With cataract-blinded eyes closed tight and her 64-pound frame curled in a fetal position on a bed, Conception Vega ended a tortuous journey that led the 89-year-old Chicago mother into mental institutions and, finally, to a suburban nursing home. She died last month in a nearby hospital. All of her teeth were rotted. The little money she had was gone. The only clothes she owned were the ones on her back.
“She looked like one of those people in concentration camps,” said Vega’s eldest daughter, Esther Vasquez, 68. “She was 115 pounds when she entered the nursing home, but lost 50 pounds. She was little more than skin and bones.”
Vega’s tragic deterioration reflects the failures of a nursing home industry that has worked alongside the state to profit from two vulnerable populations–the elderly and the mentally ill–by placing them under the same roof, state Public Aid records show. Recent government policies have accelerated the flow of the mentally ill into nursing homes to unprecedented rates. And the homes are eager to welcome psychiatric patients, even if they are ill-equipped to handle their special needs.
While there is nothing inherently unsafe about housing the elderly and mentally ill together, an investigation by the Tribune shows myriad problems in many facilities that do, including outdated medical protocols, staffing shortages and violence directed at the elderly by psychiatric patients.
The experiences of Vega, the daughter of Mexican immigrants to Chicago, mirror a decades-old relationship between the State of Illinois and nursing home owners in which the mentally ill have become financial pawns, their quality of life shaped by political forces beyond their control.
Vega likely would have spent her life in state psychiatric institutions, but she was transferred into a nursing home in 1980–along with thousands of other psychiatric patients–as part of a state strategy to tap into millions of dollars in Medicaid reimbursements. For the next 18 years, she lived in three nursing homes.
In 1996, Vega’s final stop as a psychiatric patient was Emerald Park Health Care Center, a geriatric nursing home in Evergreen Park that had begun to fill empty beds with mentally ill patients. Once again, state Department of Public Aid records show, the state and the owners of the facility would profit from her placement there.
Vega’s case history, contained in state Department of Public Health records, also shows a particular side to the potentially volatile commingling of nursing home populations: how mentally ill residents often receive poor or inadequate treatment.
When she arrived at Emerald Park, Vega’s physical and mental disabilities quickly isolated her. Her days were spent in lonely exile, her only companion a blaring television as she incessantly rocked in a chair, her right hand occasionally and inexplicably swinging up to slap her face, according to her daughter.
In the months to come, the nursing home staff failed to provide necessary care and services as she withered away, according to state Department of Public Health inspection reports. Vega’s family said it was not notified of her condition, even when a surprise annual inspection by the state on July 27 led to her immediate hospitalization.
The home’s primary owner, Morris Esformes, said Emerald Park should not be judged by what happened to one patient, nor should conclusions be drawn from a state investigatory report that provides a snapshot of conditions.
Vega was not the victim of mistreatment or inadequate care, he said, explaining that her weight loss–a common symptom among the elderly–was aggravated by age, physical disease and decades of severe mental illness.
The annual inspection showed at least five other patients suffered unhealthy weight losses, state inspectors concluded.
State investigators also found that the home was short-staffed, leading to a reduction in specialized psychological treatment. When a female nursing aide was asked by state inspectors why a patient suffering Alzheimer’s disease had not received sensory stimulation treatment as ordered by a physician, the nursing aide replied that “she has 21 residents to be responsible for and she just can’t do everything.”
Thousands of mentally ill patients, shuttled to nursing homes as the state continues downsizing psychiatric institutions, are welcomed by owners because of the subsidies that accompany them. A patient like Vega can generate up to $100 a day, with the cost being shared by state government and Medicaid funds.
“There is not a self-interest in emptying those beds,” said Jan Holcomb, executive director of the nonprofit Mental Health Association in Illinois. “A full bed is a funded bed.”
But the greatest cost is being shouldered by the patients.
On Sunday, the Tribune reported on the results for the elderly when nursing homes are unprepared to accept young, able-bodied psychiatric patients. In one case, Victor Reyes, a 20-year-old schizophrenic placed in a Downstate nursing home, went on a rampage, beating a 69-year-old woman into a coma last year for denying him sex. Reyes then fled from the nursing home, killing a local resident by running him over with a stolen car.
State inspection records show a pattern of assaults directed at the elderly by psychiatric patients. There are also distinct perils facing psychiatric patients when they are housed in nursing homes.
A Tribune analysis of state nursing home records and inspection reports shows:
– The majority of homes with the greatest number of mentally ill patients consistently fail to provide adequate treatment for psychiatric disorders or provide clean facilities. Public Health records show that 10 of 13 homes with the most mentally ill patients have failed since 1997 to meet minimum health and safety standards.
Most often, deficient conditions are not life threatening, but encompass minor assaults, theft of food by aggressive patients, lack of clean towels and soiled rooms and beds.
Last year, at Lake Park Center in Waukegan, state records show that required psychiatric treatment was not provided to a mentally ill patient who set his bed on fire; another male patient, who was inexplicably cut on his chin, was observed for two days pacing back and forth along a hallway without therapy; a woman diagnosed with schizophrenia traded cigarettes for sexual favors.
At Albany Care in Evanston last year, nine of 30 mentally ill patients’ treatment plans had not been updated for up to 10 months, state records show. One patient suffered a 21-pound weight loss without medical intervention.
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Activities were not properly planned nor behavioral progress measured for 9 of 14 mentally ill residents surveyed at Belmont Nursing Home in Chicago last year, state records show. For three weeks, the home did not employ a certified activity director, as required by state regulations.
– Mood altering psychotropic drugs are commonly used to control patients’ behavior when therapy has not been provided.
On June 17, state inspectors discovered that a 34-year-old blind, schizophrenic woman had been sitting naked on a toilet for up to 14 hours a day at Carlton At The Lake nursing home in Chicago. Her meals were frequently delivered and consumed in the bathroom.
Even though the woman was diagnosed as schizophrenic, the home provided no specialized treatment other than large doses of Thorazine in an effort to change her behavior, state inspection files show.
State inspectors found that psychiatric therapy wasn’t conducted on scheduled days and that employees continued to pump the mood-altering drug into the woman’s system without evaluating the effects.
Citing failure by the home to help the woman, the state transferred her to a state institution where specialized care could be administered. The home was cited by the state for providing inadequate care, nursing home and state records show. But as is often the case, the home was not fined or otherwise punished.
– The state’s nursing home regulatory system is based on selective enforcement that delivers little punishment to facilities judged in violation of health and safety rules.
Most nursing homes are subject to state and federal inspection. Federal enforcement regulations stipulate that owners, in some cases, can set their own deadlines to correct deficiencies. If a fine is levied, owners automatically receive a one-third discount if they agree not to appeal.
Under state regulations–considered more stringent–only one in four nursing home owners were ordered to pay fines last year after being cited for serious violations, typically involving death or serious injury.
Department of Public Health officials said fines are a last resort if compliance is not achieved. In the cases cited above, all deficiencies were corrected, state records show.
A family torn apart
A half century of state policies concerning the mentally ill, and the current rush to house them alongside the elderly, are reflected in Conception Vega’s passage from institutions to a nursing home.
Vega’s wishes as she entered her first psychiatric facility were modest: to live in a dignified way and without pain. But even that simple desire would be denied.
As cataracts robbed her of her sight, the 33-year-old Vega also was diagnosed with schizophrenia.
In 1942, institutionalization was the preferred treatment for mental illness. Vega, a resident of the West Side, was committed to the Manteno state institution in Manteno, Ill.
At the time, thousands of Illinois citizens were committed to 15 facilities statewide, where criteria for admission were based on little more than being different or untreatable. Many of the institutions were more like prisons than hospitals. But there weren’t many options.
Vega’s family was torn apart.
“We were told to put on our Sunday clothes,” said Esther Vasquez, then 13 years old, one of Vega’s six children.
“We were taken to court and told that we were wards of the state. We were separated and taken away right there.”
In 1947, Vega was involuntarily sterilized to prevent more children–a procedure since banned. Vasquez stayed in Chicago, married and made regular visits to her mother as she was moved from Manteno to another state institution, Chicago State Hospital. She remained there for 33 years.
Vasquez recalled the facilities as dark and noisy, with patients prone to screaming and running naked.
By 1980, the state decided to transfer Vega from Chicago State Hospital as part of a nationwide push to empty large government psychiatric facilities. At the institution, the state had paid costs associated with Vega’s care and treatment; at the nursing home, the state could bill the federal Medicaid program for half the expenses.
Waiting for the mentally ill was a small group of Chicago businessmen, who stood ready to funnel this steady stream of revenue into their nursing homes.
For the next 16 years, she led a quiet life at two nursing homes, punctuated only by minor medical problems. But in early 1996, a serious infection in Vega’s leg required hospitalization, prompting Vasquez to look for a new nursing facility closer to Chicago so she could visit more often.
Turn for the worse
In 1996, the 249-bed Emerald Park Health Care Center, primarily a geriatric facility, agreed to accept Vega along with other mentally ill patients, who made up about 11 percent of the residents. Today, 30 percent of the beds are filled with psychiatric patients, a nursing home administrator said.
Its owner, Morris Esformes, said he entered the business in 1969 as a 23-year-old ordained rabbi. Today, the 52-year-old Esformes is a multimillionaire and business partner to Leon Shlofrock, also one of the state’s most influential owners, state records show. Together, their homes hold more mentally ill patients than any other owner in the state.
Esformes is a 51 percent owner of Emerald Park, one of his 18 Illinois nursing homes. He also has one nursing home each in Florida and Missouri.
While Esformes and other owners maintain that profit margins are not exorbitant, the businesses’ bottom line is often obscured by lucrative consulting contracts paid to other companies they control, and by six-figure salaries they pay to themselves and their relatives, nursing home financial records filed with the state show.
Emerald Park, for example, reported profits of $554,000 on gross revenues of $6 million in 1997. But that number does not reflect a $1 million consulting fee paid to another Esformes-owned management company, state nursing financial records show.
In addition, owners collected another $725,000 in dividends and other payments.
On its surface, Emerald Park seemed like a good place for Vega, Vasquez recalled.
But quickly, her view of the facility began to change, she said.
“I would buy her clothes, but when I’d visit the next time, I’d see the clothes on other patients,” Vasquez said, adding that frequent concerns about her mother’s weight loss were met with assurances that everything was fine.
With a tight budget and incapable of caring for Vega on her own, Vasquez said she had few choices but to keep her mother where she was.
Vega lived perpetually in the past, her mind embracing visions of her family’s once happy life on West Harrison Street. Vega’s alcoholic husband, a baker by trade, had abandoned the family after her blindness set in, Vasquez said.
During visits at Emerald Park, Vasquez and her mother engaged in a comforting and familiar exchange:
Vega would ask her daughter, “Do you know where the children are?”
Vasquez always replied, “Yes, they are in school.”
At that point, Vega would smile, ending the dialogue, saying, “Yes, they are good kids.”
As they maintained their monthly visits, Vega’s condition deteriorated, Vasquez said.
By January of this year, Vega’s weight had dropped to 88 pounds and nobody could explain why, Vasquez said. For the first time, nursing aides had to spoon-feed Vega, who preferred cream cereals and yogurt, according to nursing home medical records obtained by Vasquez, who was entitled to them as a legal guardian.
On June 8, nursing home records show Vega had dropped to 65 pounds, according to state inspectors.
Starting on July 27, six state Department of Public Health inspectors fanned out at the home to quantify whether hundreds of health and safety regulations were being followed.
Bathrooms smelled of foul odors with mold and mildewed walls, according to public health records. One room was covered in brown smear and littered with cigarette butts. Another bathroom, on the second floor, was locked because, an employee admitted to inspectors, nobody wanted to clean up after the residents.
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A state investigator noted that a mouse ran over her shoes while she was inspecting the second floor in front of the nursing station.
Scheduled activities, considered an essential component of treatment for mentally ill patients, were not held in some cases, public health records show. A music class was scheduled for July 28, but it had little to do with music. An employee simply read questions from a card such as, “How does music make you feel?” Nearly an hour later–after 10 of the 30 attending residents had fallen asleep–a patient finally asked, “Can you put some music on for us to liven things up?” No music was played.
In the report, Vega’s appearance was described as “extremely thin and pale.”
One inspector noted that the wheelchair-bound Vega was left in the hallway, bleeding from her gums and lips. Vega had been sent to a dental clinic, but the home failed to obtain authorization from Vasquez, her mother’s legal guardian. She was sent home untreated, state inspectors said. Lab work to assess her loss of weight had not been completed, they added.
Prompted by the inspectors’ concerns, Vega was taken to a nearby hospital.
Esformes said the majority of public health inspectors, who are typically registered nurses, have little specialized training or experience with assessing quality of care involving mentally ill patients. Consequently, state inspectors often cite homes for deficiencies, such as patient weight loss, without understanding the difficulties of treating psychiatric illnesses.
Nursing homes provide the most cost-effective and comprehensive treatment for chronically mentally ill people and offer a far better alternative than state facilities or simply shoving people onto the streets, a strategy employed by a dozen other states, he said.
Esformes said Vasquez rarely visited Vega.
However, Vasquez said she visited her mother about once a month, sometimes bringing food or clothes. Although visitors could sign in, the log book was usually unavailable or located on other floors, Vasquez said.
She said she learned of her mother’s whereabouts only when the hospital sent a telegram to Vasquez’s home seeking permission to perform “a full mouth teeth extraction.” Every tooth needed to be removed.
Vasquez, who was not notified that state inspectors had seen her mother, said she began accumulating her own information about what happened inside Emerald Park.
Her mother maintained a modest bank account, about $200, with the home, Vasquez said. Ledger sheets, which detail each patient’s transactions, show numerous purchases for clothes and personal items or services, Vasquez said.
By law, Vega’s purchases that exceeded a few dollars needed to be approved by Vasquez, who said she was never contacted.
“I asked the home for mom’s clothes,” Vasquez said. “An employee told me she didn’t have any clothes. All they could find was one pink slipper in her room.”
Even more disquieting, Vega’s signature is found beside many small payments for soft drinks and hair cuts and other unclassified expenditures, carefully handwritten in ink between narrow ledger lines, according to nursing home records obtained by Vasquez.
“Mom was blind, spoke mostly Spanish and hasn’t written her name for decades,” Vasquez said. “There was no way she made those signatures.”
Cathy Joseph, nursing administrator at Emerald Park, acknowledges that the signatures were probably made by an employee for record-keeping purposes. Although the home was cited by the state earlier this year for bookkeeping irregularities involving patient accounts, all problems have since been corrected, she said.
Joseph added that all deficiencies cited by the state involving Vega’s case, such as failure to provide prompt nutritional lab tests, have been corrected. The state plans subsequent inspections to verify changes.
The nursing home had difficulty reaching Vasquez for permission involving dental services and to notify her that Vega had been hospitalized, because Vasquez had failed to update nursing home files with her unlisted telephone number, Joseph said.
But Vasquez said she provided the home with her phone number during a June meeting.
In the final days, Vasquez sat for hours at her mother’s bedside at Christ Hospital and Medical Center in Oak Lawn, watching the array of tubes and wires connected to machines that confirmed that the curled body on the bed had fallen into a deep coma. On Aug. 12, without regaining consciousness, Vega died of heart failure.
Following the death–still unaware that the state had raised an alarm about her mother’s condition just weeks before–Vasquez filed a complaint with the Department of Public Health alleging possible neglect and theft of money, she said.
In a response mailed to Vasquez, Public Health officials said they had investigated the complaint and found no merit to the allegations. No mention was made about the prior state findings, or that the home was cited for violations involving Vega. The case was closed, the letter said.
Public Health officials told the Tribune that the letter should have acknowledged the previous findings.
For Vasquez, it’s another troubling question about her mother’s final years.
“Nobody should have to live like she did,” she said. “Nobody should have to die like that.”