Hope I Die Before I Get Old

Stricken with dementia and unable to care for herself, Lucille Ayers died a horror-movie death.

"My mother basically died staked to an ant pile," her son James says. "She was eaten alive."

Before her health declined, Ayers, a devout Catholic, opened her home to visiting priests and troubled teens who needed a place to stay. She was known for her cakes and other treats she baked on a daily basis. When her son Thomas developed diabetes, she tinkered with her recipes until no one could tell there wasn't any sugar in her chocolate chip cookies.

But Ayers couldn't take care of herself. She started leaving pots on the stove and forgetting about them. She needed to live someplace with round-the-clock nursing care, someplace where the staff would keep a close eye on her so she'd be safe.

After visiting scores of nursing homes and assisted-living facilities, Ayers and her two sons settled on Peppertree Square, an assisted-living facility in Peoria.

On September 1, 2003, Lucille Ayers' caretakers found her covered with ants. "Ants in her bed, all over body, in hair," a staff member wrote in a log book.

The staff moved Ayers to another room, but didn't summon an exterminator, even though the log shows ants were found in at least two other rooms that day.

Ayers spent a second night in another room after ants were found in her shower. She returned to her room the next night. An exterminator arrived the next day -- three days after the infestation began -- and either sprayed or inspected rooms where ants had been discovered, according to a Peppertree Square report to the Arizona Department of Health Services.

According to the paperwork, Ayers was fine when a staff member gave her some medication at 2 a.m., 17 hours after the exterminator's visit. At 3:20 a.m., she was being attacked by thousands of ants and bleeding from a gash on her right arm that she suffered after falling out of bed, likely in a fruitless effort to flee. Her sons believe their mother was in such a state of shock that she couldn't get away.

The staff stripped off her clothing and threw water on her to wash away the insects. A Peoria police officer reported Ayers was conscious, but not speaking. She was bruised and still covered with ants when she arrived at the emergency room at Boswell Memorial Hospital in Sun City.

When Thomas got to the emergency room, his mother was calling his name. Her body was shaking. Ants were crawling from her nose, ears and mouth. They were black, about a quarter-inch long. "The nurses were wiping them off as fast as they'd come out," Thomas recalls. "They'd already cleaned her three times, and the paramedics had cleaned her twice. The whole side of her face was just black from the fall."

Thomas Ayers called his brother. "'Don't bother coming down,'" James recalls his brother saying. "'You don't want to see her like this.'"

Lucille Ayers died two days later. She was 87. The official cause of death was cardiorespiratory failure due to coronary artery disease, but Ayers' sons say the ants killed her. At least one expert agrees. An accumulation of ant venom triggered the medical problems that caused her death, according to Dr. Mark Fischione, a pathologist with the Maricopa County Medical Examiner's Office who has been retained by the sons' lawyer.

"It is my opinion, to a reasonable degree of medical certainty, that Ms. Ayers died as a result of complications of numerous ant bites," Fischione writes in a letter to attorney John Brewer, who has sued the Oregon-based owner of Peppertree and the exterminator.

In a report to the Arizona Department of Health Services submitted two weeks after Ayers died, Peppertree Square never mentioned the first ant attack. Rather, Peppertree Square simply said that ants had been found in her room. The state never followed up on the facility's investigation, closing the case with no citations issued.

Thomas and James Ayers say they should have been told the first time ants attacked their mother. Had they known, they say they would have pulled her out of the facility. They also say Peppertree Square should have kept her out of her room for several days after the first attack instead of sending her back as soon as they thought they had taken care of the ants.

At the very least, regulations required that Peppertree Square notify Ayers' family the first time she was attacked by ants, confirms Lisa Wynn, deputy assistant director for the Arizona Department of Health Services. Trouble is, the state, which didn't conduct an independent investigation, didn't know about the first incident until New Times informed it of the log entry.

The Arizona Department of Health Services is charged with protecting residents at assisted-living facilities and nursing homes. But a New Times analysis shows regulators are soft on the facilities that are supposed to keep the state's elderly safe, particularly nursing homes, which house the most vulnerable.

Since 2001, DHS has issued at least 65 citations to 30 of the 77 nursing homes in Maricopa County for neglect, abuse and mistakes so serious that residents either suffered injuries or death.

Fewer than half of those citations resulted in fines or other punishment.

Government has a strong hammer, even in Arizona, where social services are notoriously below par. The state can revoke licenses and shut down nursing homes. It can issue fines. It can appoint temporary managers to take over homes when administrators aren't keeping residents safe.

But that doesn't happen very often.

When nursing homes do pay, it's usually at the barrel of a lawsuit, and years after the fact. Now the Legislature might change that ("A Legal Matter").

At Glendale Care Center, a nursing home on the west side of town, at least five residents died in 2000 and 2001 because of poor care, according to lawsuits filed in Maricopa County Superior Court. The home's owner has settled most of the cases. After the first three deaths in 2000, the federal government issued a $17,000 fine and banned new Medicaid or Medicare patients for three weeks. After two more deaths in 2001, the feds banned new patients for all of two days.

The state issued no fines or other penalties.

In fact, until 2003 the state never fined nursing homes at all. Even now, fines aren't automatic. When they are levied, fines are paltry, and the state rarely invokes the maximum $500 penalty.

State health officials haven't shut down an Arizona nursing home in at least seven years, and officials can't recall any cases where the state has appointed temporary administrators to protect residents.

The regulators admit that they're not where they need to be.

"Frankly, I would like to see more civil penalties and criminal prosecution on a larger scale," Wynn says. "Slowly, we're ramping up. We're really improving in the way we investigate complaints. You'll probably see a more gradual shift toward civil monetary penalties."

But regulators sound more like lobbyists for the nursing home industry than watchdogs as they explain why they haven't gotten tough. Nursing homes, they say, operate on tight financial margins.

"We don't want to . . . ," begins Mary Wiley, assistant director of the state health department's division of licensing services. Wynn finishes the sentence.

"Hasten their demise," Wynn says.

But real people are dying out there.

In theory, the nursing home business is heavily regulated. In practice, enforcement is an exercise in threats and wrist taps. As usual, government officials cry poverty.

State regulators say they're hampered by a shortage of experienced inspectors and a high turnover rate.

DHS is now fully staffed with 27 inspectors who respond to complaints and conduct annual inspections, but there's a big caveat: More than half have been on the job less than nine months, and it takes at least 10 months for a nursing home inspector to become proficient. Besides inspecting each of the state's 134 nursing homes annually, a process that can last as long as five days for each home, these inspectors respond to more than 800 complaints each year.

The number of possible violations exceeds 150, including everything from failure to treat bedsores to failure to deliver mail to residents. At least four agencies have a hand in nursing home oversight, but the buck stops with DHS, which is responsible for finding out what went wrong and issuing citations.

There's no shortage of information on the Internet, but it's divided between federal and state Web sites, with no single place a consumer can go to find out whether a home is good, bad or mediocre. In short, you have to dig to get to the truth.

Unlike online information, verbatim reports include allegations that could be true, but that the state wasn't able to prove. It can take weeks for DHS to produce inspection and complaint reports, which cost 25 cents per page and contain detailed information rather than online summaries that often don't capture the full gravity of a violation. Otherwise, you must settle for a bureaucracy's abbreviated version or trust a nursing home to produce inspection reports upon request.

New Times has found:

• The Arizona Department of Health Services has a history of downplaying the seriousness of violations in reports to the federal government, which can fine homes or ban admissions.

• Penalties are light. The maximum fine is $500, although that can be ballooned in some cases -- say, a bedsore that goes untreated for several weeks -- if the state levies the penalty on a per-day basis. Other states have much bigger sticks. In Washington state, the maximum fine is $3,000; in California, it's $100,000.

• DHS doesn't report cases to the Attorney General's Office for listing on the state elder-abuse registry, as required by state law. The registry is supposed to serve as a quick way for the public to find out who's been giving substandard care.

Since the health department started issuing fines last year, the state, as of August, had fined a dozen Maricopa County nursing homes a total of $30,650. The biggest were levied against Plaza Del Rio in Peoria, which was hit with a $14,100 penalty for not getting a state license after an ownership change, and Freedom Plaza Care Center in Peoria, which paid $8,050, also for not getting a license after the home changed hands.

At least nine Maricopa County nursing homes haven't been punished at all after inspectors found patients had suffered real harm because of poor care. The cases include:

• In February 2003, the state found that Suncrest Healthcare Center in Phoenix near South 24th Street and East Southern Avenue hadn't given morphine to a woman before such simple tasks as taking a shower, as ordered by her physician. Her pain was obvious when the staff cleaned a bedsore: "During the hour-long treatment, the resident, who is non-verbal, occasionally widened her eyes and batted and waved her left hand in the air toward the nurse, clenched the side rail with her left hand, displayed facial grimacing, including tightly closed eyes, and her body was shaking." The state inspector who wrote this account found that the woman hadn't gotten any pre-treatment painkillers for at least two weeks. The state found a total of 15 violations, including a woman who went three days without a shower and a woman who sat naked from the waist up in a hallway for several hours, in full view of staff, visitors and other residents. Rooms and halls reeked of urine, and floors, walls and privacy curtains were stained with feces.

• In February 2003, the state found that the staff at Bryans Extended Care Center in Phoenix, which has since been acquired by a new owner, didn't change the bandage over a sore on a resident's heel for 11 days. The resident developed gangrene and had his leg amputated below the knee.

• In September 2003, investigators determined a resident fell out of bed at Phoenix Mountain Nursing Center in northeast Phoenix after the home used improper bed rails. The resident suffered a fractured hip.

• In September 2003, Heather Glen Care Center in Glendale was cited for failure to get dental care for a resident with loose and broken teeth. He cried out when his teeth were touched, and jerked away when a staff member approached with a toothbrush.

• In February of this year, the state found that Highland Manor Health and Rehab in Phoenix hadn't given enough water to a resident who suffered dehydration so serious he was sent to a hospital.

• In April, the state found that Life Care Center of Scottsdale hadn't properly treated or assessed pressure sores in four residents. The home also hadn't followed doctors' orders in tracking hydration in two residents, one of whom developed a urinary tract infection. And the home hadn't used the proper bed rails for a resident who fell out of bed and broke her hip.

In yet another case that resulted in no fines, Eugenia Zarembski fell and broke her right leg in the spring of 2003. Her doctor told the staffers at Plaza Del Rio, a Peoria nursing home, to keep a leg brace in place at all times. They took him literally.

Three weeks passed before anyone looked under the brace, even though the staff knew Zarembski was at high risk for developing pressure sores and was supposed to be checked weekly from head to foot. By the time a nurse found the sore on Zarembski's right calf, it had turned black. She had a cluster of less serious sores around her knee.

Three days after the sores were found, Zarembski's family took her out of Plaza Del Rio and sent her to a nursing home in Modesto, California, where the staff noted she was "dirty and unkempt." She smelled of old urine, according to admission notes written the same day she left Plaza Del Rio. Dirt was caked between her toes. "Teeth dirty, unbrushed," her new caretakers noted. Her right heel was black from another sore; her left heel was red and mushy.

Zarembski died on October 4, 2003, from pneumonia. She was 94. Malnutrition, pressure ulcers and orthopedic trauma were contributing factors, according to an autopsy report. In a lawsuit filed in September, Zarembski's niece says the nursing home and the physician who ordered the leg brace are responsible for her aunt's death.

Zarembski wasn't the only one who suffered at Plaza Del Rio. While investigating her case, a state inspector found that three other residents had suffered harm because their pressure sores weren't properly treated. One woman hadn't had the bandage over her sore changed for two weeks; her daughter told the inspector that the staffers never repositioned her mother to help the sore heal. The staffers certainly seemed busy: In full view of the inspector, a nurse's assistant summoned via a call light to help change the woman's soiled undergarments bellowed, "I told them don't put me down for no lights 'cause there's no time for lights here."

Because of "lack of sufficient evidence," inspectors couldn't substantiate an allegation that Plaza Del Rio hadn't given Zarembski enough food. The complaint report shows the state relied on the home's records, which showed Zarembski gained two pounds during her three weeks at Plaza Del Rio and weighed 91 pounds when she was sent to California. There's no evidence the state checked with the Modesto home that admitted her the same day she left Plaza Del Rio.

According to the Modesto home, Zarembski weighed 75 pounds when she arrived, 16 pounds less than claimed by Plaza Del Rio.

Plaza Del Rio wasn't fined or otherwise punished. In the world of nursing home enforcement, a bedsore here and there doesn't count. Eugenia Zarembski and these other folks were gimmes in a system built on second chances.

The Department of Health Services says no fines were levied in any of these cases because violations were considered isolated incidents. "That has changed," says Catherine Corbin, program manager in the department's enforcement section. The department now considers fines when just one resident is injured or killed, she says. But punishment still isn't certain, even in homes with histories of not meeting standards.

Life Care Centers of Scottsdale, for instance, had 20 violations between July 2003 and September 2004, twice as many as the statewide average. The home had 18 violations in each of the two previous inspection periods, which can last as long as 15 months. Since July 2001, inspectors have cited Highland Manor for 50 violations.

Yet neither of these homes has been punished, even after the state documented real harm to residents.

Nursing homes are big business in Arizona. All told, the state has 16,104 beds in 134 nursing homes that collect more than $30,000 a year for each Medicaid resident. If every bed was filled, with Medicaid paying the bills, that works out to a conservative $483 million a year.

Until last year, Arizona relied on someone else to punish nursing homes, referring the worst violations found by state inspectors to the federal government for sanction. It was a haphazard way to hold homes accountable.

The federal system has long been criticized for going light on bad nursing homes. For one thing, the federal government doesn't always follow state recommendations for sanctions. For another, the feds give grace periods: If violations get fixed within 30 to 60 days, no punishments are levied. And homes that pay fines without appealing receive a 35 percent discount.

Furthermore, the federal system is reactive rather than preventive. In most cases, someone has to be killed or hurt before the federal government takes action. Even then, the feds don't require states to refer cases for sanction if only one person dies or is injured. Homes on the brink are rarely punished at all for violations that have the potential to injure or even kill.

Besides issuing fines as large as $10,000, the federal government can terminate a home from the Medicaid program or temporarily stop a home from accepting new Medicaid or Medicare patients. A ban on new residents is a huge hammer, given that the government pays about 60 percent of nursing home costs in the United States.

Since 2000, the federal government has banned new admissions to homes within Maricopa County on just eight occasions, and for periods as short as two days, even when poor care has led to death. During the same period, the feds have levied $180,600 in fines against 14 nursing homes in the county. Three homes still haven't paid fines totaling more than $76,000 that were levied as long as two years ago.

"There's so little enforcement going on," says Toby Edelman, an attorney with the Center for Medicare Advocacy in Washington, D.C. "We don't say, 'Yes, you have to fix it for the future, but there's also a consequence because this person died.' If you don't pay your taxes, they might prosecute you if it's really bad. You can't just say, 'But I paid my taxes last year.' So what? You have to pay your taxes every year."

Since 1997, the Government Accountability Office (formerly the General Accounting Office), which audits federal agencies to determine whether they're doing good work, has been pointing out cracks in the system. Five years ago, the GAO found that the threat of sanctions doesn't force change in bad nursing homes because the homes fix things during grace periods, then lapse.

In July 2003, the GAO cited Arizona as one of several states that underreport serious problems, allowing problem homes to escape punishment.

The GAO looked at state and federal records from between 2000 and 2002, when the state boasted a 25 percent reduction in the number of serious violations found in nursing homes, the biggest drop of any state in the nation. On the surface, the statistics showed that the state's nursing homes had improved dramatically. But a closer look showed that the state wasn't doing its job.

According to the GAO, Arizona was letting nursing homes off the hook by not telling the federal government about homes with a pattern of harming residents. States are supposed to notify the feds when inspectors find two or more incidents that resulted in injury or death within two years. The feds are supposed to follow up with immediate sanctions. Arizona made 24 referrals to the feds during the two-year period, but the GAO found that an additional nine cases should have been sent to the federal government.

The GAO also determined that the state was downplaying the seriousness of violations, ruling that no one had been harmed in homes with a history of problems when, in fact, residents had suffered real injuries. In one case in which the state found no harm, a resident who was supposed to be turned every hour to prevent her bedsore from worsening went as long as eight hours without being turned. The charge nurse told inspectors she didn't know a doctor had ordered frequent turning. The woman's bedsore progressed from relatively minor to a wound deep enough that muscle or bone suffered permanent damage.

Starting last year, the Arizona Department of Health Services began levying its own fines instead of relying solely on the federal government. The change came after a critical report from the state auditor general issued the month before Governor Janet Napolitano took office in January 2003. The auditor general pointed out that the state had never fined a nursing home and that inspectors weren't following up when homes self-reported problems to the state. The auditor general also said the department wasn't releasing enough information to the public about complaints and annual inspections.

In September, the state auditor general ruled that the problems had been fixed.

But the state still has a long way to go.

When they are levied, fines are small. For example, in October 2003, state regulators determined that Sun View Care Center in Youngtown had harmed residents by improperly using bed rails. Three residents had climbed over their rails and fell, all three within a month's time. Two suffered broken bones. According to the state report, the home kept using the same rails for one woman even after she fell twice. The third time, she fractured her hip.

The state could have levied a $500 fine for each resident who fell and increased it even more with a sanction for every night someone slept in a dangerous bed.

Instead, Sun View paid a $500 fine.

In theory, there should be plenty of information about nursing homes available to the public.

The attorney general maintains an elder-abuse registry that's supposed to include a report from any state agency that substantiates an allegation of abuse, which includes neglect that has resulted in injury.

The Bush administration has advocated a market-based approach to improving nursing homes. By posting information about inspection results on the Internet, consumers can make informed choices before putting loved ones in nursing homes.

The hope is that bad nursing homes will disappear because no one would place a relative in a home that provides poor care. The reality is, there's no place consumers can check to find all the information they need.

The Arizona Department of Health Services posts the dates and amounts of state fines against nursing homes on its Web site, but no information about violations that prompted the punishments. For that kind of detail, a consumer must refer to the federal government's Web site, which has no information about fines either from the state or federal government.

Even then, what shows up on the Internet can be a far cry from what actually happened. Take, for instance, a woman at Desert Cove Nursing Center in Chandler who developed gangrene in her right foot in early 2003. There was no mention of required weekly skin checks in the woman's record, nor had the home adequately addressed her risk for developing circulation problems in her foot. A dialysis center outside the home called paramedics when she complained of a headache, and was not as responsive as usual. By then, her toes were black, and doctors doubted whether they could be saved.

The state took no action, so nothing appears on the state's Web site. The federal government fined the home $1,500 and dutifully summarized the violation on its Web site for consumers.

Here's how the violation read: The home failed to "comply with program requirements between annual inspections; although it corrected these problems before the most recent inspection."

Unless you make a public records request, wait days or even weeks for a response and pay for the inspection report, that's all the information you'll get.

It's a problem easily solved: The state health department could post inspection reports on the Internet so the public would have a firsthand picture of what really goes on in nursing homes. At least three states, including Alabama, Iowa and Minnesota, post reports online. Industry insiders say they're all for it, but Arizona health officials plead poverty -- there's no money to post inspection reports on the Web, they say.

Theoretically, the public shouldn't have to rely on the department's Web site to find out what's going on in nursing homes.

Under Arizona law, any state agency that substantiates an allegation of abuse or neglect that has caused an injury must tell the Attorney General's Office and provide a written copy of its decision so that the information can be included in the state's elder-abuse registry. The registry is filled with complaints filed by lawyers who have sued nursing homes, but the state health department doesn't forward copies of inspection reports documenting harm to the Attorney General's Office for inclusion on the registry, which is easily accessible to the public.

The system is so big that it's become unwieldy. With at least four agencies that take complaints, the regulatory process can be confusing, for both nursing homes and consumers, says Linda Schoenbeck, director of utilization services for the Health Services Advisory Group, which has a federal contract to help nursing homes improve. She remembers a meeting a few years ago on nursing homes in the Governor's Office. "I was in this room with all these people, and I'm thinking, 'We're all taking care of the same patients, but we don't even know each other,'" she recalls.

Schoenbeck's organization is supposed to teach nursing homes how to provide good care. The federal government calls it a non-punitive way to improve care. But it's a voluntary program. Just 20 of the state's 134 nursing homes are taking part.

William J. Scanlon, former head of the GAO division that deals with nursing home issues, criticizes the notion that training can take the place of sanctions.

"Most of us know from raising children about the basics required to sustain a human being, basics that some nursing home residents do not receive," Scanlon told the U.S. Senate Committee on Finance last year. "The types of deficiencies we have been talking about involve practices so egregious, so lacking, that one does not have to be a health professional to instantly understand their inadequacy."

The nursing home industry argues that government reimbursements are so low that nursing homes can't afford to pay big fines. If the government got tough, the elderly would suffer because homes would go out of business and there'd be a shortage of nursing homes, say the apologists.

Scanlon doesn't believe the hype.

"We've been hearing that same sort of line for the last 30 years," Scanlon tells New Times. "We still have an industry that's about the same size, relative to the size of the elderly population, as it's been for the last 30 years." Beyond that, Scanlon, who left the GAO and became a private health care policy consultant earlier this year, notes that most nursing homes provide good care. "Why do 80 percent of facilities manage to comply?" he asks. "If 80 percent can do it under the same system -- the same Medicaid rates and the same rules -- why can't the other 15 to 20 percent?"

Fines don't always force improvement. And when that happens, the state is reluctant to take further action. Esperanza Manor in south Phoenix is a case in point.

The nursing home on South Seventh Street near South Mountain Park is a home for the poor. Every resident is there courtesy of Medicaid. The home has had a series of owners over the years, but problems have remained a constant.

In 1999, while the home was operating as Thunderbird Healthcare Center, residents were repeatedly assaulting each other so savagely that two men ended up in the emergency room. The home also came under scrutiny after a woman suffered fatal burns that same year. The state failed to substantiate an allegation that she'd been left too long in the sun; the home maintained that the burns resulted from a reaction to a prescription drug. But the incident triggered outrage. Lawmakers organized a task force to study how well the state enforces nursing home standards and keeps the public informed about conditions in nursing homes.

In the end, nothing changed.

Four years later, the home, now called Esperanza Manor, was a quiet hellhole. There was no outrage and no publicity. But people suffered badly.

"When staff pulled the resident's right fingers partially open, the resident loudly screamed out. A foul, pervasive odor emanated from the resident's hand. All fingernails were observed to be yellow and brown and 1/4 to 1/2 inch long. Brown debris was noted under the fingernails and from the hand when the hand was washed. Indentations, that did not lessen when the skin was rubbed, were present on the palm where the fingernails had been and imprints of the resident's fingernails were observed on the palm, which did not lessen when rubbed. The skin of the resident's palm was observed to be white-colored and macerated."

That's a firsthand account from a state inspector who found five Esperanza Manor residents with hands clenched into near fists because they weren't provided splints or hand exercises. Indeed, they didn't even have towels. Residents used sheets and pillow cases to dry off after showers.

No one died at Esperanza Manor last year, but judging from state reports, that was a matter of luck. The home didn't promptly transfer a hypoglycemic resident to a hospital, as his doctor ordered. More than four hours after the transfer order, a relative found the man in a seizure with a pulse of 140, twice the normal rate. Fire department paramedics rushed him to the emergency room. Records showed that the home hadn't checked his medical condition for five hours. The home didn't provide psychiatric care or psychological screenings for suicidal residents, including one man who tried to kill himself with a drug overdose.

One resident had halitosis so bad that the hallway outside his room reeked. Inspectors found no toothbrush or toothpaste in his living quarters and concluded he'd received no dental care. The home's staff didn't change bandages on another resident with oozing sores on his feet, nor did the staff tell the resident's doctor when he developed an allergy to his prescribed antibiotic.

"The resident was observed several times to have loose, soiled, wet gauze wrapped around both of his feet with either no additional foot wear or soiled, wet slipper socks," an inspector wrote.

Residents who were allowed to smoke unattended had burn holes in their clothing. An incontinent resident wandered the home for hours in soiled pants. A staff member who sat beside a man did nothing even though he "had a milky, white nasal drainage that was going into his mouth as he fed himself. The staff member did not make any effort to wipe the drainage and the resident continued to feed himself through the meal." Instead of providing separate bowls, the staff mixed a blind resident's food together. The staff gave corn flakes to another resident who was supposed to eat puréed food only. No one intervened when she poured water over the cereal and shoveled still-dry flakes into her mouth.

Residents were placed in front of a television that didn't work, left to stare at a screen that showed only static. Perhaps understandably, some residents took to drinking, smuggling in bottles of whiskey and getting so drunk that the staff couldn't safely administer medication.

All this was documented after the federal government hit the home with a $30,600 fine in April of last year upon finding Esperanza Manor had failed to correct dozens of violations.

The home declared bankruptcy, and the fine remains unpaid.

Inspection records show that Esperanza Manor got worse after the fine was levied. Prior to the fine, state inspectors found 38 violations between January and May of last year. Afterward, the state issued 48 citations, including three for violations that resulted in residents being harmed.

The state issued no fines, nor did DHS bring in a temporary administrator to manage day-to-day operations, as the law allows.

The federal government never barred new admissions.

Lisa Wynn, who's in charge of enforcing standards at DHS, says inspectors who found the most serious violations remained at the home until the problems were fixed.

Big deal, says Steve Garcia, a California-based lawyer who says he's heard from one potential plaintiff and researched the home's inspection history. With such a shocking list of deficiencies, it should have been clear that the home couldn't be trusted to keep residents safe, he says.

"Why didn't licensing do something about it?" Garcia asks. "Why did they just allow them to continue to operate in a fashion that allows these things to happen?"

Homes that rely exclusively on Medicaid to make ends meet are asking for trouble, Garcia says, because reimbursements are so low. "You might as well start up the ambulances outside to ship them to the coroner's office," he says. Medicaid pays less than $120 a day; the average charge to a private insurer in the Phoenix area in 2002 was $162, according to a survey by MetLife.

Garcia adds the obvious: "If it's not enough money, don't take the people."

Esperanza Manor made the front page of the local paper last February when the home put 22 residents on a charter bus and threatened to dump them at a Maricopa County business office because the county hadn't paid its bills for residents sent there under the county's health plan. As the bus cruised through the city, the county cut a check for $186,000 and the residents were returned to Esperanza Manor.

The bus stunt prompted meetings between the governor's staff, the Department of Health Services and the Attorney General's Office, Lisa Wynn says, but the meetings led to nothing but a report to the state Board of Examiners of Nursing Care Institution Administrators and Assisted Living Managers for possible unprofessional conduct.

The board, which has the power to discipline nursing home administrators, has been embroiled in internal squabbling and had its funding taken away this year by the governor because of ineffectiveness. It took no action. "We went and investigated," Wynn says. "There was really nothing we could do."

Infinia, the Utah-based owner of Esperanza Manor, sold the nursing home to Dallas-based Centers for Long Term Care on April Fool's Day. The company replaced the home's administrator shortly after acquiring the facility, which is now called Mara Villa Care Center.

At least on the surface, Mara Villa is undergoing a face-lift. The walls are coated with fresh paint, linoleum on the floors is being replaced. A new administrator took over shortly after the home was sold. Other supervisors, including the home's social services director, have been replaced. The number of citations has plummeted. But serious problems remain, according to inspection reports.

In June, a resident who was supposed to be fed only puréed food choked to death on a banana, which wasn't on his prescribed diet. "It was a mistake," acknowledges Peggy Grunden, the home's administrator.

In May and June, a nurse four times failed to give a resident an antibiotic via a special IV line, and the resident's doctor wasn't told. Grunden says the incident prompted Mara Villa to stop accepting residents who require drugs administered through such IVs.

Grunden says she fired a nurse last spring who was overheard speaking with a resident who told her he had tried committing suicide several times.

"The next time you try, let me know and I'll show you how," the nurse told him, according to inspection records.

That incident, as well as others in which nursing assistants reported cases of the staff shoving, kneeing and slapping residents, showed that problems at Esperanza Manor were deeper than the state had known.

"We've had several allegations of abuse -- I'll be up-front about that," Grunden says. Although the law requires health-care workers to report abuse to the state, Grunden says some supervisors left over from the old regime demanded silence. "The certified nursing assistants were afraid they'd lose their jobs," Grunden says.

Neither the state nor the federal government has sanctioned the home's new owners for the most recent violations. None of the violations inspectors found since the home changed hands in April appeared on the federal government's Web site for consumers until New Times asked about the omissions. The day after the newspaper called the feds, the choking death appeared as a failure to "provide food in a way that meets each resident's needs."

Like most nursing home residents, the inhabitants of Mara Villa Care Center aren't in a position to protect themselves.

Katherine Bautista, 82, drifts in and out of lucidity as she describes life at the home where she's lived for eight years. Call lights aren't always answered promptly, she says. "I used to have pretty good service, but lately it hasn't been no good," she says. She misses taking trips in the home's van, which is parked outside but is so old and broken down that it's no longer considered safe. "We went to the airport," she says. "We went to the park and had a picnic."

But Bautista isn't the type who complains a lot. The fresh paint and new flooring please her eyes, she says. Drying off with sheets and pillow cases is no big deal. "I don't mind," she says. "At least you can get dry with it."

Ronald, age unknown, is even more stoic.

Do you have any complaints?, he's asked.

"I don't give a damn," he answers.

Does a lack of towels bother you? "Don't bother me worth a shit," he responds.

How do you spell your name?

"I don't give a damn."

E-mail [email protected], or call 602-407-1715.

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Bruce Rushton