Second of four articles
At West Point Adult Home in eastern Virginia, 44-year-old Carolyn Sabo attacked her 83-year-old housemate last August, jabbing her behind the ear with a pair of blunt scissors and sending her to the hospital.
At Church Hill Manor in Richmond in 2002, a 30-year-old resident who had been expelled from a previous home because of "anger problems" pushed a tenant twice his age down a flight of stairs, seriously injuring him.
Two male residents of Summerville at Mount Vernon in Fairfax County repeatedly terrorized other residents and staff. One of the men yanked a resident from her wheelchair in 2000. Workers at the home, which has since changed management, locked themselves in an office for safety, leaving residents to fend for themselves.
The attacks, documented in public records, are among hundreds of cases of violence that have erupted since 1995 in Virginia's assisted living facilities, 627 homes licensed to care for more than 34,000 disabled adults.
Thousands of documents kept by state and local agencies reveal repeated sexual abuse, beatings and other assaults. Richmond police, for example, were called to disturbances more than 1,800 times since 1996 at just two dozen facilities in that city.
In a system plagued by problems of poor care and neglect at the hands of owners and workers at the homes, such incidents represent another layer of danger: violence committed by the residents themselves, aimed at their housemates and caregivers.
Many problems are the consequence of poor supervision and workers ill-prepared to handle aggressive outbursts, state inspection reports show. In some cases, the violence can be traced to the practice of placing mentally ill residents who have criminal backgrounds in homes with more vulnerable residents, including those with mental retardation or dementia.
More than 370 times since 1991, assisted living facilities were used to house people caught up in the criminal justice system, including those who were found not guilty by reason of insanity or incompetent to stand trial.
State corrections officials also have placed violent sex offenders in the homes while those residents are on probation or after release from prison. More than 40 violent sex offenders -- including rapists and pedophiles -- resided in licensed Virginia assisted living facilities in the past 18 months, according to state registries.
The result is a volatile combination of residents, placed together in close quarters. And often, new residents are brought to the homes without their complete records, leaving caretakers and other residents unaware of what might be a violent history.
"We mix folks who are still bouncing off the walls in with the little old lady in the corner," said Howard M. Cullum, a former state mental health commissioner and Virginia's former health and human services secretary. "This is a bad mix."
For nearly three decades, Virginia has been emptying its large institutions for the mentally ill and mentally retarded, moving those patients into much smaller settings in communities across the state -- often to assisted living facilities. Since the early 1980s, the number of beds in public institutions has been cut by more than half, triggering a search for housing for former patients, some of whom have violent histories.
Facility operators said they feel pressured to take in these difficult residents because they need to keep beds full to pay their bills. As a result, the operators often gamble on the unknown.
Virginia licensing regulators do not track how often residents abuse one another. But a review of emergency calls to Richmond police from 24 homes since 1996 hints at the disorder: Police investigated 16 robberies, 30 sex offenses, 81 reports of armed people, 118 fights, 330 assaults and 1,209 reports of disorderly conduct.
Evidence of the problem also is scattered throughout state records and court filings: At Bednar's Rest Home, a converted motel in Keysville, staff caught a resident molesting a paralyzed stroke victim in 1999. At Victorian Haven in Elkton the same year, a schizophrenic resident who had been in and out of psychiatric hospitals went into a rage and injured several residents at breakfast. At Ridgefield Retirement in Marion in 2002, a male resident sexually assaulted a female resident, inspectors said.
At Sunrise of Springfield in February, a man with dementia wandered into the room of an 81-year-old woman while she slept and repeatedly punched her in the face, severely bruising her, records show. Three weeks earlier, the same man was found by staff members in another woman's room, holding her head under the covers and telling her to "shut up."
State-funded studies have long warned that care, supervision and funding were inadequate given the mix of residents. A 1988 study found that one in five mentally disabled residents had been violent in the past year, assaulting others, destroying property, setting fires or showing suicidal tendencies.
When newcomers are admitted to facilities -- to which they are referred by social workers, relatives, doctors or hospitals -- the homes often receive only sketchy information about the residents' backgrounds, owners said.
The state instituted screening procedures and annual evaluations of residents in the 1990s after officials became alarmed that large numbers of patients were being moved out of state hospitals and placed haphazardly, with little effort to find a home that fits the resident's condition. But the evaluations often gloss over a difficult resident's history, sometimes in a deliberate effort to make placements easier.
"It's like a used-car salesman. If you don't ask what the damage is, they won't tell you," said Grant Goldman, an owner who is past president of the Virginia Adult Home Association, a trade group of about 120 facilities. "They will tell you just enough to consider the person, but they won't tell you he is a pyromaniac."
State regulations require facilities to obtain the histories of new residents but do not give the operators the power to demand the records. Those who hold the records -- mental health workers and others -- said they can't divulge more to the facilities because of confidentiality laws.
That problem has worsened recently because of new federal privacy restrictions on medical records, said Mary Ann Bergeron, executive director of the Virginia Association of Community Services Boards, which represents regional mental health agencies.
Bergeron defended the need to withhold some information from the homes because the facilities are not meant to treat residents, only to provide housing and some supervision, she said.
"I am not sure that a residential facility needs to have every bit of information about a person because they are not treating them. . . . It would be an invasion of privacy," she said.
She added that community service boards, which also refer residents to homes, are better than they were in the past about gathering and disclosing key information.
She also said that some risk is inherent. Caretakers "have to recognize they are working with people who are unpredictable by the very nature of the illness," Bergeron said.
When schizophrenia patient Natasha Key was sent to Emmanuel Adult Home in Chesapeake in 1996, much of her history was left untold.
E.M. Griffin, who owned the seven-bed home, said Key's records contained no indication that she was volatile, had assaulted her mother or had been hospitalized at least 20 times. When Griffin talked with Key, her family and a social worker, the owner said she was pressured to admit Key quickly because she could no longer live at home.
"Really, the only thing I knew about her was that she had abused substances before," Griffin said in an interview. "Why would you think they had anything to hide?"
About 10 months later, Key, 24, got out of bed, slipped into the kitchen and picked up a butcher knife as the lone employee on duty ate in another room. Key later told her mother that she was furious because her roommate, a mildly mentally retarded woman named Pearl Giles, 53, had complained about Key's smoking. Voices in Key's head told her to decapitate Giles, she told her mother. Key climbed on top of Giles as she slept and stabbed her in one eye, the face, the back of the neck, the stomach and an arm.
"When I woke up . . . there was blood everywhere," Giles said in an interview. She was hospitalized for months and underwent repeated surgeries. Scars still crease her face and stomach.
After the attack, a court psychiatrist who interviewed Key while she was in jail determined that she was in "psychosis" and that she might become "very volatile" for no apparent reason. A judge ordered Key sent to Central State Mental Hospital in Petersburg, where a later evaluation reported that she heard voices commanding her to "do something."
Griffin learned of Key's numerous earlier hospitalizations only after the attack. Had she known, Griffin would not have admitted Key, she said.
"They give us what they think we should see and expect you to provide quality care for these residents and when something goes wrong, they disappear," Griffin said, referring to the mental health agencies that have sent her residents.
The Chesapeake Community Services Board, which referred Key and Giles to the home, declined to discuss the case, citing confidentiality. Candace Waller, the board's executive director, said that in general, it is in everyone's "best interest that the home have all the information they need because if they don't, it's not going to work out."
On the other hand, she said, it is unnecessary to turn over a person's entire history -- a file that could be inches thick -- because "you don't have to read the entire file to know the most important pieces of information."
Key eventually was found competent to face charges and pleaded guilty to unlawful wounding, a felony. She was sent to prison after violating probation, was later hospitalized at Central State and was released to her family this month, her mother said. Key did not respond to requests for an interview.
Her mother, Ramona Brown, said Key continues to hear voices. "I want people to know that my daughter did this because she is mentally ill," Brown said.
In the 1990s, the state tried to ensure that residents would be placed in facilities that were able to meet their needs. But a state study in 1997 found that half the community service boards surveyed were sending hospital patients to facilities not based on finding an appropriate fit, but rather on the availability of beds. Two years later, a review by state Medicaid officials found that assessments were frequently incomplete and that facilities' plans for resident care were inadequate.
Reshard Lee Butler arrived in 1997 at Grace Home, a decrepit former hospital in Richmond, with an assessment from a social worker at a Richmond hospital. The form described his behavior as "appropriate," according to court documents.
By that time, Butler had been hospitalized more than 25 times for psychosis. Doctors had repeatedly classified him as violent and homicidal, according to his medical records. His mother, Diana Butler, said he had been jailed more than 10 times.
She gave Grace Home a report on the latest hospitalization of her 23-year-old son, she said, and told the facility that he had been forced to leave another home after he put his fist through a window.
"I told them this child was a mental patient and he needs to take his medication on time and if he don't, he will become violent," Diana Butler recalled. She said she also warned them that he liked to sneak out so he could drink. "They said they had violent people before and they were fine," Butler said.
Reshard Butler had been at Grace Home for four weeks when he left the home and drank two pitchers of beer and flew into a rage, smashing his television and furniture. Rescue workers wrestled his slender, tattooed body to a gurney and took him to the hospital. There, records noted, he was "psychotic, wild, agitated . . . all out of behavioral control."
The next day, the hospital sent him back to Grace Home. The staff accepted him, noting in a log that he was "in good spirits. No problem."
A month later, in January 1998, he attacked resident Jean Allen, 61, who lived across the hall. Allen was a slight woman with close-cropped hair who battled emphysema and sporadic bouts of depression. She bided her time by sculpting horses out of wire, paper and glue.
Butler called Allen into his room, then sexually assaulted her, she said in court records.
The state earlier threatened to close Grace Home because of various problems, including insufficient staffing, but had left it open when owners promised to make changes. Officials at the home said in court papers that they did not know the extent of Butler's violent history and that they relied on the social worker who referred him. Shridhar V. Bhat, one of Grace Home's owners, denied in court papers ever seeing a doctor's report when Butler was admitted that cited psychotic and violent behavior, though the report was labeled "cc: Grace House."
Bhat said in a deposition that a staff worker told him that Butler had psychiatric problems but that he was medicated and "well-behaved."
"That's the information she got," Bhat said. "And I said, 'Fine, take him in.' "
In a court deposition, Bhat questioned whether the rape occurred. Butler pleaded guilty and went to prison in September 1998. After his release in 2002, he was arrested for armed robbery in California, his mother said.
"He should have been sent to a mental facility," she said.
Jean Allen, who now lives in her own home, blamed the facility.
"These places need to be under strict guidelines. . . . They need to be monitored, to really have somebody with authority over them to be sure they're doing the right thing," she said.
Grace Home closed in 2001 under pressure from city building inspectors concerned that it was unsafe for residents.
Troubled tenants often pass from home to home, with brief stops in hospitals or jails after an outburst or a health crisis. Other residents ask to move.
Caretakers and advocates agreed that the frequent movement makes it more difficult for staffs to know the residents well or to give them appropriate services.
"We continue to bounce 'em without them getting any help," said Janet Bellamy, who has run assisted living facilities in Richmond. "That bothers me."
When Gerald J. Wood, 53, came to Sunrise Retirement Home of Warrenton in 2001, it was his second shot at assisted living.
Wood, a former technician for Bell Atlantic, in 1995 received a diagnosis of Huntington's disease, a fatal condition that destroys brain cells and leaves its victims prone to angry outbursts. At one point, Wood assaulted his wife of more than 25 years, according to court papers.
After the couple separated, he moved to Manorhouse, an assisted living facility in Charlottesville. There, he assaulted three residents, in one case breaking a woman's wrist. In February 2001, Manorhouse's medical director said Wood was a "serious risk" to fellow residents and the facility discharged him.
Wood next went to a psychiatric unit at Culpeper Memorial Hospital and then to Sunrise in Warrenton, according to court records. Sixteen days into his stay at the facility, as residents lounged in the television room after lunch, Wood suddenly went berserk. He threw several housemates to the floor, according to police reports. No Sunrise employees were in the room.
Nurse's aide Sue Elliott told police she heard a loud commotion, went into the room and saw Wood holding a female resident "over his head, by her waist" and was "getting ready to throw her down to the ground." Elliott told Wood to put down the resident, which he did.
Another resident, Mary Province Marocchi, 84, who weighed 112 pounds, was collapsed on the floor, bleeding from her head, with broken bones, witnesses told police. Another resident was sprawled on the floor and a third was on his side, strapped into his upended wheelchair.
The staff called 911 and told rescue workers that Marocchi apparently had fallen from a chair, according to law enforcement records. Marocchi died two days later of a cerebral hemorrhage.
Detectives learned of the ordeal not from the facility, but from the county medical examiner. Wood was arrested and charged with murder, but was found incompetent to stand trial. He was hospitalized at Western State Hospital in Staunton.
Melody Snow-Brown, executive director at Sunrise of Warrenton, said in an interview after the incident in 2001 that Sunrise didn't know details of Wood's history.
"If I had more of his background, we would have investigated further," she said. "But based on the physician's report, it was checked that he wasn't a danger to others. They're the experts."
Sunrise records show that the home had indications that Wood could be violent: An evaluation completed about the time of his admission, and signed by Snow-Brown, noted Wood to be aggressive, abusive or disruptive "less than weekly." It also said he was disoriented and "becomes angry -- will strike out at times."
Licensing inspectors reprimanded Sunrise of Warrenton for failing to report the assault to licensing inspectors or to devise a plan to deal with Wood's aggressive behavior. Marocchi's family sued Sunrise and in September settled the case with a confidential agreement.
The Volatile Mix
In addition to the elderly and mentally impaired, the homes also accept convicted felons on parole, sex offenders and those ruled incompetent to stand trial or who are not guilty by reason of insanity. In many cases, they qualify for a state subsidy because they are indigent and suffer from some disability, but there is little information on this group because no one tracks them. They come to the homes through various paths: from state mental hospitals, on the recommendation of a parole officer, or with the help of a social worker.
Banana Anderson, who operates Aloha House in Charlottesville, said that until recently, she housed a 44-year-old man who was on parole for murder and robbery. The man had been living at a homeless shelter, and his social worker referred him to Anderson's home, she said. She learned about his history only after he talked about it. She discharged him after he boasted of his crimes, scaring the other residents.
Tiffanie's Manor for Young Adults in downtown Richmond has housed several convicted sex offenders, most of whom have some mental impairment, administrator Josephine Gatling said. The 140-bed home, which also cares for dementia patients and other disabled people, is listed in a Department of Corrections manual as potential housing for inmates leaving prison.
Gatling said the sex offenders living there "look at my ladies as little sisters. They don't really mess with them."
Six sex offenders sent to adult homes in Richmond, including pedophiles and rapists, have been rearrested while living in the facilities, records show. They have been caught using cocaine and marijuana, getting drunk, pursuing children in violation of probation, fighting and disappearing for nights at a time.
A sex offender living at Tiffanie's Manor was found guilty again in 2002 of assault and battery after he beat another resident. And a 38-year-old man, convicted in 2001 of sexually assaulting a 9-year-old, moved to Tiffanie's, where he "grabbed another . . . resident's testicles . . . to inflict pain," a probation officer wrote last year.
Many homes cannot afford to segregate their living quarters by their patients' needs, meaning that dementia victims might live with former convicts, and paranoid schizophrenic tenants might be housed with the mentally retarded.
In many cases, homes do not employ guards or surveillance systems. At night, many have only one or two people on duty, and in facilities of fewer than 20 residents, the workers are allowed to sleep during their shift under state regulations.
Franklin Manor Rest Home in Rocky Mount in 1998 was reprimanded by inspectors after a male resident who was "known to be sexually active" was found in bed with a female resident who was "known to be disoriented and easily led." After that incident, staff workers told inspectors that they would make hourly rounds to monitor the man.
Within four weeks, another woman reported that the male resident had raped her. The facility closed and reopened under new owners, who did not respond to a request for comment.
Department of Corrections officials do not know how many sex offenders or other former convicts live in assisted living facilities in Virginia. They defended the placements, which often are arranged between probation officers and owners of the homes. The officials noted that sex offenders on probation are monitored closely and must attend treatment programs.
"In many instances, even under the worst-case scenarios, having a person in a residential setting is going to be better than having the person wandering the street," said Mario Woodard, a special programs manager for the state Department of Corrections.
The "most tightly managed" group of formerly hospitalized psychiatric patients in the state are those found not guilty by reason of insanity, said James Morris, director of forensic services for the state Department of Mental Health, Mental Retardation and Substance Abuse Services.
Morris said the mentally ill in the criminal justice system often end up in adult homes because of a lack of housing options.
When Percell A. Cox was released from prison in November 2002, probation officers took him straight to Bellamy's Adult Home in Richmond.
Cox, 43, who suffers from schizophrenia, had received a five-year sentence for rape. Earlier, he served more than 10 years in prison for robbery and other crimes.
In an interview, Cox said he was adjusting to life at Bellamy's, which houses a mix of elderly and mentally ill men and women. But he continued to hear voices that "tell me to kill this person or kill myself," he said.
By spring 2003, Cox told his probation officer that he had violated probation by using cocaine and that he "couldn't take it anymore." The voices, he said, told him to stab himself. "He wanted to go to jail and serve out his remaining sentence," the officer wrote.
Cox was arrested, but he was released after a court hearing. Records show he is living at another adult home in Richmond.
Staff researcher Bobbye Pratt and database editor Sarah Cohen contributed to this report.