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In his "Stories I'd like to see" column, journalist and entrepreneur Steven Brill spotlights topics that, in his opinion, have received insufficient media attention. This article was originally published on Reuters.com. 1. Is higher ed the capital of featherbedding? This sentence in an LA Times editorial two weeks ago about Homeland Security Secretary Janet Napolitano becoming the president of the...

by A.C. Thompson, ProPublica, and Jonathan Jones, Special to ProPublica

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Part 1

The Emerald City

Part 2

They're Not Treating Mom Well

Part 3

A Sinking Ship

Part 4

Close the Back Door

Documentary

Watch the Film

More

Back

Behind the Scenes

How This Series Was Reported

Emeritus Response

A Media Strategy to Thwart Federal Oversight

Profiles

Those Lost and Those Left Behind

Part 1

Part 2

Part 3

Part 4

Documentary

How It Was Reported

Profiles

A Media Strategy to Thwart Federal Oversight

Life and Death in Assisted Living, Part 2 “They’re Not Treating Mom Well”

by A.C. THOMPSON, ProPublica and JONATHAN JONES, special to ProPublica, July 30, 2013

in collaboration with

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When the ambulance crew arrived, about 8:20 p.m., Joan Boice was in the TV lounge, face-down on the carpet. Her head had struck the floor with some velocity; bruises were forming on her forehead and both cheeks. It appeared she’d lost her balance and fallen out of a chair.

But no one at the assisted living facility could say precisely how the accident had occurred. No one knew how long Joan had been splayed out on the floor. She had defecated and urinated on herself.

Worried that Joan might have injured her spine, the emergency medical personnel gently rolled her over and placed her on a back board. They pumped oxygen into her nostrils.

It was Sept. 22, 2008 — just 10 days after Joan had first moved into Emerald Hills.

No Emeritus employees accompanied Joan to the hospital. And even though Joan’s husband, Myron, was living in the facility, the Emeritus workers didn’t immediately alert him that Joan had fallen and hurt herself. Joan, confused, injured, and nearly mute, ended up in the local hospital by herself, surrounded by strangers.

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It was supposed to have been a festive night for Joan’s son Eric and his wife, Kathleen, who lived nearby. They were throwing a birthday party for their daughter, then in elementary school. The celebration was interrupted when a doctor called from the hospital with news of Joan’s fall. As Kathleen recalled it, the physician was somewhat baffled — he didn’t understand what Joan was doing in the emergency room without a family member, and he was having trouble deducing the extent of her injuries because she couldn’t communicate.

California law requires assisted living companies to conduct a “pre-admission appraisal” of prospective residents, to ensure they are appropriate candidates for assisted living.

But Emerald Hills took Joan in without performing an appraisal. It wasn’t for lack of time. The Boices had signed the contract to live at Emerald Hills more than two weeks before Joan moved in.

Joan, then, had taken up residence in the memory care unit at Emerald Hills. The unit — referred to as a “neighborhood” by the company — is a collection of about a dozen small apartments on either side of a central hallway. At each end of the hallway are heavy doors equipped with alarms, which sound when anyone enters or leaves. The alarm system is meant to prevent residents from simply walking off.

On the day Joan moved into Room 101 in the unit, a company nurse named Margaret “Peggy” Stevenson briefly looked her over. The nurse realized that Joan needed to be monitored closely to keep her from falling — she wrote it down in her cursory assessment — but facility records show she didn’t craft any kind of detailed plan for her care and supervision.

Stevenson, asked years later about Joan, said she could recall nothing about her or her stay at Emerald Hills.

Kathleen had immediate suspicions about Joan’s fall. The family, she said, had warned the facility not to leave Joan sitting in a chair without supervision because she was liable to try to stand up, lose her balance, and topple to the floor. Joan had fallen several times during an earlier stay in an assisted living facility near Sacramento, but the staff had developed a specific plan to address the issue.

Despite the warning, Kathleen said that when she visited Emerald Hills during Joan’s first days there she often found her mother-in-law sitting in a chair alone.

The recent track record at Emerald Hills featured a host of falls similar to Joan’s, and ambulances were often called to take the injured off to the hospital. Falls are a particular hazard for the elderly, and assisted living facilities like Emerald Hills are required to report them to state regulators.

Internal company records documented 112 falls at Emerald Hills in 2008. Some residents fell repeatedly.

Consider the case of one Emerald Hills resident, 83-year-old Dorothy “Dottie” Bullock.

On April 5, 2008, an Emeritus employee discovered Bullock “on the floor in a semi-seated position” in the memory care unit, according to a state report. She “was unable to tell” the worker what had happened to her. The incident was described as a fall in state records. Emerald Hills sent her to the hospital.

On April 7, Bullock, back at Emerald Hills, fell again, according to the handwritten log of her personal attendant, who was hired by Bullock’s husband to give her extra help.

On April 8, Bullock, complaining of pain, was hauled by ambulance back to the hospital. Doctors concluded that she’d fractured her pelvis, but soon returned her to Emerald Hills. She fell again on April 12.

Bullock would fall again months later, for the final time.

Emeritus records show Bullock tumbled in front of her apartment and was found on the carpet with her aluminum walker beneath her. Blood spilled from her nose and a “bump” developed on her forehead, according to the company documents. The impact broke a vertebra in Bullock’s neck and crushed her nasal bones and sinus structures, hospital records show. A CT scan revealed possible fractures of both eye-sockets and the base of the skull.

Dottie Bullock died in the emergency room.

While Emeritus recorded the fatality in its internal logs, the company did not report her death to state regulators, a violation of California law. The state requires assisted living facilities to file reports on all deaths, even those believed to be from natural causes, so that it can look into suspicious or troubling incidents.

Emeritus said it lacked information about Bullock’s death and thus could not say why it had occurred.

Bullock’s personal attendant, Julie Covich, says Bullock was not supervised properly.

“I think there was neglect,” said Covich, who usually visited Emerald Hills once or twice a week to help out Bullock. “I would go in there and never see a caregiver.”

“It was hard to find anyone that was running the place,” she said. “It was crazy.”

“Heads on the Beds”

In early 2008, the year Joan Boice entered Emerald Hills, Emeritus rolled out a new business campaign. The company dubbed it the “No Barriers to Sales” effort.

The concept was straightforward: Move as many people as possible into Emeritus facilities. Wall Street was looking closely at the company’s quarterly occupancy numbers and a few percentage points could propel the stock price upward or send it tumbling down.

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With the housing market foundering, Emeritus needed to step up its sales efforts.

In case there was any confusion about just how seriously the company took this new campaign, a company vice president sent a blast email to facility directors across California. In the body of the email, the vice president got right to it: “SALES and your commitment to sales is your highest priority right now.” Facility directors, the message concluded, would be “held responsible for census and occupancy growth.”

Emeritus employees across the country realized they were entering a new era.

“There was a different sense of urgency. The tone was different,” said a former Emeritus manager who ran a facility at the time. “The message from above was put as many people as possible in the beds and make as much money as possible. That’s what they said. Verbatim. Honestly.”

According to Lisa Paglia, a regional executive in California at the time, Budgie Amparo, the company’s top official for quality control, was openly critical when a Northern California facility declined to admit someone who did not have a doctor’s evaluation.

Such evaluations, which are designed to keep out seniors with problems that assisted living facilities aren’t equipped to handle, are required under a California law known as Title 22.

But on a conference call with roughly half a dozen California managers, Paglia said, Amparo declared that the Northern California facility should have admitted the resident.

“Our priority,” Amparo declared, according to Paglia, “is to get the heads on the beds.”

The issue arose again in October 2008 during a training session for approximately 25 facility directors and salespeople held at an Emeritus property in Tracy, Calif. During the seminar, a company vice president reiterated Amparo’s instruction to disregard California law, according to court records and interviews.

The mandate prompted something of a staff revolt.

At least one facility director spoke out at the meeting: His license to operate the facility was at stake, he said.

An employee who worked at the Tracy facility eventually alerted California regulators. The state dispatched an investigator, and state records show that the investigator met with employees who confirmed that a company official had approved the practice of admitting someone without a doctor’s report. The investigator reviewed a random sample of seven resident files, finding that two people had been moved in illegally, documents show.

Amparo, a nurse whose full title is executive vice president of quality and risk management, denies directing employees to violate the regulation. In a written statement, Emeritus said, “Neither Budgie Amparo nor any of our other officers issued a directive to violate Title 22 or any other law. Emeritus does not condone allowing residents to move in without the proper documents.”

Emeritus eventually fired Paglia, and lawyers for the company have since portrayed her as a poor worker who failed to do her job competently. Along with two other former Emeritus employees, Paglia sued the company alleging wrongful termination, and wound up settling on secret terms.

For assisted living chains such as Emeritus, there is a powerful business incentive to boost occupancy rates and to take in sicker residents, who can be charged more.

Emeritus, for its part, rejects any suggestion that a quest for profits has tainted its admission practices. But in interviews, former Emeritus executives described a corporate culture that often emphasized cash flow above all else. The accounts of the executives, who spoke independently but anonymously, were strikingly consistent.

“It was completely focused on numbers and not human lives,” said one executive, who worked for Emeritus for more than three years and oversaw dozens of facilities in Eastern states.

The company’s emphasis on sales and occupancy rates, the executive said, transformed the workforce into “a group of people who were grasping at every single lever they could pull to drive profitability.”

Emeritus operates a sophisticated, data-driven sales machine. There are occupancy goals for each facility, as well as yearly company-wide goals. The company tracks dozens of data points — including every move-in and move-out of residents — in a vast database. It posts a monthly snapshot of each facility’s sales statistics on an internal website, allowing employees to see which strategies are most successful.

Sales specialists are instructed on how to use psychology to persuade potential customers to sign on. One suggestion: Give the customer “a sense of control and choice by offering two possible options.” A 2009 Emeritus sales manual, which runs 181 pages, encourages sales people to generate publicity by hosting seminars on Alzheimer’s or organizing charity efforts in the event of a natural disaster like a “flood or earthquake.”

Emeritus motivates its workforce with a broad range of financial incentives. There are bonuses for hitting monthly occupancy goals. Bonuses for hitting yearly occupancy goals. Bonuses for boosting overall earnings. And the money doesn’t just go to sales people: The company hands out checks to maintenance workers, nurses, facility directors and other workers.

Nurses play a key role in assisted living, providing much of the hands-on care. But nurses at Emeritus facilities are also expected to be deeply involved in increasing revenue by making sales.

During more than a year of reporting, ProPublica and PBS Frontline spoke to 10 facility directors who said nurses were required to participate in weekly conference calls focusing on little but economics. Those accounts are backed by an internal Emeritus document that lays out the agenda for the weekly calls and that shows an overarching concentration on finances.

Doris Marshall was at the forefront of Emeritus’s efforts to have nurses play the dual roles of caregivers and salespeople. After receiving her nursing license in 1984, Marshall had spent many years tending to patients in the emergency department of a Southern California hospital, and she’d later gone on to help run a nursing school.

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But Marshall was intrigued by the assisted living business and in March 2008 she signed on to supervise 10 Emeritus properties scattered across Northern California. Amparo, the company’s head nurse, convinced Marshall to take the job, telling her nurses “had a voice” at Emeritus.

Marshall was to oversee the well-being of roughly 800 elderly people. But her job description went well beyond that: She was to help with “marketing” and “attaining financial goals.” Her job, in the end, actually involved very little nursing.

Instead, she said, she was drawn into Emeritus’s evolving strategies aimed at upping its revenues. The company planned to bring in more seniors with Alzheimer’s and dementia because they could be charged more, she said. Her boss gave her a digital tracking tool showing how much more money Emeritus could make by admitting sicker, frailer residents.

By the fall of 2010 Marshall was worn out and disillusioned. She quit.

Emeritus’s extraordinary drive to put heads in beds — perhaps routine in, say, the hotel industry — has distorted the admissions process at some facilities, records and interviews show. Since 2007, state investigators have cited the company’s facilities more than 30 times for housing people who should have been prohibited from dwelling in assisted living facilities.

A 2010 episode at an Emeritus facility in Napa highlighted the perils of improperly admitting people. The facility rented a room to a 57-year-old woman with an eating disorder, depression, bipolar disorder and a history of suicide attempts. The woman, who was distraught over the death of her husband, taped a note to her door saying she wasn’t to be disturbed and committed suicide, overdosing on an amalgam of prescription painkillers.

The state’s investigation into the death was scathing: the woman should never have been allowed to move in; the staff had missed or ignored bulimic episodes and her obvious weight loss; no plan of care was ever developed or implemented despite the resident’s profound psychological problems.

Emeritus, asked to respond to the state’s investigation, said only that the woman had overdosed on drugs she had brought into the facility on her own, and that as a result they could not be faulted in her death.

“She Barely Even Talked to Us”

In the aftermath of her fall in September 2008, Joan returned to Emerald Hills. But the staff, inexperienced and often exhausted, worried about her.

“She couldn’t walk, she couldn’t feed herself, she barely even talked to us, and her health wasn’t that good,” recalled Jenny Hitt, a former medication technician at Emerald Hills.

But if concern was abundant at Emerald Hills, expertise was in short supply.

Alicia Parga ran Joan’s memory care unit. On some weekends, she managed the entire building — not only the wing of residents with dementia, but the rest of the three-story assisted living facility, one that could hold a total of more than 100 residents.

After Parga started on the job, it took Emeritus roughly 18 months to give her any training on Alzheimer’s and dementia. The state regulations were hardly substantial: Someone such as Parga was obligated to get six hours of training during her first four weeks on the job. But even that requirement wasn’t met.

Emeritus has insisted that Emerald Hills had properly trained personnel to care for Joan and others, and they described Parga as a woman deeply invested in tending to the residents.

But Parga, who had barely earned a high school degree, wasn’t even familiar with the seven stages of dementia. Though she was responsible for the well-being of 15 or more seriously impaired people, as well as the supervision of employees, Parga was paid less than $30,000 per year.

Catherine Hawes, a health care researcher at Texas A&M University, conducted the first national study of assisted living facilities. In her view, training is absolutely crucial. A well-educated employee can “interpret non-verbal cues” from people like Joan, intercept seniors before they wander away from the building, or keep residents from eating or drinking poisonous substances.

“You can do great care,” she said. “You just — you’ve got to know how.”

Other than the Emeritus employees working in the memory care unit at Emerald Hills, only one person saw Joan enough to know what kind of daily care she was getting: Her husband, Myron.

He was worried. And he did his best to sum up his concerns to his son Eric:

“They’re not treating Mom well.”

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by A.C. Thompson, ProPublica, and Jonathan Jones, Special to ProPublica

XXX

XXX

XXX

XXX

Part 1

The Emerald City

Part 2

They're Not Treating Mom Well

Part 3

A Sinking Ship

Part 4

Close the Back Door

Documentary

Watch the Film

More

Back

Behind the Scenes

How This Series Was Reported

Emeritus Response

A Media Strategy to Thwart Federal Oversight

Profiles

Those Lost and Those Left Behind

Part 1

Part 2

Part 3

Part 4

Documentary

How It Was Reported

Profiles

A Media Strategy to Thwart Federal Oversight

Life and Death in Assisted Living, Part 1 “The Emerald City”

by A.C. THOMPSON, ProPublica and JONATHAN JONES, special to ProPublica, July 29, 2013

in collaboration with

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OFFON  (What's this?)

Joan Boice needed help. Lots of it. Her physician had tallied the damage: Alzheimer’s disease, high blood pressure, osteoporosis, pain from a compression fracture of the spine. For Joan, an 81-year-old former schoolteacher, simply getting from her couch to the bathroom required the aid of a walker or wheelchair.

The Alzheimer’s, of course, was the worst. The disease had gradually left Joan unable to dress, eat or bathe without assistance. It had destroyed much of the complex cerebral circuitry necessary for forming words. It was stealing her voice.

Joan’s family was forced to do the kind of hard reckoning that so many American families must do these days. It was clear that Joan could no longer live at home. Her husband, Myron, simply didn’t have the stamina to provide the constant care and supervision she needed. And moving in with any of their three children wasn’t an option.

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These were the circumstances that eventually led the Boice family to Emeritus at Emerald Hills, a sprawling, three-story assisted living facility off Highway 49 in Auburn, Calif. The handsome 110-bed complex was painted in shades of deep green and cream, reflecting its location on the western fringe of the craggy, coniferous Sierra Nevada mountain range. It was owned by the Emeritus Corp., a Seattle-based chain that was on its way to becoming the nation’s largest assisted living company, with some 500 facilities stretching across 45 states.

Emeritus at Emerald Hills promised state-of-the art care for Joan’s advancing dementia. Specially trained members of the staff would create an individual plan for Joan based on her life history. They would monitor her health, engage her in an array of physically and mentally stimulating activities, and pass out her 11 prescription medications, which included morphine (for pain) and the anti-psychotic drug Seroquel (given in hopes of curbing some of the symptoms of her Alzheimer’s). She would live in the “memory care” unit, a space designed specifically to keep people with Alzheimer’s and other forms of dementia safe.

At Emerald Hills, the setting was more like an apartment complex than a traditional nursing home. It didn’t feel cold or clinical or sterile. Myron could move in as well, renting his own apartment on the other side of the building; after more than 50 years of marriage, the couple could remain together.

Sure, the place was expensive — the couple would be paying $7,125 per month — but it seemed ideal.

During a tour, a salesperson gave Myron and his two sons, Eric and Mark, a brochure. “Just because she’s confused at times,” the brochure reassured them, “doesn’t mean she has to lose her independence.”

Here are a few things the brochure didn’t mention:

Just months earlier, Emeritus supervisors had audited the facility’s process for handling medications. It had been found wanting in almost every important regard. And, in truth, those “specially trained” staffers hadn’t actually been trained to care for people with Alzheimer’s and other forms of dementia, a violation of California law.

The facility relied on a single nurse to track the health of its scores of residents, and the few licensed medical professionals who worked there tended not to last long. During the three years prior to Joan’s arrival, Emerald Hills had cycled through three nurses and was now employing its fourth. At least one of those nurses was alarmed by what she saw, telling top Emeritus executives — in writing — that Emerald Hills suffered from “a huge shortage of staff” and was mired in “total dysfunction.”

During some stretches, the facility went months without a full-time nurse on the payroll.

The paucity of workers led to neglect, according to a nurse who oversaw the facility before resigning in disgust. Calls for help went unanswered. Residents suffering from incontinence were left soaking in their own urine. One woman, addled by dementia, was allowed to urinate in the same spot in the hallway of the memory care wing over and over and over.

The brochure also made no mention of the company’s problems at its other facilities. State inspectors for years had cited Emeritus facilities across California, faulting them for failing to employ enough staff members or adequately train them, as well as for other basic shortcomings.

Emeritus officials have described any shortcomings as isolated, and insist that any problems that arise are promptly addressed. They cite the company’s growing popularity as evidence of consumer satisfaction. They say that 90 percent of people who take up residence in assisted living facilities across the country report being pleased with the experience.

Certainly, the Boice family, unaware of the true troubles at Emerald Hills, was set to be reassured.

“We were all impressed,” recalled Eric Boice, Joan’s son. “The first impression we had was very positive.”

And so on Sept. 12, 2008, Joan Boice moved into Room 101 at Emerald Hills. She would be sharing the room with another elderly woman. After a succession of tough years, it was a day of great optimism.

Measuring the dimensions of his mother’s new apartment, Eric Boice sought to recreate the feel of her bedroom back home. He arranged the furniture just as it had been. He hung her favorite pictures in the same spots on the wall. On her dresser, he set out her mirror and jewelry box and hairbrush.

Joan, 5-foot-2 and shrinking, had short snow-and-steel hair and wintry gray-blue eyes. Eric looked into those eyes that day at Emerald Hills. He thinks he might have seen a flicker of fear. Or maybe it was just confusion, his mom still uncertain where, exactly, she was.

A Reform Movement Winds Up on Wall Street

The Emeritus Corp., the assisted living corporation now entrusted with Joan’s life, sat atop an exploding industry.

Two decades earlier, Keren Brown Wilson had opened the nation’s first licensed assisted living facility in Canby, Ore., a small town outside of Portland. Wilson was inspired by tragedy: A massive stroke had paralyzed her mother at the age of 55, forcing her into a nursing home, where she was miserable, spending the bulk of her days confined to a hospital bed.

Wilson aimed to create an alternative to nursing homes. She envisioned comfortable, apartment building-style facilities that would allow sick and fragile seniors to maintain as much personal autonomy as possible.

“I wanted a place where people could lock the door,” Wilson explained. “I wanted a place where they could bring their belongings. I wanted a place where they could go to bed when they wanted to. I wanted a place where they could eat what they wanted.”

These “assisted living” facilities would offer housing, meals and care to people who could no longer live on their own but didn’t need intensive, around-the-clock medical attention. The people living in these places would be called “residents” — not patients.

It took Wilson nine years to persuade Oregon legislators to rewrite the state’s laws, a crucial step toward establishing this new type of facility. After that, states across the country began adopting the “Oregon model.”

But what began as a reform movement quickly morphed into a lucrative industry. One of the early entrants was Emeritus, which got into the assisted living business in 1993, opening a single facility in Renton, Wash. The company’s leader, Daniel Baty, had his eyes on something much grander: He was, he declared, aiming to create a nationwide chain of assisted living facilities.

Two years later, Baty took the corporation public, selling shares of Emeritus on the American Stock Exchange, and piling up the cash necessary to vastly enlarge the company’s footprint. Many of Emeritus’s competitors followed the same path.

The company’s rapid growth was, at least in part, a reflection of two significant developments. Americans were living longer, with the number of those in the 65-plus age bracket ballooning further every year. And this growing population of older Americans was willing to spend serious money, often willing to drain their bank accounts completely to preserve some semblance of independence and dignity — in short, something of their former lives.

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As the assisted living business flourished, the federal government, which oversees nursing homes, left the regulation of the new industry to the states, which were often unprepared for this torrent of expansion and development. Many states didn’t develop comprehensive regulations for assisted living, choosing instead to simply tweak existing laws governing boarding homes.

In this suddenly booming, but haphazardly regulated industry, no company expanded more aggressively than Emeritus. By 2006, it was operating more than 200 facilities in 35 states. The corporation’s strategy included buying up smaller chains, many of them distressed and financially troubled, with plans to turn them around.

Wall Street liked the model. Market analysts touted the virtues of the company and its stock price floated skyward. One of the corporation’s appeals was that its revenues flowed largely from private bank accounts; unlike hospitals or nursing homes, Emeritus wasn’t reliant on payments from the government insurance programs Medicare or Medicaid, whose reimbursement rates can be capped. As the company noted in its 2006 annual report, nearly 90 percent of its revenues came from “private pay residents.”

In filings with the Securities and Exchange Commission and in conference calls with investors, Emeritus highlighted many things: occupancy rates; increasing revenue; a constant stream of complex real estate deals and acquisitions; the favorable demographic trends of an aging America.

“The target market for our services is generally persons 75 years and older who represent the fastest growing segments of the U.S. population,” Emeritus stated in a 2007 report filed with the SEC.

Today, the assisted living industry rivals the scale of the nursing home business, housing nearly three-quarters of a million people in more than 31,000 assisted living facilities, according to the U.S. Department of Health and Human Services.

Keren Brown Wilson, the early and earnest pioneer of assisted living, is happy that ailing seniors across the country now have the chance to spend their final years in assisted living facilities, rather than nursing homes. But in her view, the rise of assisted living corporations — with their pursuit of investment capital and their need to please shareholders — swept in “a whole new wave of people” more focused on “deals and mergers and acquisitions” than caring for the elderly.

She speaks from experience. After her modest start, Wilson went on to lead a company called Assisted Living Concepts, and took it onto the stock market. Wilson left the company in 2001, and it has encountered a raft of regulatory and financial problems over the last decade.

“I still have a lot of fervor,” said Wilson, who now runs a nonprofit foundation and teaches at Portland State University. “I believe passionately in what assisted living can do. And I’ve seen what it can do. But for some of the people, it’s just another job, or another business. It’s not a passion.”

“A Phenomenal Deal”

Joan Boice, born Joan Elizabeth Wayne, grew up in Monmouth, Ill. It was a tiny farm belt community, not far from the Iowa border. Her father, a fixture in the local agriculture trade, owned a trio of riverfront grain elevators on the Mississippi and a fleet of barges. As a teenager, she spent her summers trudging through the fields, de-tasseling corn.

In 1952, accompanied by a friend, Joan packed up a car and followed the highway as far west as it would go. Then in her early 20s, she was propelled by little more than the notion that a different life awaited her in California. In a black-and-white snapshot taken shortly after she arrived, Joan is smiling, a luxuriant sweep of dark hair framing her pale face, gray waves curling in the background. It was the first time she’d seen the Pacific.

Joan had been a teacher for two years in Illinois, and she quickly found a job at an elementary school in Hayward, a suburb of San Francisco. In certain regards, her outlook presaged the progressive social movements that were to remake the country during the next two decades. She viewed education as a “great equalizing force” that could help to remake a society far too stratified by class, race and gender.

“She was just free-spirited and confident,” Eric, her son, said.

Joan met Myron Boice through a singles group at a Presbyterian church in Berkeley. On their wedding day, Joan flouted convention by showing up in a blue dress. The Boice children came along fairly quickly: Nancee, then Mark, then Eric.

Myron Boice was a dreamer. A chronic entrepreneur. He sold tools from a van. He made plans to open restaurants. He had one idea after another. Some worked; others didn’t.

Joan’s passion for education never dissipated. Even in her late 60s, she continued to work as a substitute teacher in public schools. After retirement, she began volunteering with a childhood literacy program.

But age eventually tightened its grip, and hints of a mental decline began surfacing around 2005. Eric grew worried when she couldn’t figure out how to turn on her computer twice in the span of a few months. Then she forgot to include a key ingredient while baking a batch of Christmas cookies. The cookies were inedible.

The elderly couple was still living in the San Francisco suburbs, when, in late 2006, a doctor diagnosed Joan with Alzheimer’s. As her mind deteriorated, Myron struggled to meet her needs. The situation was worsened by the fact that none of the children lived nearby. Mark was in Ohio. Nancee was about an hour away in Santa Cruz. And Eric and his wife, Kathleen, were roughly two hours away in the foothills of the Sierra.

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“We offered my parents to come and live with us,” Eric recalled. But Myron said no. He and Joan wouldn’t move in with any of the kids. The family patriarch refused to become a burden.

A physician encouraged Joan and Myron to consider assisted living. It made sense. And so Myron sold their home in 2007 and the couple moved into a facility called The Palms, near Sacramento. The move put them approximately 40 minutes away from Eric and Kathleen.

“They were very attentive to every single thing she needed,” Kathleen Boice said of the staff at The Palms. “They actually re-taught her to eat with a fork and a knife.”

By 2008, however, Myron wanted a change. He wanted to be closer to his son and daughter-in-law and grandkids. He wanted different meals, a new environment. Myron began hunting for a new place to live, a search that led to Emeritus at Emerald Hills in Auburn.

Emeritus opened the Emerald Hills complex in 1998. It was, in many ways, a classic Emeritus facility, situated in a middle-class locale that was neither impoverished nor especially affluent. It was a sizable property, capable of housing more than 100 people.

In part because of its appetite for expansion, Emeritus was in the early stages of what proved to be a period of enormous stress. In 2007, the company had made its biggest acquisition to date, buying Summerville Senior Living Inc., a California-based chain with 81 facilities scattered across 13 states.

The purchase — which expanded Emeritus’s size by roughly one-third — helped the company make another major leap, bouncing from the low-profile American Stock Exchange into the big leagues of commerce, the New York Stock Exchange. News of the Summerville deal propelled the company’s stock to a new high. Emeritus was poised to become the nation’s No. 1 assisted living chain.

But the timing for this bold move turned out to be wretched. The real estate market was freezing up, and it would soon collapse, plunging the nation into an epochal recession. For Emeritus, the economic slowdown and then the housing crash posed direct challenges. Its services didn’t come cheap, so many people needed to sell their homes before they could afford to move into the company’s facilities. With the real estate market calcified, Emeritus’s customer pool shrank.

“Our stock price plummeted,” recalled Granger Cobb, Emeritus’s chief executive officer, who joined the company as part of the Summerville deal. The company’s occupancy rates had been trending skywards. Now they went flat.

At Emerald Hills, the economic slowdown that summer was making life tough for Melissa Gratiot, the lead sales agent.

“It was way harder to move residents in,” she remembered.

But there was some good news. She was close to a significant sale, this one to a couple. Gratiot worked the pitch. She talked with the family. She emailed. She gave them a tour of the facility’s memory care unit, called The Emerald City. She told the family she’d received approval from higher ups to offer the family “a phenomenal deal.”

Gratiot closed the sale. On Aug. 29, 2008, Myron and Eric signed the contract, and the family opened its wallet: A $2,500 initial move-in fee; $2,772 for Joan's first two weeks in Room 101; another $1,660 for Myron.

There had been one oversight, though. No one at Emeritus with any medical training had ever even met Joan, much less determined whether Emerald Hills could safely care for her.

Correction (7/29): An earlier version of this story stated that Emeritus at Emerald Hills had failed a company audit of its memory care unit before Joan Boice moved in. It has been corrected to say an audit found flaws in the facility’s medication handling process before Boice moved in. The memory care unit was audited while Boice was living there and failed nearly every important test.

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by Blair Hickman

Months after Joan Boice, a former schoolteacher, checked into Emerald Hills assisted living facility, she was dead. She had suffered from a range of health ailments, including Alzheimer’s, when she checked in. But as our recent investigation shows, neglect and a swarm of bedsores, improperly cared for by staff, likely contributed to her death.

Joan is not alone. The assisted living industry is a growing, multibillion dollar industry that serves nearly 750,000 people across the country – yet it’s loosely regulated. That’s why we’re looking into how the push for profits may be affecting quality care.

If your loved one has lived in an assisted living facility, you can help our ongoing reporting by sharing your story below. We promise we’ll keep your information confidential.

If you have concerns sharing your story here, please feel free to contact reporter A.C. Thompson at A.C.Thompson@propublica.org

The Wall Street Journal's Dennis Berman has an excellent piece on the future of the truck driver, whom he notes has been almost uniquely insulated from the decline of the working class. Now the robots are coming for these jobs too. Gigantic automated trucks produced by Caterpillar are replacing most of the 180 drivers at one iron mine in Australia....

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by Cora Currier

In a major national security speech this spring, President Obama said again and again that the U.S. is at war with “Al Qaeda, the Taliban, and their associated forces.”

So who exactly are those associated forces? It’s a secret.

At a hearing in May, Sen. Carl Levin, D-Mich., asked the Defense Department to provide him with a current list of Al Qaeda affiliates.

The Pentagon responded – but Levin’s office told ProPublica they aren’t allowed to share it. Kathleen Long, a spokeswoman for Levin, would say only that the department’s “answer included the information requested.”

A Pentagon spokesman told ProPublica that revealing such a list could cause “serious damage to national security.”

“Because elements that might be considered ‘associated forces’ can build credibility by being listed as such by the United States, we have classified the list,” said the spokesman, Lt. Col. Jim Gregory. “We cannot afford to inflate these organizations that rely on violent extremist ideology to strengthen their ranks.”

It’s not an abstract question: U.S. drone strikes and other actions frequently target “associated forces,” as has been the case with dozens of strikes against an Al Qaeda offshoot in Yemen.

During the May hearing, Michael Sheehan, Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict, said he was “not sure there is a list per se.” Describing terrorist groups as “murky” and “shifting,” he said, “it would be difficult for the Congress to get involved in trying to track the designation of which are the affiliate forces” of Al Qaeda.

Sheehan said that by the Pentagon’s standard, “sympathy is not enough…. it has to be an organized group and that group has to be in co-belligerent status with Al Qaeda operating against the United States.”

The White House tied Al Qaeda in the Arabian Peninsula and “elements” of Al Shabaab in Somalia to Al Qaeda in a recent report to Congress on military actions. But the report also included a classified annex.

Jack Goldsmith, a professor at Harvard Law who served as a legal counsel during the Bush administration and has written on this question at length, told ProPublica that the Pentagon’s reasoning for keeping the affiliates secret seems weak. “If the organizations are ‘inflated’ enough to be targeted with military force, why cannot they be mentioned publicly?” Goldsmith said. He added that there is “a countervailing very important interest in the public knowing who the government is fighting against in its name."

The law underpinning the U.S. war against Al Qaeda is known as the Authorization for Use of Military Force, or AUMF, and it was passed one week after the 9/11 attacks. It doesn’t actually include the words “associated forces,” though courts and Congress have endorsed the phrase.

As we explained earlier this year, the emergence of new or more loosely-aligned terrorist groups has legal scholars wondering how effectively the U.S. will be able to “shoehorn” them into the AUMF. During the May hearing, many lawmakers expressed concern about the Pentagon’s capacious reading of the law. Sen. John McCain, R-Ariz., described it as a “carte blanche.”

Obama, in his May speech, said he looked forward “to engaging Congress and the American people in efforts to refine, and ultimately repeal, the AUMF’s mandate.” But he didn’t give a timeframe. On Wednesday, Rep. Adam Schiff, D-Calif., introduced an amendment that would sunset the law at the end of 2014, to coincide with the U.S. withdrawal from Afghanistan. It was voted down the same day, 185 to 236.

The AUMF isn’t the only thing the government relies on to take military action. In speeches and interviews Obama administration officials also bring up the president’s constitutional power to defend the country, even without congressional authorization. 

Reuters has long been one of the most prolific producers of climate change journalism, leading The New York Times and the Guardian for most climate-centric articles in 2011. But a new assessment lends credence to recent claims that the newswire is pulling back its coverage after the addition of a global-warming skeptic to the company's editorial management. On Tuesday, Media...

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by Kara Brandeisky

Although the House defeated a measure that would have defunded the bulk phone metadata collection program, the narrow 205-217 vote showed that there is significant support in Congress to reform NSA surveillance programs. Here are six other legislative proposals on the table.

1) Raise the standard for what records are considered “relevant”

The Foreign Intelligence Surveillance Court has reportedly adopted a broad interpretation of the Patriot Act, ruling that all the records in a company’s database could be considered “relevant to an authorized investigation.” The leaked court order compelling a Verizon subsidiary to turn over all its phone records is just one example of how the Foreign Intelligence Surveillance Court has interpreted the statute.

Both Rep. John Conyers, D-Mich., and Sen. Bernie Sanders, I-Vt., have introduced bills requiring the government to show “specific and articulable facts” demonstrating how records are relevant.  Similarly, legislation introduced by Sen. Mark Udall, D-Colo., would require any applications to include an explanation of how any records sought are relevant to an authorized investigation.

2) Require NSA analysts to obtain court approval before searching metadata

Once the NSA has phone records in its possession, Sen. Dianne Feinstein has explained that NSA analysts may query the data without individualized court approvals, as long as they have a “reasonable suspicion, based on specific facts” that the data is related to a foreign terrorist organization.

A bill from Rep. Stephen Lynch, D-Mass., would require the government to petition the Foreign Intelligence Surveillance Court every time an analyst wants to search telephone metadata. From there, a surveillance court judge would need to find “reasonable, articulable suspicion” that the search is “specifically relevant to an authorized investigation” before approving the application. The legislation would also require the FBI to report monthly to congressional intelligence committees all the searches the analysts made.

3) Declassify Foreign Intelligence Surveillance Court opinions

Right now, court opinions authorizing the NSA surveillance programs remain secret. Advocacy groups have brought several Freedom of Information Act suits seeking the release of Foreign Intelligence Surveillance Court documents, but the Justice Department continues to fight them.

Several bills would compel the secret court to release some opinions. The Ending Secret Law Act — both the House and Senate versions — would require the court to declassify all its opinions that include “significant construction or interpretation” of the Foreign Intelligence Surveillance Act. Under current law, the court already submits these “significant” opinions to congressional intelligence committees, so the bill would just require the court to share those documents with the public.

The bills do include an exception if the attorney general decides that declassifying an opinion would threaten national security. In that case, the court would release an unclassified summary of the opinion, or — if even offering a summary of the opinion would pose a national security threat — at least give a report on the declassification process with an “estimate” of how many opinions must remain classified.

Keep in mind, before Edward Snowden’s disclosures, the Justice Department argued that all “significant legal interpretations” needed to remain classified for national security reasons. Since the leaks, the government has said it’s now reviewing what, if any, documents can be declassified, but they said they need more time.

4) Change the way Foreign Intelligence Surveillance Court judges are appointed

Current law does not give Congress any power to confirm Foreign Intelligence Surveillance Court judges. Instead, the chief justice of the United States appoints the judges, who all already serve on the federal bench. The judges serve seven-year terms. Chief Justice John Roberts appointed all 11 judges currently serving on the court – ten of whom were nominated to federal courts by Republican presidents.

A bill introduced by Rep. Adam Schiff, D-Calif., would give the president the power to appoint surveillance court judges and give the Senate power to confirm. The president would also choose the presiding judge of the surveillance court, with Senate approval.

Alternatively, Rep. Steve Cohen, D-Tenn., has offered a bill that would let the chief justice appoint three judges and let the House Speaker, the House minority leader, the Senate majority leader, and the Senate minority leader each appoint two judges.

5) Appoint a public advocate to argue before the Foreign Intelligence Surveillance Court

Currently, the government officials petitioning the Foreign Intelligence Surveillance Court do not face an adversarial process. Surveillance targets do not have representation before the court, and they are not notified if a court order is issued for their data.

In 33 years, the surveillance court only rejected 11 of an estimated 33,900 government requests, though it the government has also modified 40 of the 1,856 applications in 2012. 

Two former Foreign Intelligence Surveillance Court judges – Judge James Robertson and Judge James Carr – have argued that Congress should appoint a public advocate to counter the government’s arguments. Carr wrote in the New York Times, “During my six years on the court, there were several occasions when I and other judges faced issues none of us had encountered before. […]Having lawyers challenge novel legal assertions in these secret proceedings would result in better judicial outcomes.”

Sen. Richard Blumenthal, D-Conn., has promised to introduce a bill that would provide a “special advocate” to argue on behalf of privacy rights and give “civil society organizations” a chance to respond before the surveillance court issues significant rulings.

The surveillance court can actually invite advocates to argue before the court, as the Supreme Court did when the Obama administration refused to defend the Defense of Marriage Act.  

“There’s nothing in law that would prevent the FISA court from hiring an advocate as an additional advisor to the court, except the need to obtain security clearances for that advocate, which would have to be granted by the executive branch,” explained Steven Bradbury, who served as the head of the Office of Legal Counsel in the Department of Justice from 2005 to 2009.

Bradbury has argued that the surveillance court may not need a permanent public advocate because its legal advisers already fulfill that role.

6) End phone metadata collection on constitutional grounds

The Justice Department has maintained that mass phone metadata collection is “fully consistent with the Fourth Amendment.” That reasoning is based on the 1979 Supreme Court decision Smith v. Maryland, where the Court found that the government does not need a warrant based on probable cause to collect phone records. The Court reasoned that whenever you dial a phone number, you voluntarily share that phone number with a telecom, and you can’t reasonably expect a right to privacy for information shared with third parties. As a result, the Court ruled that the collection of phone records is not a “search” and does not merit protection under the Fourth Amendment.

Sen. Rand Paul, R-Ky., has introduced a bill declaring that the Fourth Amendment “shall not be construed to allow any agency of the United States Government to search the phone records of Americans without a warrant based on probable cause” — effectively shutting down the NSA’s phone metadata collection program.

MIAMI -- With Florida embarking on an ambitious effort to privatize much of the state's prison healthcare--the largest such undertaking in the nation--the time is ripe for journalists to take a deeper look into the history of such programs, and the companies getting massive contracts for taxpayer dollars. Newspapers in Florida have nibbled around the edges of this complex story,...

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