Is quality of elder care in jeopardy?

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While the number of care facilities has doubled, frequency of inspections has declined.

Before going to sleep on Aug. 31, 2006, a 72-year-old woman living at Oceanside Home Care in Los Osos was fed some macaroni salad and corn bread.

The next morning staff at the six-bed residential care home found her lying unconscious on the bedroom floor. Paramedics took her to the hospital after diagnosing a diabetic coma--her second in three weeks.

The woman, whose identify was not released by state investigators, never regained consciousness and died in the hospital seven days later.

Her death prompted an investigation by state officials, who found Oceanside had "insufficient and unqualified" staff who failed to monitor the woman's diabetes. The woman's memory was impaired, and staff did not follow her prescribed diet, record her glucose levels and track her insulin injections, inspectors found.

Small residential care facilities for the elderly such as Oceanside position themselves as less restrictive and cheaper alternatives to nursing homes. The number of small facilities in San Luis Obispo County doubled in the past decade, mirroring statewide growth trends.

Given the rapid growth, coupled with the poor track record of some facilities and an indication that some accept people who are increasingly frail, watchdog groups say more state regulation and oversight are needed.

The lack of oversight has led to a "catch me if you can" attitude among some facilities, often called assisted living or board-and-care homes, said Terry Donnelly, executive director at the California Advocates for Nursing Home Reform.

State licensing officers inspect the facilities once every five years unless they receive a complaint like they did from the Long Term Care Ombudsman following the diabetic woman's death at Oceanside.

Following its investigation, the California Department of Social Services' Community Care Licensing Division told Oceanside owner Loreta Gregorio to hire more staff and train them better. They fined her $150.

Gregorio deferred requests for comment to her attorney, Michael Levin. He said his client hired a consultant for six months to improve facility operations, and on two subsequent visits in late 2006, state inspectors noted no deficiencies.

Assisted living in smaller home settings allows people to "age in place" said Charles Skoein, president of the Community Residential Care Association of California, a trade group that lobbies for small board-and-care homes.

The entire residential care industry should not be punished for a few bad homes because the majority provides adquate, qualified staff and excellent care, Skoien said. Legislation to "micromanage" the industry is unnecessary, he added.

"The bad ones are always going to be bad," Skoien said, "and what we have to do is weed them out on the basis of poor care."

Rapid growth, lack of training

Small residential care homes dominate the assisted living industry. Often they are converted single-family homes with three or four bedrooms.

In 1998, San Luis Obispo County had fewer than 40 small board-and-care homes for the elderly. Today, there are 74 with 10 or fewer beds.

"That's a good thing, because the county is getting older and those people will need a place to live. But the oversight has not kept pace," said Karen Stenson, executive director of the county's Long Term Care Ombudsman program.

State law requires residential facilities to have adequate staff-to-resident ratios. But it does not define adequate, leaving much room for interpretation, Stenson said. Having too few staff and having untrained staff are the most common complaints at facilities, she said.

The staffers must undergo 10 hours of annual training; that training can be given by an administrator, who must have 40 hours of training.

The lack of training was Arroyo Grande resident Sharon Burton's complaing about the facility that accepted her dementia-stricken mother even though none of the staff had training in dementia.

"They must pass out these licenses like candy," Burton said.

Knowing that her 78-year-old mother could be difficult to care for, Burton said she visited 32 assisted-living facilities, large and small, before settling on a six-bed facility in Los Osos.

But after just a few weeks, not believing the facility could guarantee her mother's safety, Burton moved her back home with a full-time caregiver. Burton doubted the staff could adquately track her mother's multiple prescriptions, because none had medical training and many spoke limited English, she said.

She wants stricter state regultions. She also said families must research facilities and plan to stay closely involved in a loved one's care.

Homelike settings

Proponents of small residential facilities say they provide a less expensive and "homier" option for elderly people who can no longer live alone but do not require the intensity of care given in nursing homes. The vast majority of such facilities have kind owners and stff that provide personalized care to create a homelike setting, said Mike Sudarff, who runs a local business that helps families place a loved one. "I think the good providers are worlds away from skilled nursing facilities," he said.

San Luis Obispo County has high-quality facilities, but it often takes time and a fat wallet to find and afford them, ombudsmen say. The good facilities often have waiting lists.

While running a business that helped families relocate elderly relatives into assisted living or residential care homes, Heahter Ristad visited nearly all such homes in San Luis Obispo County and saw their wide range in quality.

Ristad said she visited homes that served two pieces of bread with a slice of onion and called it lunch. She also saw facilities that had caregivers whose English could not communicate with residents, let alone read medication labels and call doctors.

But she also visited homes were residents had multiple menu options, full activity calendars and caregivers who strived to create a homelike atmosphere.

Ristad said she works to create the latter experience at Aunt Carol's Place, the six-bed facility she opened in May in San Luis Obispo. "In eight years, I've seen them all and know what families like and don't like," Ristad said.

Caregivers with good communication skills, tasty food, social activities, transportation to medical appiontments and diligent medication management are crucial to making families feel comfortable when leaving a relative in a new place, she said.

But that atmoshere is not cheap. The two single rooms each coast about $5,000 a month. A shared room is slightly less expensive. The master suite, which can accomodate a couple and has a whirlpool bathtub and private patio, costs $10,000 a month.

Those are average prices for facilities in San Luis Obispo, officials say. Facilities in Los Osos and Paso Robles tend to be less expensive, and facilities in Santa Maria are the least expensive on the Central Coast.

Older, sicker and needier

Consumer advocates acknowledge that residential homes fill a need and that many do provide high-quality care. But they caution that insufficient regulation and data collection make it nearly impossible for consumers to make informed decisions.

Unlike nursing homes, which are federally regulated, states monitor assisted living homes. Assisted living homes also have social licenses, which are less restrictive than the medical licenses required for nursing homes.

California does not require residential care homes to report information on the health status of its residents, occupancy rates or how many residents eventually transfer to nursing homes. As a result, little is known about them. But noting that nursing home occupancy rates have remained constant, while the elderly population has increased, experts assume residents in small facilities are increasingly ill, frail and needy people, who a decade ago would have been in nursing homes.

Keeping more people in homelike settings is generally a positive thing, but not if clients need high levels of care and are expecting to receive it there, Donnelly said.

The facilities are not required to have trained medical staff, though they admit bed-bound people, those far into the stages of dementia and clients with complicated chronic conditions, requiring complex regimens, he said.

"They have camouflaged residential care as a social model," Donnelly said, referring to the less lenient licensing.

Beneath the marketing

For six years, Mary Sorenson cared for her husband in their Arroyo Grande home after his diagnosis with Alzheimer's disease in 2000. Eventually, the task exhausted her, and she agonizingly moved Russ into a care facility. She looked at dozens of small and large assisted living facilities in the county and decided on a new six-bed home in Paso Robles that claimed to specialize in dementia care for $5,000 a month.

Sorenson expected to feel relief, but she quickly learned that no one on the facility staff had dementia care training or knew how to work with her husband. One evening, she received a call from a staff member who asked her to drive the 50 miles to Paso Robles to clean her husband after he had soiled himself.

Sorenson moved her husband to another facility before he died in December 2006. She wants people to know they may receive limited care in some residential homes despite their hefty price tag.

"You're not getting skilled nurses, but if you're going to pay for dementia care, they should know about dementia," Sorenson said. "I never thought about a convalescent home, but in the end, he may have gotten better care."