In the last year of her life, as her health faded at an Albert Lea, Minn., nursing home, Opal Sande became a target.
For months, the 89-year-old grandmother, blind and suffering from Alzheimer's disease, was tormented by workers who abused her and 14 other residents. According to court documents and state records, workers pinched nipples, rubbed crotches and got in bed with some residents to simulate sex. They also spit in some residents' mouths and covered their lips to prevent them from screaming.
Last month, a court-ordered arbitrator blamed the Good Samaritan home for failing to prevent what he called a "sordid, sad, shameful story" of abuse.
"I roll this over in my mind all the time," said Sande's daughter, Myrna Sorensen. "Why did I put her there? Why did they do that to her?"
The 2008 case is part of a broader problem across Minnesota, where 2,000 providers are entrusted to care for thousands of elderly and vulnerable adults.
In the past six years, according to records reviewed by the Star Tribune, state regulators have substantiated 273 cases of abuse and exploitation at nursing homes, assisted-living facilities and in-home care agencies.
In 381 other cases of suspected abuse and exploitation -- including 96 reports of sexual abuse -- the state was unable to prove that misconduct took place, even though regulators found some evidence of wrongdoing in almost two-thirds of those investigations, records show.
Federal officials have repeatedly faulted Minnesota for how it reviews complaints of abuse and neglect. Twice in the past four years, federal records show, state regulators did not properly investigate 40 percent of reported complaints.
"Something is broken," said Deb Holtz, the state's ombudsman for long-term care.
Holtz said there's a "general sense of frustration" among advocates for the elderly that so many cases of reported abuse go unpunished.
In nursing homes and other care settings across the state, workers have harmed residents in a multitude of ways. They yelled at them and reduced them to tears with threats of punishment. Residents were slapped and punched, sometimes hard enough to cause bruising or bleeding. Workers stole checks, credit cards and jewelry. In at least 17 cases, victims were sexually abused.
State Health Department officials said they could have been more aggressive in some cases.
"I know we're not perfect," said Darcy Miner, director of the Compliance Monitoring Division, which includes the state Office of Health Facility Complaints (OHFC).
Miner said the agency's enforcement strategy is geared toward correcting problems, not punishing violators. Moreover, she blamed some investigative shortcomings on the departure of four investigators, which she said hampered the agency's ability to thoroughly probe each complaint. The agency has since filled those positions and added three additional investigative jobs, and a new director is making sure investigators spend more time in the field, she said.
"I'm really proud of the improvements we've made," Miner said.
To curb abuse, industry leaders say they have taken action to improve awareness of the issue and educate their workforce.
"You're never going to be able to guarantee that something bad won't happen," said Darrell Shreve, a vice president with Aging Services of Minnesota, a trade group that represents nursing homes and other senior housing providers. "These are human beings. We do screenings. We have background checks. ... We have training. We do a lot in this state."
'No action necessary'
To meet federal guidelines, states are supposed to properly review and investigate complaints of abuse and other problems at least 90 percent of the time. But Minnesota's Health Department missed that mark in each of the past four years.
In 2008, for instance, state regulators decided "no action necessary" after a resident was reportedly hit on the head at a Minneapolis nursing home and treated for multiple bruises at a nearby hospital. Investigators should have visited the facility to look for signs of abuse or neglect, according to federal officials.
Altogether, the state failed to do its job right in at least 40 percent of the 2008 and 2009 cases reviewed by the federal Centers for Medicare and Medicaid Services. Last year, the state's failure rate dropped to 22 percent. Minnesota is one of just three states that failed to properly review and investigate nursing home complaints in at least four of the past five years. According to federal records, none of the other 47 states failed more than two annual reviews.
In some cases, Minnesota regulators made no efforts to find out if allegations of abuse and neglect were true by visiting nursing homes and gathering evidence, even if residents were in immediate jeopardy, records show.
In other cases, the state moved too slowly. Last year, for instance, it took 11 days for state investigators to show up at a New Brighton nursing home to investigate a report of sexual and emotional abuse. State regulators should have recognized the threat faced by residents and visited the facility within two days, according to federal records.
In Minnesota's official response to the 2010 federal review, state regulators said they are "moving in the right direction" and are committed to meeting all federal requirements.
Regulators are sometimes hampered by a lack of cooperation. State law requires workers to promptly report suspected abuse, but some employees never acted or it took months to alert the state, records show.
At the Edgewood Vista assisted living facility in the Iron Range town of Virginia, Minn., employees failed to report numerous incidents of physical and emotional abuse involving four residents in 2009, according to a state report. A male resident was hit in the chest, stuck in a corner as punishment and dressed in a clown suit to humiliate him.
"Why would you want to degrade anybody that much?" asked Jean Hill, the man's widow. "You can put them in prisons and they'd be treated better."
Edgewood Vista administrator Paul Clark said some employees didn't think anyone would follow up if they reported the abuse.
"Why that belief was there, I'm not sure, because I was new at the time," Clark said. "But we refreshed everybody on their responsibility in reporting."
Instead of fining the facility for breaking the rules, state regulators gave Edgewood Vista 14 days to fix its internal reporting procedures, records show. Such tolerance is typical in Minnesota. Over the past five years, Minnesota regulators cited nursing homes for fewer violations per investigation than their counterparts in all but two other states, federal records show.
At Westwood Health Care Center in St. Louis Park, a 79-year-old woman told an employee that she had been sexually abused twice in October 2007 by a nursing assistant who had been repeatedly accused of misconduct at various facilities, state and police records show. But when the employee tried to file a report, her supervisor shrugged it off and warned the worker not to bring it up again, according to the state's investigation.
The state didn't conduct an on-site investigation until March 2008, after the woman -- who was no longer living at Westwood -- filed a written complaint with the facility. She told police she wanted to protect other female residents.
The alleged abuser admitted he touched the woman between her legs without her permission "because she never told me not to," according to the statement he gave St. Louis Park police. But state regulators never obtained that report and concluded that the allegation of sexual abuse was "inconclusive" after the nursing assistant denied wrongdoing, records show.
Westwood officials told state investigators they suspended the worker as soon as they received the written complaint. The facility also revised its abuse-prevention and reporting policy and provided workers with additional training, records show. Westwood was not fined for failing to properly report the alleged abuse.
A Westwood official said he could not answer questions about the case.
"Who cares what happened four years ago, if in fact it happened?" said Thomas Paul, corporate administrator for AVIV Health Care, which owns Westwood. "And if it did happen, it's all certainly been taken care of and corrected, not only by the Health Department but by the facility."
Tough cases to prosecute
Many abuse cases at nursing homes and other care providers never get prosecuted. The nature of the allegations can be difficult to prove in court. Sometimes police are not called right away or critical evidence goes uncollected. Victims may suffer dementia or die before a case can be brought to trial.
Sometimes, even an eyewitness isn't enough to guarantee a conviction.
In 2005, a female aide at a Minneapolis nursing home heard one of her patients "holler out" for help. She found a nursing assistant named Robert Nyambane in the 79-year-old woman's bed, with his pants down to his knees, lying on top of his victim "in a sexual position," according to a state report.
State investigators substantiated the allegations and Nyambane was stripped of his right to work as a nursing assistant. It was the second time the state had investigated him. In 2002, Nyambane was accused of sexually assaulting a vulnerable adult at another facility, but state investigators were unable to substantiate the complaint because "neither party was more credible than the other," state records show.
After police investigated the 2005 incident, Nyambane was charged with fourth-degree criminal sexual conduct. But the case fell apart.
The victim's dementia was so bad she was unable to give a statement to police. There was no physical evidence of sexual assault and witnesses gave contradictory testimony, according to the findings of a state judge who oversaw the legal proceedings.
In 2007, Nyambane was deemed mentally ill and unfit to stand trial, records show.
Prosecutors had slightly better luck with Peter M. Juma, who in 2009 told St. Louis Park police that he had sexually abused a morbidly obese nursing home resident who had repeatedly tried to kill herself.
A co-worker described Juma as a "happy-go-lucky" employee who was popular with female residents, but she also said that another employee had filed a complaint against Juma in 2008 over an "unwanted touch."
Juma was barred from working as a nursing assistant after state investigators substantiated the abuse allegations against him.
After the Hennepin County attorney's office determined the evidence didn't meet the criteria of a felony sexual assault, Juma was charged with abuse of a vulnerable adult, a gross misdemeanor. He pleaded guilty in 2009 and was sentenced to 120 days at a county workhouse.
Less than a year later, Juma was charged with sexually assaulting a 6-year-old girl who lives in his apartment building in Maple Grove. He is in jail awaiting trial on those charges. Prosecutors plan to use his previous conviction to help prove motive and intent, records show.
Warning signs ignored
Three years have passed since abuse at the Evangelical Lutheran Good Samaritan Society nursing home in Albert Lea shocked Minnesotans.
Two of the young women implicated in the abuse, Ashton Larson and Brianna Broitzman, pleaded guilty last year to three counts of gross misdemeanor disorderly conduct and were sentenced to three 60-day stints in jail. Last month, a judge determined they could forgo one of the 60-day terms because they had met the terms of their probation.
Jan Reshetar said her mother-in-law, Grace Reshetar, suffered an "unbelievable" amount of abuse at the home, including an act of simulated sex in her bed.
Said Reshetar, "We look back on it and we think to ourselves: Why didn't we listen to her when she said, 'I don't want to be here'?"
Workers who were not involved in the abuse told investigators they knew about the misconduct and failed to report it, but state investigators didn't cite the home for any violations. In their report, investigators noted the home addressed problems before the state began its on-site investigation. Among other actions, managers immediately suspended accused workers when they found out about the abuse and instituted mandatory training for all workers regarding the state's Vulnerable Adults Act, including how to report abuse and neglect.
But last month, an arbitrator in a related civil case said nursing home managers were partly to blame for the fiasco.
Gregory M. Weyandt, the arbitrator, said the nursing home "should take no comfort" in his ruling, even though he found in favor of the facility when he decided that the alleged victim did not prove he was abused. Weyandt concluded that other residents of the facility had been abused, and he said he was "outraged" by what happened at the home.
Weyandt said managers could have prevented abuse if they had paid attention to numerous "warning signs" in an aide's conduct and completed timely performance reviews. He also criticized the home for staff shortages and lax enforcement of policies aimed at protecting vulnerable residents.
"Good Samaritan not only failed in protecting the residents of its facility, but it failed its employees," Weyandt said in his May 9 decision.
A Good Samaritan spokesman declined to answer questions about the arbitrator's criticism. "The arbitrator's ruling was in our favor," spokesman Mark Dickerson said in an e-mail statement. "It did not award damages."
State regulators said they continue to wonder if they should have taken a tougher stand on Good Samaritan's conduct, but they believe recent policy changes will make it easier to levy sanctions in the future.
"In some of these cases we probably need to do more and we need to hold them accountable for the fact that it did go on so long," Miner said.
Computer-assisted reporting editor Glenn Howatt contributed to this report. Brad Schrade • 612-673-4777