Now the aging baby boom generation is poised to further stretch a system that becomes dangerous when homes don't have enough staff, don't train workers well and suffer from high turnover, experts said.

Although much is done to try to protect residents in long-term care, the regulatory safety net has holes, the Wisconsin State Journal found in an eight-month investigation of elder abuse in the state. The newspaper's findings, culled from interviews with dozens of experts and a review of hundreds of pages of government reports and databases, show:

• In 2006 in Wisconsin, more than one in four nursing homes --well above the national average ? were cited for causing actual harm to vulnerable residents or putting them in immediate jeopardy, new federal data shows.

• Nursing hours per resident fall below the national average, and some training requirements are at the national minimum.

• The number of state inspectors for long-term care has decreased despite the increasing population in facilities. The governor's office and Department of Health and Family Services can't explain the decline but stress that inspectors are being shifted from nursing homes to assisted living, the fast growing form of long-term care.

Otis Woods, director of the Wisconsin Department of Health and Family Services Division of Quality Services, which enforces regulations, defended his operation and the industry it regulates. Overall, "the quality of care in Wisconsin facilities is very good," he said.

Still, in the past decade, the number of complaints per 100 nursing home beds rose from 2.7 to a projected 3.7 for this year. In 2006, the state got 447 abuse allegations at nursing homes -- a four-year high -- and substantiated 154, data shows.

The state had 107 abuse allegations at assisted-living facilities, substantiating 25.

Experts and advocates debate whether large numbers of citations mean poor care or vigorous inspection. And those in the state's long-term care industry maintain that residents get good care and are almost always safe, noting a single incident can bring multiple citations.

"Any incident of abuse is intolerable," said Thomas Moore, executive director of the Wisconsin Health Care Association, which represents 150 nursing homes.

Enforcement an issue

Case study

In 2002, an unattended resident was found dead in a bathtub, cockroaches bobbing in the water, the nursing call cord tied out of reach and the call lights turned off at the breaker box at the now-closed Jackson Center in Milwaukee, said William Hanrahan, a former state assistant attorney general targeting elder abuse and now a Dane County Circuit Court judge. Even in the presence of state investigators in Medicaid Fraud Unit jackets, caregivers were still shouting at patients, Hanrahan said, adding, "It was almost absurd how horrible the place was."

Nursing homes, increasingly serving the most poor, frail and ill, operate under heavy federal and state regulation, while assisted living facilities, still mostly private pay, have lighter state rules. Elder advocates say the state falls short in both areas.

"Enforcement is not adequate," said attorney Jason Studinski of Portage, who specializes in elder abuse cases in nursing homes and assisted-living facilities.

The state's 403 nursing homes, which house 38,700 residents, must be inspected at least every 15 months under federal law. The 2,643 assisted living facilities, housing 35,400 people, are to be checked every two years under state policy, but there is no law requiring it. The state's numbers reveal that 11 percent of them don't get full inspections every two years.

"Resources have not kept up with the pace of growth in the (assisted-living) industry," Woods said.

Wisconsin and industry officials unsuccessfully sought permission from the federal government to allow abbreviated inspections of good-performing nursing homes to concentrate resources on troubled ones ? just like the state's system for assisted living.

State and industry officials say the assisted-living system has served them well, noting that 40 percent of the facilities qualified for abbreviated inspections last year. All complaints came from just 16 percent of facilities, state officials said, adding that the system allows them to make the most of their resources.

But state spending devoted to enforcement isn't keeping up with increases in the numbers of people in long-term care.

Since 2004, despite increases in the long-term care population, the state has cut the number of long-term care inspectors from 108 to 100. In the area of assisted living, the state has added one inspector since 2004, for a total of 30, although the assisted-living population rose 12 percent from 2004 to 2006 alone.

The state couldn't say how much funding or personnel has been devoted annually to inspecting long-term care facilities in the last five years. But funds for the Division of Quality Assurance, which handles inspections in hospitals, nursing homes and other facilities, fell 3.4 percent to $21.5 million.

"I do believe we have adequate resources" overall, the division's Woods said. "More would always be great."

Training falls short

Case study

Ralph Baumgarter, 69, a resident at City View Nursing Home in Madison, caught a cold. His doctor ordered the facility to get him to the office the next day. Over nine days, staff failed to do so and Baumgarter got very ill. On the 10th day, he was admitted to the hospital, where he remained for a month until his death in 2005. The state, which conducted four inspections at the facility that year, can't discuss specific cases but did issue 13 federal citations, including one for failing to notify a physician for change of condition. Criminal charges weren't brought because the incident dealt with gross neglect, not intent. Madison attorney Matthew Boller won a $1 million abuse and neglect verdict against the facility.

For an elder in long-term care, "staffing and training are the linchpins of quality of life," said George Patarocke, director of the Wisconsin Board on Aging and Long-Term Care, which advises the governor and Legislature.

But the state's standards are inadequate, Patarocke said.

Wisconsin requires 2.5 hours of nursing per resident a day, fewer than some states, such as Florida's 3.9 hours. A national nursing home reform group recommends 4.1 hours. Providers in Wisconsin delivered an average 3.6 nursing hours per day in 2006, slightly below the national average, according to research by Dr. Charlene Harrington at the University of California - San Francisco, who does statistical analyses and writes scholarly articles on the nation's long-term care system. Harrington's research, however, shows Wisconsin's rates higher than the national average in some areas, such as facilities with Medicaid-only beds.

The state's staffing requirements for assisted-living facilities are "very, very vague," Patarocke said. The state requires "adequate" or "sufficient" levels, rather than any specific ratios.

Staff is critical, he said, noting an incident last year in which a nursing home resident's care plan called for two aides to move him from his bed to a commode but, when no help was available, a single worker attempted the maneuver. The resident fell, hit his head, fractured bones and died in the hospital.

State training requirements for nursing assistants -- the federal minimum 75 hours -- also are insufficient, Patarocke said. "This is the area where Wisconsin looks worst," he said, recalling another case when a poorly trained nursing assistant caused a resident to slip into a diabetic coma and lose a leg.

"We need to look at 120 hours," he said, adding that more specialized training is needed to care for those with illnesses like Alzheimer's.

Gov. Jim Doyle is willing to consider higher standards for staffing and training, spokesman Matt Canter said.

Brian Purtell, director of legal services for the Wisconsin Health Care Association, said the industry typically delivers more training than the state requires.

"The state doesn't reimburse us (through Medicaid payments) for the care we're now providing. We've got to address that gap," he said.

Reimbursement low

Case study

In Wisconsin, the disparity between nursing home operating costs for Medicaid patients and Medicaid reimbursements hit a record $232 million in the 2005-06 payment year, the Wisconsin Health Care Association says. The deficit is the third largest in the nation and double the national average, an October national study shows.

The industry said the deficit makes it hard to provide good wages that attract and keep high-quality workers.

"It's a shameful situation," said John Sauer, director of the Wisconsin Association of Homes and Services for the Aging, which represents nonprofit providers of care, housing and services.

The industry sought a 5 percent increase from the state in each year of the biennium, but the new state budget delivers no increase in the first year and 5 percent in the second.

"One year of no increase in an already underfunded system will result in more (nursing home) closures," said the nursing home association's Moore. "And in terms of quality improvement measures, it presents more of a problem, as well."

The increase "is just a step," Canter said, noting some other state operations will see cuts in the next two years. "Clearly, the governor would like to go further."

Elder advocates sympathize on the Medicaid issue but say it's hard to back more funding while CEOs of long-term care companies make huge salaries and corporations reap enormous profits.

"It doesn't do any good to raise Medicaid rates if they don't require it to be put into staffing," Harrington said.

'Chump change'?

Case study

A registered nurse at Stone Crest residence in Wausau decided an unresponsive resident needed hospitalization but waited 75 minutes to get permission from someone making the resident's medical decisions before calling 911. The resident died in the ambulance en route to the hospital. The state sought a correction plan and initially imposed a $1,000 fine, which was reduced to $650.

The state is tough with bad long-term care facilities, said Woods, who oversees inspections.

If inspectors find serious problems at a facility, they can order corrective actions, impose fines, deny new admissions or shut it down. The state insists on change and puts chronic poor performers out of business, Woods said.

From 2000 through 2005, the state revoked licenses at five nursing homes, and pressure may have contributed to 32 other closures, he said. Since 2001, the state revoked licenses at 48 assisted-living facilities.

The state's system of citations and fines is strong, Patarocke said, but its application is "basically flawed." Violators, he and others said, can cut fines by 35 percent by paying quickly. In 2006, the state imposed $3.75 million in fines but collected just $1.56 million. Since 2000, the state has assessed $17.3 million but collected only $8.4 million. The discounts allow the state to focus on care rather than drawn-out appeals, said Karen Timberlake, deputy director of the Department of Health and Family Services.

More troubling, a fine may be "chump change" to big corporations, while denying new residents would cut deeper, Patarocke said. For assisted living, fines are "grossly inadequate," he said.

But fines hurt struggling facilities, making it harder to improve, the state Health Care Association's Moore said.

Elder advocates said that government at all levels and the industry must do better to protect elders in long-term care because they are among the most vulnerable members of society.

"It's sad for the good facilities that are out there," but across the nation, "I think people have every reason to be fearful," said Jane Wells, director of public policy for the National Citizens Coalition for Nursing Home Reform, a nonprofit based in Washington, D.C.