Pleasant View Place assisted living home on Madison's West Side hasn't been hit with a complaint or state citation in at least three years.

Over the same period, Heartland House of Pioneer Ridge in Platteville piled up enough complaints and citations to earn about $20,000 in fines. In January, the state ordered it to stop admitting new residents, and this fall revoked its license.

Uneven quality of care is one of the serious growing pains in Wisconsin's rapidly expanding assisted living industry, which caters to vulnerable senior citizens who need daily help, but don't require the skilled care found in nursing homes.

The number of elderly in assisted living homes increased 75 percent from 1997 through 2006. However, the state has not added enough inspectors to keep pace and has vague standards for caregivers, the State Journal found in a review of state records and dozens of interviews with experts, regulators and assisted-living operators. 

Reports of poor conditions and inadequate care being filed with the state have increased. Complaints per resident grew three-fold from the mid-1990s to 2002, when a stinging state audit prompted reforms.

Still, in 2006, complaints continued to come in at twice the mid-'90s rate, and the state isn't complying with its own inspection standards, the State Journal found.

Shocking stories of abuse and neglect persist.

In 2006, the state received 718 complaints about assisted living facilities, alleging problems such as elderly with bedsores severe enough to require hospitalization, sexual abuse of residents, and homes without enough staff or training. 

In one case, the state found a caregiver had thrown a resident on a bed, which caused a fall to the floor and fractured arm that contributed to the resident's death a short time later.

The state issued 2,569 health citations and imposed 996 penalties last year.

In a look at assisted living five years after the state audit, the State Journal found:

•Important state requirements for staffing levels and training are vague or nonexistent.

•Since 2004, the state has added one inspector, for a total of 30, but the number of residents rose 12 percent from 2004 to 2006 alone.

•The state still has no law dictating how often assisted-living facilities must be inspected. Officials concede that 11 percent still don't get full inspections every two years, as required under Department of Health and Family Services policy.

Assisted-living growth

In 2006, there were 2,634 assisted living facilities in Wisconsin. The number of residents reached 35,400 last year, while total nursing home residents dwindled to about 40,000.

The shift should continue as more aging baby boomers choose newer options for long-term care. Wisconsin and other states are moving to systems that let Medicaid cover assisted-living costs. For now, most residents pay privately and most facilities operate for profit.

"There are some very fine-quality facilities. Some (providers) are growing into it. Some people are in over their heads," said Marge Jenkins, social services manager at Meriter Retirement Community in Madison, which offers all levels of housing and care for seniors.

A new approach

Assisted living homes aren't subject to the heavy, long-established oversight that is given to nursing homes, which operate under federal and state regulation and must be inspected at least every 15 months. 

The federal government plays little role with assisted living, leaving it to states, which offer a mishmash of rules.

In Wisconsin, the state has special rules for Community-Based Residential Facilities (CBRFs), the most common type, small Adult Family Homes, and the new trend, Residential Care Apartment Complexes. 

In response to the 2002 audit, the state Department of Health and Family Services formed a unit to oversee assisted living, increased expertise of inspectors, focused inspections and enforcement on bad performers, and offered facilities more direct advice on how to improve.

By September of this year, the state has reduced its backlog of complaints 125 from 600. 

The department began using abbreviated regular inspections for places in operation at least three years that had no proven complaints or enforcement actions in that time.

The move allowed the department to concentrate limited resources on poor performers.

"We really went after them," said Kevin Coughlin, who oversees licensing and inspection of assisted living for the department's Division of Quality Assurance. "A lot of those (bad) facilities closed."

Total fines rose from $88,230 in 2000 to $547,300 in 2006, because of growth and tougher enforcement, Coughlin said.

The state revoked eight licenses in 2002, and an average of nine per year since then. 

Last year, 40 percent of assisted living facilities qualified for abbreviated inspections, and all complaints and enforcement occurred in less than a fifth of facilities, said representatives of the state and industry.

The state, however, still isn't doing biennial inspections in 11 percent of facilities, as its own policy requires. The department's resources have not kept up with industry growth, officials said.

And residential care apartment buildings still get no regular inspections.

Dr. Charlene Harrington of the University of California-San Francisco, who writes statistical studies and scholarly articles on long-term care, says inspections are important and that citations signal vigorous oversight. 

Under her measure, the state's record since the state audit is mixed.

In the last five years, the assisted living population rose from 28,298 to 35,442. But citations fell sharply from 4,963 in 2002 to 2,421 in 2004, before climbing slightly to 2,569 in 2006.

Taking ownership

The industry, Coughlin said, has "stepped up and has taken ownership" of problems.

In fact, the Wisconsin Assisted Living Association's newsletter prominently reports some of the most serious violations found by the state each year.

Overall, "I think the quality of care is improving," but "there are still a lot of issues," association executive director Jim Murphy said.

'Vague' rules 

The state has some of the nation's strongest assisted living regulations, but it's partly because many other states have done very little, elder advocates say.

In general, "state licensing of assisted living is very poor," said Janet Wells, director of policy for the National Citizens Coalition for Nursing Home Reform, which advocates for all sorts of long-term care.

"The state does not have adequate human resources devoted to an area where the growth rate is phenomenal," said George Patarocke, executive director of the state's Board on Aging and Long-Term Care, which advises the governor and Legislature.

Wisconsin's rules for staffing and training remain "very, very vague," Patarocke said.

For example:

•The only state requirement for administrators is that they be 21 years old, have a high school diploma or equivalent, and minimal experience.

•Staffing must be "adequate" or "sufficient" at facilities, but the law doesn't specify how many employees that means. Nationally, at least 15 states have minimum staffing ratios. Michigan requires "adequate" staff but enforces a minimum staff-to-resident ratios depending on a facility's size.

•Wisconsin requires that administrators and staff at CBRFs, the most common kind of facility, get 60 hours training and follow-up, but many staff get no specialized training about illnesses such as Alzheimer's. Some other states, including California and Texas, now require it.

"Are staff able to meet the needs? That's an issue we're concerned about," said Heather Bruemmer, who directs the state's ombudsman program for long-term care.

Assisted living homes must exceed state standards in order to provide quality care, said Greg Griffin, the owner of ElderSpan Management, which runs five assisted living facilities in southern Wisconsin, all of which have clean records for at least three years.

Griffin, a former hospital administrator, offered a chilling assessment of the sort of place that could operate under the minimum rules.

"It would scare me," he said. "I would not want to put my mom or dad in there."

'A huge burnout'

At ElderSpan, all administrators are registered nurses and there's at least one caregiver — usually a certified nursing assistant — for every dozen residents, he said. Training is done by a registered nurse or licensed practical nurse.

But even ElderSpan struggles with staff-to-patient ratios and employee workloads.

Mary Broaden, a CNA, quit the chain's Dodgeville facility this fall after less than two months because she felt sustaining quality care for residents was too stressful on an overworked staff.

Griffin, who disputed Broaden's assessment of ElderSpan's practices, said he had high hopes for Broaden and was surprised she resigned.

Too often in the industry, staff suffer low pay, hard work with unreasonable hours, and little role in decision making, said Sherry White, who's worked as a resident aide in several Dane County facilities and now is administrator of Pleasant View Place in Madison, which hasn't had a citation in three years.

"You want to make a difference but it's a huge burnout," said White, who is leaving her position to continue her education.

The state, with input from advocates and the industry, is considering new draft rules for CBRFs that would raise standards for administrators, fire safety protection, staff training and handling medications.

After CBRF rules are done, the state will consider new rules for Adult Family Homes and apartment complexes.

On the bottom line, "assisted living regulations need to be revised to reflect what's happening (in the industry)," Division of Quality Assurance director Otis Woods said.