in his wing of the building, and workers had failed to lock away a bottle of industrial strength dishwashing liquid.
At some point that night, George picked it up and drank it.
.
It contained a highly caustic chemical which severely burned his lips, esophagus and lungs.
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>> When he was in the hospital, his face almost looked like what you picture in a horror story of a death mask.
And I hope that he wasn't aware of what was going on, but we certainly were afraid that he was just in horrific pain because he would almost try to sit up... >> Well, one time he did sit up.
>> He did sit up.
>> And opened his eyes, yes.
>> And we said, "Daddy, we're right here."
>> THOMPSON: The hospital couldn't save George, and on March 4, 2009, he died.
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The state of Georgia found Emeritus negligent in George's death.
The sisters sued the company and settled with them.
Now, for the first time, they're speaking publicly.
>> He suffered a horrific death, and our children saw it, our husbands saw it, we saw it, and... >> I remember just sitting by his bedside praying that God would just go ahead and take him, because he wasn't going to get any better and I just felt like he was suffering so horribly.
>> THOMPSON: After your father died, the state did an investigation, and the state said, "We're going to fine this facility $601."
>> Well, in my opinion, I think they just got a slap on the wrist.
And I've said all along, had this been a daycare facility that, where a child died, the place would have been shut down, and to only get a fine of $601, I just think is outrageous.
>> It means nothing.
Nothing.
>> THOMPSON: The Emeritus Corporation is headquartered here in Seattle, Washington.
We asked the CEO, Granger Cobb, about what happened to George McAfee.
>> The incident with...
The tragedy, I should say, with Mr. McAfee was devastating for all of us, and it was a situation, it was human error.
We had a staff member that failed to secure a locked cupboard.
Mr. McAfee got access to this dishwashing liquid, drank it and had absolutely tragic results, and our heart goes out to the family.
When you're dealing with this many residents, particularly a population that can have unpredictable behavior or is frail and is kind of a high-risk population to begin with, we will have situations from time to time, but they are the vast, you know, minority.
I mean, it is really the exception to the rule.
>> Welcome to Emeritus, where you'll find all the comforts of home.
>> THOMPSON: Cobb heads a company that has long been at the forefront of the assisted living industry.
>> You can teach the skills, but you can't teach the passion.
You have to have a passion for seniors.
>> THOMPSON: Assisted living was created to offer seniors who could no longer live on their own a more home-like environment than nursing homes.
And since most facilities offered little or no medical care, they were loosely regulated.
>> Seniors can enjoy their golden years to the fullest.
>> THOMPSON: Assisted living blew up in the 1990s.
It grew very rapidly.
Do you think that companies were attracted to this sector of senior care because it had less regulation than nursing homes?
>> Oh, I'm sure, and particularly the for-profit companies.
When you look at the system, you don't have to worry about federal government, you don't have to worry about rules and regulations like you have to with a nursing home, for example, and you can charge whatever the market can bear.
I mean, if there are people who are willing to pay $5,000, $6,000, $7,000 a month for care, you can charge that, and there's no limitation on fee increases.
>> THOMPSON: With those kind of prices and the enormous cash flow they generate, Emeritus has been embraced by Wall Street.
The company's shares trade on the New York Stock Exchange.
Last year, it took in nearly $1.6 billion in revenue.
>> (cheering) >> THOMPSON: And with the baby boomers starting to retire, Emeritus is looking to grow even bigger.
>> So the 75-plus demographic is growing by about 400,000 individuals per year, so there's this increasing demand.
And frankly, out 15 years when the baby boomers start hitting, it's going to grow by a million a year.
And so there's this huge demand that is already here, and on the horizon, is going to increase.
And I think that, you know, what we're looking at is to be able to service that demand as it continues to grow.
>> THOMPSON: But increasingly, that demand has been coming from seniors with complex medical problems.
>> When we were trying to figure out what assisted living is or was, I had this image that it was apartment-style buildings where people had a lot of independence, they didn't need a lot of assistance.
>> THOMPSON: Catherine Hawes studies the assisted living industry.
>> Then we did the first national study, and of course that wasn't what assisted living was.
People showed up in wheelchairs and walkers.
It wasn't the well elderly who are out golfing, you know, on the weekends.
And, you know, there was this big, "Is there a parking place for every resident?"
These are not people who can drive!
And there were these spiral staircases, which no one ever uses.
Because if all you need is hospitality, you don't leave your home.
Most of us want to stay in our home as long as we can.
>> THOMPSON: In her study for the Department of Health and Human Services, Hawes found that while residents in assisted living didn't have as many physical limitations as people in nursing homes, many suffered from Alzheimer's and other forms of dementia.
>> When you go into assisted living, you see a lot of cognitive impairment.
So there's a lot of early memory loss, short-term memory loss, a lot of impaired decision-making.
>> THOMPSON: Newer research shows that the number of residents with dementia is rapidly increasing.
>> We found that about two-thirds at any point in time have dementia.
So the majority.
The implications, therefore, are anybody who operates assisted living needs to know that dementia is the major player.
It's the major condition that leads to people living there.
>> THOMPSON: To meet the growing demand for dementia care, Emeritus has been opening memory care facilities across the country.
>> Understanding how Alzheimer's disease affects the brain... >> THOMPSON: But though residents now need much more care, assisted living remains loosely regulated.
>> ...the overall needs of each resident.
>> We pretend assisted living facilities are not medical facilities.
They're non-medical.
And yet, the people who are in these facilities today have acute medical needs.
The same people who are in assisted living today are the people who were in nursing homes ten years ago.
And this is not to say that all the facilities aren't prepared to deal with them, but I'd say the overwhelming majority certainly aren't prepared to deal with that.
>> THOMPSON: Emeritus invited us to come to one of their facilities in San Diego.
It has a "memory care unit" where seniors pay upwards of $5,000 a month to live.
>> Five, six, seven, eight!
>> THOMPSON: So we're in the memory care unit, or memory care community.
>> We call it the memory care neighborhood.
>> THOMPSON: Memory care neighborhood, in Carmel Valley.
>> THOMPSON: Kelly Scott runs Emeritus's memory care program.
>> So this is our program, we call it our Join Their Journey Program, and this is where we're caring for folks with dementia.
And it's really a specialized program to meet their needs.
We find out a lot about who they are as individuals, and then the day is set up around what is purposeful and meaningful to them as individuals.
>> 10:30, 350... >> THOMPSON: But some question whether memory care units like this one provide enough care.
>> Has anyone got a shovel?
>> You're going to have a memory care unit.
That's a good marketing tool for families.
A: there's demand and you're trying to keep occupancy up.
B: you can charge more for memory care.
I mean, all you've really done is created rooms around a courtyard, but still, that's nice, and it's much safer.
But then they say they've got staff who are trained to do memory care, and that's where it starts to kind of fall apart, because the staff are generally not well trained to do dementia care.
>> THOMPSON: Lay out for me, if we're here in Carmel Valley, we're at your facility, what would the typical training consist of for somebody in this facility?
>> Who's working particularly in memory care?
>> THOMPSON: In the memory care unit.
>> For our staff that works in memory care, they're going to go through what we call General Orientation, which everybody in the community would go through, and then we have an eight-hour class that's the Join Their Journey class, and that's really where we cover everything from disease process to how we serve a meal slightly differently to folks who have dementia, to how to engage, how to approach, how to communicate, you know, overcoming some communication barriers at times.
>> THOMPSON: So the eight-hour intro is sort of the minimum.
>> That's our company standard is going to be the eight hour.
>> Eight hours?
That's nothing!
Who's going to explain, "This is what the disease is, "this is the impact that it has on people's physical health and on their behaviors."
You've got to know how to interpret nonverbal cues that something's going on with this resident, because they can't tell you verbally, you know, in the same way that a two-year-old can't tell you or a one-year-old.
I mean, you've got to do a lot of training for memory care units.
You can do great care.
You've just got to know how.
>> THOMPSON: For the past year, ProPublica and Frontline have been examining assisted living and Emeritus, the industry's biggest chain, which is home to more than 40,000 seniors.
"Resident was assaulted by another resident due to lack of care by facility; substantiated."
There's no national data on assisted living, so we focused on California, the state with the most assisted living facilities.
During the last three years, Emeritus had more substantiated consumer complaints per bed than any of its major competitors.
"Facility has insufficient staff to monitor residents."
>> THOMPSON: We found authorities in other states have cited Emeritus for numerous legal violations, from a shortage of staff to taking in seniors too sick to legally live in their buildings.
Go to that one.
You just have somebody apparently falling out of a second-story window.
>> THOMPSON: And we identified more than two dozen questionable deaths, many of which have never been reported on.
>> So she froze to death.
>> THOMPSON: She froze to death.
>> On Christmas day.
>> THOMPSON: On Christmas day.
Her name was Mabel Austin, and she suffered from dementia.
One night, she wandered out of an Emeritus facility in Texas and froze to death.
In Colorado, Herbert Packard was beaten to death by a resident with brain damage.
In Massachusetts, Angenette Stewart was repeatedly sexually assaulted.
An investigation found that Emeritus workers knew about the attacks and didn't stop them.
In Florida, Richard Borrack, who had Alzheimer's, slipped out of a facility one day and was never seen again.
When we asked Emeritus to comment on these incidents, the company refused.
But Granger Cobb did agree to comment generally on the problems we'd found at his company.
>> It's a fact of life and it's not peculiar to assisted living versus any other business, but from time to time, human beings will make mistakes.
>> THOMPSON: But some things are pretty cut and dry.
In some states, if you have a particular condition, you can't be in a facility.
In some states, if you are posing an immediate harm to yourself or others, you can't be in an assisted living facility.
What are the risks of having somebody who has a prohibitive condition, something that should keep them out of assisted living, living in this kind of environment?
>> Well, if we can't adequately care for the resident, we shouldn't have them.
If we cannot care for them sufficiently, we will not jeopardize their health or their condition by keeping them in our community.
>> THOMPSON: But in our reporting, we came across a revealing incident near Jackson, Mississippi.
It involved a woman with dementia named Merle Fall.
Merle went to live at Emeritus at Ridgeland Pointe at the end of a long, happy life.
>> She was a lot of fun to be around.
Our friends all loved her.
She said whatever came to mind and she was always the life of the party.
Everybody always loved her.
>> THOMPSON: In the early stages of her dementia, Merle lived with Diane's sister, Linda.
But when Linda felt she could no longer keep Merle safe, the sisters called Emeritus.
The company sent a nurse to evaluate Merle.
>> She came in, she sat down right there on the couch with Mother, Mother was sitting there too, she reached over and held Mother's hand, and she never asked any questions.
As a matter of fact, it was only later that I understood she was here to evaluate Mother, to find out whether she was suitable for Ridgeland Pointe, because all she did was talk about what a great experience it was going to be, Mother was going to get a lot of one-on-one attention, she says she's going to get so tired of seeing my face, you know, "We're going to give her... we're going to take care of her just like she was our mother," is what they said.
>> THOMPSON: And so Merle's daughters moved their mom in at a cost of about $3,500 a month.
>> She went in on Thursday afternoon, February 25.
They had suggested that we not come by for a few days to get her used to it.
Sunday, I finally said, "We want to see her."
We got there, she was drugged, drooling, we couldn't wake her up, she had on the same clothes she had on when we took her there Thursday, she smelled of urine.
I mean, she looked like she had just been drugged the whole time.
>> THOMPSON: The sisters discussed taking Merle home, but in the end decided not to move her.
>> She was miserable where she was and she wanted to go home.
And it was really hard to leave her there.
But we truly thought it was the best thing for her, we truly thought it was a way to keep her safe.
>> THOMPSON: But just days later, Merle stuffed her clothes into a suitcase and told a caregiver that she was leaving.
Soon after, she pried open an upstairs window in the memory care unit and forced herself through it.
Then she plunged to the ground.
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>> I got a call on Saturday, March 6, nine days after she was admitted there, about ten till 8:00 that morning, said... the lady identified herself and said, "Your mother got out."
I said, "What do you mean she got out?"
She said, "She went out the window."
I said, "She went out a second story window?"
And she said, "Yes."
I said, "Is she breathing?
Is she alive?"
"She's on the ground, crawling around.
She won't get up."
>> We probably got there in less than ten minutes.
As a matter of fact, they were still putting her in the ambulance when we got there.
There was not one living soul from Ridgeland Pointe out there with her.
Nobody from Ridgeland Pointe ever came outside and said anything to us, nobody expressed any regret because they never walked out the front door, we never saw them.
>> THOMPSON: At the hospital, doctors discovered that Merle had bleeding in her brain.
Three days later, she died.
Soon after, the sisters filed a lawsuit against Emeritus.
Some cynical people will say, "Diane and Linda, "they're suing because they want money, "because they want to enrich themselves.
They see a big corporation and they want some money."
What do you say to that?
>> I'd say shut the facility down, put the people in jail, we'll drop the lawsuit.
'Cause we don't have any...
It's not the money.
It's truly not the money.
But the money is all that matters to Emeritus.
And if that's all that matters to them, it's the only way to hurt them.
And believe me, I want to hurt them.
>> THOMPSON: The daughters' lawsuit against Emeritus is ongoing, but Mississippi regulators decided not to cite or fine Emeritus for Merle's death.
>> That was one where we actually followed our policies and procedures.
They had checked all the windows in the community to make sure that none of them opened past 12 inches, which is the regulation in the state of Mississippi.
But it's so difficult sometimes with our residents that may have some memory impairment.
Sometimes their behavior is unpredictable and catches staff off guard, even when they think they're doing all the right things.
>> THOMPSON: But Maggie Carter, who ran the memory care unit at the time and was later fired in a dispute with the company, told us that Merle's death reflected a bigger problem.
>> I think that they are bringing nursing home patients to an assisted living facility.
Most patients that was in the wheelchairs or not able to assist themselves at all should have been in a nursing home, not assisted care.
>> THOMPSON: Why do you think she was admitted?
>> At the time, this is my opinion, we was low on residents and we need to keep up our numbers.
They was very strict about numbers, that we need to keep up our numbers, and at the time, memory care didn't have the capacity they wanted.
So you was under pressure to get people in that building.
When you get them in that building, you was under pressure to keep them in that building at any cost.
>> THOMPSON: Emeritus insists it only admits those who are medically suitable.
But we talked to more than a dozen other former employees who described a company focused on filling its buildings, and some said the company was willing to put seniors at risk to do it.
Now, several former Emeritus employees have agreed to talk on camera for the first time.
>> It looks like a nice building on the outside, but inside, you know, everybody's just like scrambling to do the best they can, you know, to take care of all these people.
>> THOMPSON: In 2007, nurse Mary Kasuba was the resident care director at Emeritus at Emerald Hills in Northern California.
She says the facility was so understaffed that it couldn't provide decent care for the roughly 80 seniors living there.
>> It was just very dysfunctional and not very organized, and the residents were not getting the care that they should be getting and given the kind of care that they were paying for, because they paid quite a lot of money to be able to be in that facility.
>> THOMPSON: Kasuba's biggest worry was the med room.
It was managed by workers with little training who were paid around $10 an hour, like Jenny Hitt.
>> THOMPSON: So for 80 or more residents, how many drugs are we talking about?
I mean, how many prescriptions could you conceivably be dealing with?
>> Oh, my goodness!
Thousands.
Some residents at one time can have 15 different prescriptions and different pills that they get, and some of them get pills four, five, six times a day.
There's times where I had to run down the hallways to make sure that this person is going to get their medication, and some of these medications are life or death.
>> THOMPSON: Did you worry, "Hey, I've got an impossible task here.
I could mess up and actually do something that leads to somebody's death?"
>> All the time.
>> THOMPSON: Mary Kasuba grew so concerned by the lack of staff, she sent a registered letter to corporate headquarters saying that unless improvements were made, she would resign.
>> Since I came to work with Emerald Hills, there has not been enough staff to cover any part of the day-to-day staffing needs to give the residents their quality of care that Emerald Hills advertises in its information-- not enough in the kitchen, housekeeping, resident assistances and med techs.
My biggest concern is the med room.
Staff that was in place before I was employed were placed in positions that are beyond their capacity.
They have been placed in the med room without significant training and support for their position.
A quick fix for a sinking ship.
>> THOMPSON: So you send this letter, you send it to your boss at the facility, you send it to the executives in Seattle.
Did any of them ever respond to you or address these concerns in any way?
>> No, nobody responded at all.
The letters that I sent to the corporate offices, that I sent, you know, return receipt requested, and I called and made telephone calls, nobody responded.
Nobody.
>> THOMPSON: And so Kasuba quit.
The executive vice president for quality services at Emeritus is Budgie Amparo.
>> THOMPSON: A nurse named Mary Kasuba wrote you a letter.
She was concerned that there weren't enough staff in the med room, that they didn't have enough training, that they weren't paid well enough, and that something bad could happen as a result.
>> Right.
You know, that building over time had had many changes.
I'm not going to, you know, deny that.
Now, with Ms. Kasuba's letter, it's just too unfortunate that she felt that way.
We have a lot of platforms that we have in place to allow our staff to express concern.
We have this system called Ethics First.
It's a compliance line where you could call the 800 number and lodge your complaint.
If you wanted to be anonymous, you could be anonymous.
>> THOMPSON: Jenny Hitt says she called Ethics First multiple times about what was going on at Emerald Hills.
>> Somehow they would find out that it was me and I would get questioned.
"Why didn't you bring it to us?
Don't call Ethics First."
>> THOMPSON: So even though the company had an ethics hotline, what you're telling me is your bosses said, "Don't call the ethics hotline."
>> Well, in meetings and stuff, they were like, "Oh, you can always call Ethics," but when it came down to you calling Ethics and they found out you called Ethics, it was a big deal, because they were mad.
>> THOMPSON: A big deal in a not good way.
>> No, not a good way.
>> THOMPSON: Eventually, Emeritus fired Jenny Hitt.
>> THOMPSON: So the company says, "You made a medication error, that's why we fired you."
>> Yeah.
>> THOMPSON: You don't buy that.
>> I don't buy it.
>> THOMPSON: What do you think the real reason is?
>> Because I was raising too much trouble.
I was calling Ethics and corporate and I was even talking to family members, like, "Hey, your mom and dad aren't getting this, you know, you need to get them out."
And they didn't like that.
>> THOMPSON: Even as Hitt and Nurse Kasuba were telling Emeritus the staff couldn't handle the workload, the company was trying to get more seniors in the building.
Melissa Gratiot was the lead salesperson.
>> The biggest thing I always heard was 100%, we need 100%, you know, always.
Fill the building, 100%.
It gave me a lot of anxiety because my philosophy wasn't to move in a warm body just to fill the building.
My philosophy was to make sure it was the right fit with the person, the prospective resident moving in.
And that is one thing that was hard for me, is because they wanted a hard close after every single person I met with.
>> THOMPSON: Do you think the company ever moved in people who were not a good fit for the building, that they needed services the building couldn't provide?
>> I do.
>> THOMPSON: Joan Boice was one senior Gratiot regrets moving in.
>> These photos are some of my favorites.
This one of my mom, this was when she first came out here in the early '50s.
Just kind of shows her care-free, you know, and her adventurous spirit that, you know, just to come out here as a single woman... Yeah, she was just free-spirited and confident, and I think that, you know, throughout these decades of pictures here, I see that time and time again.
>> THOMPSON: Then, when she was in her late 70s, Joan began to show signs of dementia.
>> You know, there are certain pictures where you could almost see it in her eyes that something just wasn't quite right.
>> THOMPSON: Joan's dementia got much worse.
She had trouble talking, she needed assistance walking, and she needed help eating.
In 2007, her family moved her into a facility they were happy with, but it was a long drive.
Emerald Hills was close, and it promised great care.
To be able to spend more time with Joan, they moved her.
But some of the staff didn't think Emerald Hills could take care of Joan.
>> She should never have came.
>> THOMPSON: You don't think she should have been admitted to your facility?
>> Uh-uh.
>> THOMPSON: Where do you think she should have gone?
>> Skilled nursing.
>> THOMPSON: Why?
>> She couldn't walk.
She couldn't feed herself.
She barely even talked to us.
And her health wasn't that good.
And we told them she needs to go to skilled.
>> THOMPSON: So you told the boss, "Joan Boyce needs to go to a skilled nursing home."
>> Yeah.
>> THOMPSON: What happened?
>> They said, "We can take care of their needs.
She doesn't need to move."
>> THOMPSON: Eric Boice's father spent part of every day with his wife.
He began to worry that she wasn't getting the care she needed.
He told his son.
>> My dad said, "Hey, you know, they're not treating Mom well."
And most of it I dismissed.
I wanted to believe that that couldn't be happening.
There was a good deal of denial.
>> THOMPSON: But after three months at Emerald Hills, it was clear to everyone that Joan's health had declined dramatically.
Finally, she was moved to a nursing home, and it was there that doctors discovered that Joan had an array of life-threatening wounds.
>> People that go, "How would you not know that, you know, your own mother... weren't you there?"
Yeah, my wife and I were there four to five times a week between the two of us, but we didn't make it a habit to strip my mom down.
You know, most of the time she was in a bed, blankets, sheets up on her.
You know, I didn't pull the sheet.
I sat with my mom, I held her hand, but yeah, I didn't take the sheets down and I didn't pull down her nightgown and I didn't inspect.
I never even thought.
I never even... You know, again, we were paying money to, number one, make sure that wasn't happening, and if it was, that we would know about it, that we would have been told that we could have done some things, that we could have gotten the proper medical care in there.
And it was shown later that this was all covered up, that the people that did know were being told not to say anything.
.
>> THOMPSON: On Valentine's Day, 2009, Joan Boice died.
The Boice family decided to sue Emeritus and hired elder abuse attorney Lesley Clement.
>> This isn't just about Joan Boice.
This is about everyone who has Alzheimer's or dementia.
This is about every senior who has any type of physical disability and is dependent on staff for help.
Joan Boice was not unique.
Joan Boice is typical of the resident population in assisted living today.
This is the population that they're marketing for.
This is the population they're going after.
This is the population that's going to make them a lot of money.
>> THOMPSON: Clement subpoenaed thousands of pages of documents from Emeritus headquarters in Seattle.
She says one of those documents proves that Emeritus ordered facilities to target seriously ill seniors, such as those with advanced dementia, because they could be charged more.
>> Everything I look at at the corporate level, all of their records, it's all about a push for more money, to increase the cash flow, and there's no talk about caring for the elderly.
I mean, when you read their records, you think that this is a real estate company.
>> THOMPSON: Clement uncovered evidence that while Emeritus was targeting seriously ill seniors, it was failing to hire or train enough staff to care for them.
>> The law in California says you have to have enough staff to meet the needs of your residents, each resident in your building, and it has to be enough in number and competency, and there's training that's required.
And when I looked into... subpoenaed all of the personnel files for the caregivers, I found over and over and over again they did not have the state- required mandated training, they didn't have the Emeritus required training.
Not only did the caregivers not have it, the directors didn't have it.
Is it any surprise to you that with the staffing that Emeritus had in this building that Mrs. Boice ended up falling?
>> THOMPSON: Clement took what she'd uncovered and used it to confront numerous current and former Emeritus executives under oath.
>> It is horrible to hear that.
>> THOMPSON: Catherine Ratelle was a vice president of operations at Emeritus.
>> When you were the VPO at Emeritus, did you have an understanding as to what educational background you expected of your memory care unit directors?
>> I don't recall what the expectation is.
>> How about experience?
Did you have an expectation as the VPO as to what the experience level would be of the memory care director?
>> I don't recall what it was.
>> THOMPSON: Alicia Parga, the memory care director at Emerald Hills, was on the job for 18 months without the legally required dementia training.
>> Did you feel oftentimes that you just did not have the training that you needed to do that job as the memory care unit director?
>> Yes.
>> They were constantly being told to cut labor expense.
Cut labor, cut labor, cut labor.
>> THOMPSON: Susan Rotella was one of the top three Emeritus executives in California.
She said facility directors felt they didn't have enough staff to care for their residents.
>> So there was a lot of frustration around just these kind of, you know, directions from corporate that said, "Cut labor by ten percent."
>> THOMPSON: Rotella said she asked her bosses why they didn't use a staff-to-resident ratio.
Other companies used them to ensure quality care.
>> And who or whom from the senior executive team responded?
>> Budgie Amparo, our executive vice president of Quality.
He got very agitated and he jumped up and he said, "We don't use staffing ratios "because if we did not have the right amount of staffing "in place and a resident issue occurred, or incident, "negative resident issue or incident occurred, and we didn't have the right staffing, we could be sued."
>> THOMPSON: Rotella said she immediately felt blowback from her question.
>> All of a sudden I went from being everyone's best friend to a troubled child because I was bringing up labor standards in this meeting.
>> THOMPSON: Soon after, Rotella was fired.
>> What reason did they give for your termination, if you recall?
>> I was not a "fit."
>> THOMPSON: Rotella is suing Emeritus for wrongful termination.
At the same time employees at Emerald Hills were complaining about a shortage of staff, they were reporting dozens of seniors falling in the building.
Some of the residents were hospitalized for broken bones and other injuries.
Then look at this one.
"Third fall within ten days."
And look at the time.
A lot of these things seem to happen when there's not a lot of staff on duty.
One person who fell was Joan Boice.
>> She was there ten days and she had a fall and she was found face down on the floor.
She was taken to the hospital alone.
This woman suffered from dementia.
They didn't have enough caregiving staff to put someone in the ambulance with her that could be her voice and talk for her at the hospital.
She comes back, that's it.
She's put in bed.
She's put in a wheelchair.
She doesn't move anymore.
And that's what starts her breakdown.
She was in the fetal position.
She wasn't bathed.
She had eight different areas of skin damage.
Pressure ulcers, dead skin that goes through muscle tissue.
You can see into her body.
>> THOMPSON: After consulting with a doctor, Clement concluded the pressure sores led to Joan's death.
Under state law, seniors with wounds this serious are not allowed to remain in assisted living, but Joan stayed at Emerald Hills for weeks with these sores.
Jenny Hitt testified that she tried to treat the wounds herself, even though she knew she wasn't qualified to.
She said her boss told her, "Just don't let anybody know."
Clement also discovered that it was an Emeritus policy to "Keep the back door shut."
Lisa Paglia, a former regional manager, testified about what that meant.
>> What did you understand "Keep the back door closed" to mean?
>> Don't let anybody move out unless they were deceased.
>> THOMPSON: But Emeritus CEO Granger Cobb testifying under oath disputed that description of the back door policy.
>> What does that term mean?
>> Um, it refers to trying to do everything we can in situations where residents want to stay with us, family want their loved one to stay with us, to be able to keep them.
Families usually want their loved ones to stay with us as long as possible, as opposed to skilled nursing, very institutional environment.
So we try to work with the families and do all we can to, you know, accommodate that.
>> THOMPSON: In the Boice case, lawyers for Emeritus offered a completely different characterization of the care Joan received and why she died.
>> The care providers who were providing the care made it pretty clear that they worked very hard to take care of Joan Boice.
We had testimony from witnesses who said they observed-- outside witnesses-- they observed the care staff spending hours with Mrs. Boice, you know, taking care of her, repositioning her, keeping her clean.
So the evidence dictated against Mrs. Boice being neglected.
I can understand how a family could be angry about what's happening to their loved one.
That's real.
Where we go wrong is when we take that anger that that family has and that grief and that suffering and we direct it to the people who were there for the resident.
They're not the evil.
It's the diseases of aging that are the evil.
>> THOMPSON: It was Alzheimer's and a series of strokes that led to Joan's death, according to Dr. Richard Tindall, an expert witness for Emeritus.
>> The bedsores or decubiti did not contribute to her death.
She's having more and more difficulty walking and moving.
She doesn't want to get up on her leg.
They interpreted it as a problem with the foot.
In reality, it's paralysis of the leg.
This is a stroke syndrome.
She died because of her Alzheimer's and stroke leading to a bedridden status and inability to take adequate nutrition and hydration, progressive dehydration, malnutrition, which then you stop breathing and you die.
And that is, in fact, in a hospice situation how Alzheimer's patients and severe stroke patients die.
>> THOMPSON: To counter the Emeritus case, Clement tapped one of the country's leading forensic geriatricians.
>> The key record in this particular case is the description of the pressure ulcers that she acquired at Emeritus.
We have photographic evidence and we have measurements taken at the nursing home where she went, we have a very complete description of what her condition was like when she left Emeritus.
We also have some records from before she went to Emeritus.
If you didn't know anything about Emeritus or the facility and you would look at the condition when she went in and the condition when she left, you would say, "Wow, what happened to her?
Something, you know, really bad must have happened to her."
Then you look at the operation of the facility and you say, "She was neglected.
That's how she ended up like that."
>> THOMPSON: And you think that neglect stems from there being not enough trained staff?
>> Exactly, not enough staff, so no one can help her walk, to keep her walking.
And if you don't help her move, she's going to get a pressure injury to her skin.
So those things all should have been done.
Instead, nothing was done.
>> THOMPSON: Deep into the litigation, Emeritus offered to settle the case.
>> So the company came to us and offered us $3.3 million away, to turn our back and not say any more about this case.
>> THOMPSON: They offered you $3 million?
>> Over three, yeah.
And so... And that is a substantial amount of money, but that also came with basically a gag order, an order that we wouldn't have been able to talk.
We would not have been able to share my mom's story.
They wanted us to turn over all of our investigative, everything...
They knew that we had a lot of stuff that had been uncovered, and they wanted all that.
They wanted it all to be shredded, all to be destroyed.
That was part of the bargain for the money.
And we weren't willing to do that.
>> THOMPSON: Emeritus says it never told the family it would shred the documents and that any offer it made was not an admission of wrongdoing.
And so the trial went on, and on March 5, 2013, all 12 jurors found the Emeritus Corporation liable for recklessness, oppression and fraud in the wrongful death of Joan Boice.
And they ruled that Emeritus executives were well aware of the unfitness of their employees.
The jury awarded punitive damages of nearly $23 million.
The amount came from combining Granger Cobb's annual compensation with that of the company's chairman.
And the 81 cents?
That was to remind Emeritus of Joan's age.
>> It's a huge number.
It's a devastating number.
But I think it's just a function of the size of my client.
I think they are in some ways a victim of their success and growth, and it's unfortunate that because they're large that the verdict, therefore, is large.
>> Last weekend, I was with some friends and they said, "Isn't that... aren't you just ecstatic?
Aren't you just so overjoyed with this verdict?"
And it was...
I don't think he thought it was as deep, but for me, I had to sit back, I had to stand back from that question, I had to look, and my honest answer was, "I'm not as overjoyed as I thought I would be."
He was like, and the guys that I was with were like, "What?"
Technically, yeah, we won and Emeritus lost.
But to me, it's bigger than that.
It's more about right and wrong.
And I don't feel that with this loss, Emeritus is doing anything different.
I honestly don't think they've changed their practice, their business as usual.
>> THOMPSON: We asked Emeritus executives to comment on camera, but they declined.
Instead, they responded in writing: "We are extremely disappointed that this jury found our care "of Mrs. Boice unsatisfactory and we adamantly disagree "with the outcome of this trial.
"Our dedicated and hard-working caregivers provided her "with quality care during the three months she lived with us."
The company also wrote that its violations have trended down significantly over the last five years.
And Emeritus said it is appealing the jury award.
But in response to its initial motion, the judge ruled the Boice family had proven their case and upheld the nearly $23 million award.
>> I would say that today, one of the few remedies that consumers have with regard to assisted living are lawsuits, and that's what we see.
And that's unfortunate because the industry is always complaining, "Oh, there's too many lawsuits and they are frivolous," et cetera.
I'm shocked that there aren't more, to tell you the truth.
When you have a regulatory system that's not doing its job, when you have people who are filing complaints and you might as well file those complaints down a black hole, that's what's going to happen.
It's just a horrible system right now.
>> The head of a state licensing agency told me assisted living is the rock we don't want to look under.
They know there's a problem, but they don't have the resources.
When it's nursing homes, we have federal support for a huge amount of the surveys and inspections and complaint investigations that they do, and for the training that the surveyors get.
None of that exists for inspection and regulation of assisted living.
None of it.
We're creating an industry with a million people in it who are becoming more frail, who are poorly regulated by the state.
That's why I talk about it as a ticking time bomb, because we're going to see more deaths, more injuries.
And families are going to be so shocked because they think they've made a good decision, they think they've made a safe decision.
.
>> I have dreams-- I guess they border on nightmares-- that my mom is with me and she's lucid for a moment, and, um... .
You know, and I basically use that time to apologize to her for not being the voice that she needed, for not demanding more of the people that we trusted, um, with her care.
But that's, uh... That's a fairly common dream that I have.
So... .
>> Go to pbs.org/frontline for more on what questions to ask when searching for an assisted living facility.
Explore additional reporting on the industry from our partners at ProPublica.
Learn about the debate in Washington over regulating senior care.
Plus, read our extended interviews with Emeritus CEO Granger Cobb... >> Human beings will make mistakes.
>> ...and others.
And follow Frontline on Facebook and Twitter or at pbs.org/frontline.
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>> For more on this and other Frontline programs, visit our website at pbs.org/frontline.
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Frontline's "Life and Death in Assisted Living" is available on DVD.
To order, visit shoppbs.org or call 1-800-PLAY-PBS.
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