HOME ALONE

William Balmer's life was worth $975.

Balmer, the founder of a logging business, died last August at the age of 93.

That's a good, long life by any standard. But Balmer didn't die of old age. He died, according to an investigator's report, after staff at the Pearl at Kruse Way nursing home in Lake Oswego, where he was recuperating from surgery, failed in a basic duty. Over an eight-day period, they did not give him enough water.

Lake Oswego is a long way from the desert, but records show Balmer died after being dehydrated.

"Intake and output sheets throughout his stay [at the Pearl] revealed the resident's total fluid intake was 400-760 cc per day," a state inspector's report found. (In ounces, that's between 13.5 and 26 per day.) "The recommended fluid intake for adequate hydration is 2,100 cc [71 ounces] per day. The resident's fluid needs were therefore not met."

Balmer arrived at the Pearl Aug. 4, 2006. On Aug. 21, his kidneys failing and his extremities badly swollen, he was taken to the emergency room.

Balmer's brain still worked, but nothing else did.

"He passed at 10:50 am [on Aug. 25] because of neglect, wrong prescribing of medication, not ordering IV hydration and not monitoring his hydration and condition," his daughter, Portland resident Judith Hurliman, wrote in a subsequent complaint.

After an investigation, state inspectors determined that the Pearl at Kruse Way violated both state and federal standards of care.

The punishment? A $975 fine, or about what the Pearl, which charges $6,000 per month, takes in every hour and a half when all 76 beds on the premises are full.

Meredith Cote, Oregon's long-term-care ombudsman, says the slap on the wrist is typical of Oregon's regulatory approach to long-term care.

"For the longest time this state has not focused on quality," Cote says. "In a variety of ways, a

growing number of states have higher standards than Oregon."

William Balmer was just one of thousands of Oregon seniors in the state's elderly-care system. What happened to him may be unusual, but a review of public records and interviews with long-term care experts show two things:

First, Oregon seniors citizens enjoy far weaker protections—in areas such as licensing, training and staffing levels—than in many other states. And second, for-profit long-term care providers are one of the most politically powerful groups in the state.

Although Oregon pioneered creative ways to care for seniors, critics say regulation has lagged behind innovation.

With Oregon's 65-and-over population projected to grow at more than three times the rate of population overall, the quality of care is a crucial issue.

As the Balmer family learned, however, the state agency that oversees long-term care, the Oregon Department of Human Services, has failed to implement many of the safeguards that other states require.

"There's more protection and concern for dogs in this state than there is for seniors," says Hurliman.

Hurliman may be right. For instance, Multnomah County charges more for a doggie day-care license ($85) than DHS charges to license the state's 400 assisted living and residential care facilities ($60)—and the doggie day-cares are inspected twice as often.

William Balmer never expected to end his life in Lake Oswego. A resident of the Coast Range town of Hebo, Balmer, a great-great-grandfather, avid cribbage player and ever-hopeful Trail Blazer fan, was living independently with his wife of 73 years until last June, when he fell and hit his head.

After emergency surgery at Portland's Legacy Emanuel trauma center, he went to the Pearl at Kruse Way for rehabilitation. The nursing home Balmer entered was among the newest in the state, licensed on Dec. 27, 2005.

With its central stone fireplace, soaring ceilings and landscaped courtyards, the Pearl looks more like Timberline Lodge than the stereotypical holding pen for decrepit seniors.

Newly constructed by Wilsonville-based Avamere Health Services, the nursing home (above), which includes a 47-b

ed residential-care facility for Alzheimer's sufferers and a 29-bed nursing facility for rehab patients, is the first of its kind in Oregon, says Avamere President Judy Jackson.

The Pearl is located just off Kruse Way, the metro area's hottest commercial real-estate address. The clean, well-lit facility's appearance convinced Balmer's family he was in a safe place. What they didn't know was that by choosing a home in Oregon, they were selecting a facility governed by the loosest staffing requirements in the country.

According to a study published in the February 2006 issue of the journal The Gerontologist, Oregon nursing homes (which include the rehab facility Balmer stayed in) ranked last out of 50 states in nursing hours per patient.

Other states insist on far more hours per resident per day. For instance, Florida requires 3.6 nursing hours while Oregon requires only 1.65.

Jerry Cohen, director of AARP Oregon, says that staffing is crucial to patient comfort and safety. "The more staff available to respond to patient needs and even crises, the better off patients are," Cohen says.

Hurliman agrees, saying, "At the Pearl, there didn't seem to be enough people, and those who were there didn't seem to know what they were doing."

Avamere's Judy Jackson, whose company operates more than 30 long-term care facilities in Oregon and Washington, says there's more to the story.

"We have deep compassion for the Balmer family, but we strongly disagree with the insinuation that Mr. Balmer's death was a result of the services he received at the facility," Jackson says. "Unfortunately, we do not have the legal right to discuss the details the family is omitting."

In one sense, William Balmer was fortunate to enter a nursing home.

That's because nursing homes, which rely heavily on public funding, are more regulated than assisted-living facilities, where residents have their own apartments, and residential care facilities, which have some shared common areas.

Over the past 25 years, Oregon has pioneered the shifting of seniors away from nursing homes to a variety of less institutional settings, including in-home care, foster care and assisted living and residential care facilities.

The Oregon Department of Human Services, the state's largest agency with more than 9,000 employees and an annual budget of about $5 billion, pushed the shift both to preserve seniors' independence and to save money.

The plan to shift seniors out of nursing homes has worked. A 2006 national AARP survey found that Oregon ranks 48th nationally in per-capita nursing-home population but second per capita in assisted living and residential care use.

Patient advocates argue, however, that in its focus on seniors' independence, DHS has neglected safety.

"Oregon has weaker licensure and lower standards than other states," says the AARP's Cohen.

For example, in Oregon, virtually anybody can work in an assisted-living or residential-care facility. The state requires masseuses and barbers to be trained and licensed, but those who take care of some of the state's neediest, most vulnerable citizens need no prior training at all.

"You could walk in off the street and start working at an assisted-living facility in Oregon that day," says David Fuks, CEO of Cedars Sinai Park, which operates a nursing home and assisted-living facility in Southwest Portland.

That's not true in other states. In Massachusetts and Texas, for example, caregivers must receive training before being hired and must complete a specified amount of additional training each year. In Illinois, caregivers must complete 20 hours of initial training and another 12 hours of follow-up training annually.

Staffing ratios at such facilities in Oregon are also essentially unregulated. The state requires merely that a facility provide "adequate" staffing to meet the 24-hour needs of residents.

At least 18 states have minimum staffing ratios for assisted living, according to a 2005 National Senior Citizens Law Center report. In Alabama and Florida, two states with the toughest standards, ratios can be as high as one caregiver for every 12 residents.

"People talk about Oregon being a pioneer in assisted living," says Eric Carlson, a California elder-law specialist who wrote the Seniors Citizens Law Center report. "But I think that because the state feels ownership of the concept, they've given the industry a pass when it comes to regulation."

Another area in which Oregon lags behind national leaders is licensing. In at least a dozen states, according to federal data, licensing inspectors visit facilities annually.

In Florida, the frequency is even greater—every six months. In Oregon, however, DHS requires licensure inspections only every two years—and 30 percent of facilities get inspected even less often.

Last October, Cindy Hannum, then DHS's top long-term care regulator, told the state's Long Term Care Advisory Committee that the infrequency of licensing inspections "appalled" her.

DHS spokesman Tom Towslee says inspections are a resource issue: "We have 400 facilities and 10 inspectors." Towslee adds that DHS inspects troubled facilities more frequently than every two years. He says the reason licensing fees of $60 are so low is that in 1999, 2001 and 2003, DHS asked the Legislature unsuccessfully to increase them. "After being denied three times, we were told not to come back," he says.

DHS's complaint process is also less than a model of efficiency. Last year, for instance, the agency's Adult Protective Services Unit fielded 3,317 complaints about long-term care providers, an average of nearly 10 a day. By law, the investigations are supposed to be completed within 62 days.

Only half met that standard, however, and records show that investigations routinely took hundreds of days to complete—one in Malheur County lingered for 445 days. (Over the past five years, state records show that an average of about one-third of complaints have been substantiated.)

When complaints are substantiated, the resulting fines are often not much more than a speeding ticket.

"The civil penalties are very low," says Barry Donnenfeld of Northwest Senior and Disabled Services, which serves seniors in five counties.

DHS also does a poor job of making its regulatory findings available to the public. In at least 12 states, according to federal data, licensing and complaint information about assisted living and residential care facilities is posted on a state website. Not in Oregon.

Two states—Alabama and Maine—have rating systems that tell the public whether facilities meet a number of safety standards, including having sufficient staff to meet residents' needs.

In Oregon, facilities must keep a copy of their most recent inspection report on hand. But otherwise, information is scarce.

"There's not much easily accessible information for the public to make informed choices," says Cote. "It just hasn't been a priority for DHS." (Elaine Young, DHS's top licensing official, says the issue is money.)

Even the ombudsman's office—the patient-advocacy organization every state is required to have by federal law—has far less manpower than in other states.

The AARP study found that each employee in Cote's office is responsible for monitoring 6,969 beds—a workload three times the national average for such a function.

Given the large and growing population of seniors in Oregon, it's not surprising that the senior-care industry is a big political player.

Last fall, for instance, two owners of Salem's Holiday Retirement, the nation's largest developer of unlicensed senior housing, gave more than $600,000 to Republican gubernatorial candidate Ron Saxton.

But the real power lies with the Oregon Health Care Association, which represents state-licensed for-profit long-term care providers.

In the 2006 election cycle, the OHCA contributed nearly $400,000 to candidates. That's more than such traditional Salem heavyweights as Associated Oregon Industries and the Oregon Automobile Dealers, Oregon Grocers and Oregon Restaurant associations.

(Although the OHCA gave more money to Republican legislative candidates than Democratic candidates in 2006, it also supported Gov. Ted Kulongoski's re-election.)

The group's heft ensures the industry's bottom line gets plenty of attention in Salem.

OHCA director Jim Carlson is a low-key policy wonk who joined the association in 1994 as a lobbyist. Widely respected in the Capitol and by patient advocates, Carlson has built his membership from 85 a decade ago to 550 today.

"He is an extremely effective advocate for his clients," says Cote, who is often at odds with Carlson on senior issues.

Carlson is known for creativity. In 2003, he cut a deal with Kulongoski that slapped a tax on every long-term care resident. The tax receipts flowed into DHS's budget and allowed the agency to leverage a federal Medicaid match, which meant more money for the industry.

Although Carlson says the resulting funding increase improved patient care, the AARP's Cohen is skeptical.

"Those dollars are very hard to track," he says.

Carlson has been equally effective at resisting attempts to pass tougher staffing rules at assisted-living and residential-care facilities. For more than three years, DHS has been trying to get the industry to accept tighter standards, but nothing has changed.

Staffing levels are a critical issue because people are the industry's biggest expense. "About 75 to 80 percent of operational costs are labor," says David Fuks of Cedars Sinai Park.

Carlson acknowledges that his group has stalled new rules, but says the fault ultimately lies with DHS.

"If new regulations are going to drive costs, we need to build that into the [state] budget up front," he says.

In Carlson's view, it's DHS's job to secure budget increases to pay for any new rules that have fiscal impact. He says agency staffers suffer from a culture of timidity that serves nobody. Patients and providers would fare better if the DHS were both more insistent about increased funding and a tougher watchdog, Carlson argues.

Chuck Skeketoff runs the liberal Oregon Center for Public Policy and is Carlson's ideological opposite. Yet he agrees with Carlson's assessment.

Sheketoff says DHS's conflicting missions create paralysis. "DHS has the dual obligation of promoting the industry and regulating it," Sheketoff says. "Their functions aren't distinct enough."

Carlson says he has repeatedly urged top regulators to demand more money for more investigators, but says they are afraid to challenge top management.

"They have got a military 'chain of command mentality' in DHS," he says. "And a lot of those folks are afraid of the truth."

"That's just not accurate," responds DHS's Towslee. "The issue has been money over the last three biennia." Towslee notes that the governor's current budget includes five new licensing inspectors—a 50 percent increase.

In addition to patient advocates, one other group is eager to address long-term care staffing issues.

Last year Service Employees International Union Local 503, the state's second-largest public-employee union (behind the teachers' union), planned a ballot measure to increase nursing-home staffing.

That prospect, Carlson says, caused the OHCA to ramp up its political contributions.

"We saw a $100-million-a-year unfunded mandate heading our way," Carlson says.

In July, however, Gov. Kulongoski convinced the union to abandon the measure and use its resources to defeat ballot measures 41 and 48, which would have slashed government spending.

SEIU (which represents about 1,500 Oregon nursing home workers) negotiated new staffing levels with the OHCA instead.

The new ratios, which increase staffing but not to the level that would have been required by the ballot measure, will be phased in beginning in 2008 and will apply to all of Oregon's 143 nursing homes.

The staffing increase will benefit only nursing home residents directly, but SEIU lobbyist Arthur Towers says assisted living and residential-care facilities may be next.

Like many government regulators, DHS officials say budgetary constraints limit their effectiveness. But figures show Oregon is in the middle of the pack nationally on long-term spending per capita.

Critics say that money is less of an issue than DHS's institutional mentality. "This state has become complacent about long-term care," says the AARP's Cohen. "For too long, we've rested on the laurels of what was done 20 years ago at the expense of patients."

DHS's Towslee says criticism of the agency is generally on the mark. "Training, licensing, staffing—all these areas are in need of improvement," he says. "The industry and the agency are in agreement on that, and finally there may be revenue in the system to pay for it."

For seniors' family members, changes cannot come too soon. If a brand-new facility such as the Pearl at Kruse Way cannot be trusted to keep patients safe, what could happen at aging, under-financed facilities located far from the eyes of media or family members?

"DHS is a toothless tiger," says Judy Hurliman. "Their rules didn't take care of my dad, and I don't think they are serving the public."

THE PEARL REDUX

In April 2006, James Stephan placed his 87-year-old mother, Elvera, in the Alzheimer's Care Unit at the Pearl at Kruse Way with high expectations.

"From the outside, it looks like a Sun Valley ski lodge," says James Stephan, 49. "It looks like a place I wouldn't mind living myself."

The Pearl's marketing materials boasted "a staff of highly trained professionals" who would treat Mrs. Stephan "with respect, dignity and individuality."

For its services, the Pearl charged $6,000 a month. Within a week of entering the Alzheimer's Care Unit, however, records show Elvera Stephan found herself face-down on the floor with her hands cuffed behind her back.

According to an investigator's report, on April 13, 2006, Mrs. Stephan became disoriented and demanded her car keys.

Unable to calm her, staff called Lake Oswego police. The responding officers cuffed Mrs. Stephan and tossed her on the floor, according to an investigator's report. She suffered "bruises on both wrists and a bump/bruise on her forehead," and was taken to an emergency room for treatment.

In a subsequent lawsuit, James Stephan alleged that nobody from the Pearl ever told him that police cuffed his mother; instead he found out about the incident five days later from the family of other residents.

A state inspection found that, contrary to the claims in Avamere's marketing materials, "direct caregivers at [the Pearl] had not received the required special training to work with residents of an Alzheimer's Care Unit."

The state fined Avamere $300 for the incident, one of several DHS investigated during the Pearl's first year of operation.

Since its December 2005 licensing, state investigators have sustained at least nine complaints against the two facilities at the Pearl.

DHS's Tom Towslee says there are too many variables to say precisely how that number compares with other facilities.

Avamere president Judy Jackson acknowledges the Pearl did incur an unusually large number of visits from state inspectors last year. She blames the difficulties on the "unique complexity of opening up both a skilled nursing facility and an Alzheimer's care facility under one roof."

Few people have insurance for long-term care. Those who cannot afford to pay for care get coverage through Medicaid, which comes from state and county general-fund dollars and a federal match.

Currently, the federal government matches Oregon state Medicaid funds with about 60 cents for each state dollar.

Beginning in 1981, Oregon obtained waivers from the feds and began using Medicaid to pay for a spectrum of services that are less restrictive and expensive than nursing homes.

In addition to assisted living and residential care facilities, Oregon is recognized as a pioneer in home-based care, where a visiting aide visits periodically, and in adult foster care.

The issues at the Pearl at Kruse Way were first reported by The Lake Oswego Review.

One of the ways Oregon encouraged the development of assisted living and residential care facilities in the '90s was to offer state-backed bonds for their construction.

In 2001, Service Employees International Union, which represents about 41,000 workers in Oregon, organized 10,000 Oregon in-home care providers, which marked the union's single largest addition ever in the state.

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