Once upon a time, assisted living facilities were created as a happy medium between simple retirement communities and skilled nursing homes. Elderly residents would live largely independent existences but would, as the name implies, receive largely non-medical assistance for things they could no longer do on their own. But that has all changed, as more Americans lived longer and assisted living operators realized they had a virtually unregulated goldmine on their hands.

A new episode of Frontline, co-produced with ProPublica, begins airing tonight on PBS. In it, reporters investigate allegations of understaffed and underqualified assisted living facilities operated by Seattle-based Emeritus Senior Living, the largest for-profit assisted living chain in the country, with facilities in nearly every state, around 40,000 residents, and more than $1 billion in yearly revenue.

It’s an incredibly compelling hour of TV and I highly recommend you check it out. Here are just a few of the topics covered that are relevant to many Americans, especially those who are considering assisted living for a loved one or themselves:

1. A DOUBLE-STANDARD FOR NEUROLOGICAL DISORDERS
One of the few regulations put on assisted living facilities by some states is that they can not care for people who are so ill they require medical help. And so while some elderly residents receive skilled nursing care because of a physical disability that severely inhibits movement or requires constant medical care, an alarming number or Americans with less visible — but no less critical — conditions are ending up in assisted living.

In fact, a recent study by Johns Hopkins University researchers found that more than 2/3 of residents in assisted living facilities are suffering from Alzheimer’s or dementia.

“The implications therefore are that anyone who operates assisted living needs to know that dementia is the major player, the major condition that leads to people being there,” explains Dr. Constantine Lyketsos, a dementia specialist at Johns Hopkins.

2. IT’S “MEMORY CARE,” NOT MEDICAL CARE
“When you go into assisted living, you see a lot of cognitive impairment,” says researcher Catherine Hawes of Texas A&M. “So there’s a lot of early memory loss, short-term memory loss, a lot of impaired decision-making.”

That would sound like an issue that requires a certain degree of qualified medical care, but instead Emeritus now offers “Memory Care” facilities that appear to offer families of Alzheimer’s and dementia patients a non-nursing home option.

“We pretend that assisted living facilities are not medical,” says elder care advocate Patricia McGinnis. “And yet, the people who are in these facilities today have acute medical needs. The same people who are in assisted living today are the people who were in nursing homes ten years ago.”

This sentiment is echoed by a former director of an Emeritus Memory Care operation.

“I think that they are bringing nursing home patients to an assisted living facility,” she tells Frontline.

3. TRAINING? WHAT TRAINING?
Again, when you see the attractive buildings being operated by the country’s largest assisted living group, you might believe that the professionals in Emeritus’s Memory Care units have a background in dealing with Alzheimer’s and dementia patients or undergo lengthy, thorough training. Not quite.

But this is how an Emeritus Vice President actually describes the entire training process to Frontline:

“For our staff that works in memory care, they’re gonna go through what we call general orientation which everybody in the community would go through, then we have an 8-hour class that’s the ‘Join Their Journey’ class and that’s where we cover everything from disease process to how we serve meals slightly differently to folks who have dementia to how to engage, how to approach, how to communicate… There are some communication barriers at times.”

“Eight hours?! That’s nothing,” says Hawes. “Who’s going to explain, ‘This is what the disease is, this is the impact that it has on people’s physical health and on their behaviors’? You’ve gotta know how to interpret non-verbal cues that something’s going on with this resident because they can’t tell you verbally — in the same way that a 2-year-old can’t tell you, or a 1-year-old. You’ve gotta do a lot of training for memory care units. You can do great care; you gotta know how.”

4. WHO NEEDS EMPLOYEES?
At the same time that assisted living facilities were taking on more and more patients in need of skilled care, the company was allegedly cutting the same staff needed to assist residents.

“We were constantly being told to cut labor costs,” testified a former top executive at Emeritus’s California operation. “There was a lot of frustration around these kind of directions from corporate that said ‘Cut labor by 10%.”

She said she brought her concerns to the Executive VP of Quality Control, but claims that his response was, “We do not use staffing ratios because if we do not have the right amount of staffing in place and a… negative resident incident or issue occurred… we could be sued.”

After that discussion, the former exec said she became persona non grata at Emeritus and was eventually fired because she “didn’t fit.”

5. SEE NO EVIL, HEAR NO EVIL, EVEN WHEN IT’S ADDRESSED THROUGH THE PROPER CHANNELS
An RN who formerly worked as a Resident Care Director for Emeritus says she tried to bring issues of understaffing and unqualified staffing to the attention of her bosses and executives in Seattle.

“It was all very dysfunctional and not very organized,” she tells Frontline. “The residents were not getting the care that they should be getting… the kind of care they were paying for, because they paid quite a lot of money to be in that facility.”

Things got to so bad she sent a fix-it-or-I-quit letter about the woeful condition of the facility’s medication room to Emeritus HQ that read, in part:

“The med room is a sinking ship… Staff that was in place before I was employed were placed in positions that are beyond their capacity. They have been placed in the med room without significant training and support for their position. A quick fix for a sinking ship. All wild attempts to save an already dying department.”

But she says that no one from her facility or from Emeritus HQ ever responded to her letter, and so she quit as she’d threatened.

The aforementioned Executive VP of Quality Control explains that the letter was not sent through the proper channels.

“[I]t’s just unfortunate she felt that way,” he tells Frontline. “We have a lot of platforms that we have in place to allow our staff to express concern. We have this system called ‘Ethics First.’ It’s a compliance line where you can call the 800-number and lodge your complaint. If you want it to be anonymous, you can be anonymous.”

Jenny, a former Emeritus staffer who made only $10/hour to hand out thousands of prescriptions a day at the same facility says she did file complaints via the Ethics First line and tried to do so anonymously.

“Somehow, they would find out it was me,” she recalls. “I would be questioned. ‘Why didn’t you bring it to us? Don’t call Ethics First.'”

Jenny says that publicly and in staff meetings, Emeritus bosses would extol the virtues of calling the hotline, “But when it came down to you calling Ethics and they found out you called Ethics, it was a big deal, because they were mad.”

Emeritus tells Frontline that Jenny was fired for a medicine-related error, but she maintains she was dismissed for her attempts to shine a light on shady practices.

“I was causing too much trouble,” she explains. “I was even talking to family members, and being like, ‘Hey, your mom and dad aren’t getting this; you need to get them out.'”

6. FILL THOSE ROOMS…
Texas A&M’s Hawes says that the whole Memory Care thing is just a marketing gimmick to appeal to families of elderly people they can no longer care for.

“A: There’s demand and you’re trying to keep occupancy up,” she says. “B: You can charge more for Memory Care.”

But Hawes claims it’s mostly window-dressing to appeal to the families.

“All you’ve really done is created rooms around a courtyard,” she explains. “That’s nice and it’s much safer, but then they say they’ve got staff who are trained to do memory care and that’s where it starts to kind of fall apart, because the staff are generally not well-trained to do dementia care.”

Melissa, a former sales rep at Emeritus, is one of several ex-employees who say that the company’s main goal is to get paying bodies in beds.

“The biggest thing I ever heard was ‘You need 100%… fill the building,'” she recalls. “It gave me a lot of anxiety because my philosophy wasn’t to move in a warm body just to fill the building. My philosophy was to make sure it was the right fit with the person, the prospective resident moving in… They wanted a hard close after every single person I met with.”

Elder care attorney Lesley Clement claims this allegation is bolstered by documents she uncovered when representing the family of a woman who died following three months of living at an Emeritus facility.

According to Clement, these documents show that Emeritus targeted seriously ill seniors with advanced dementia, specifically because they could be charged a higher rate.

“Everything I look at at the corporate level, all of their records, it’s all about push for more money to increase the cash flow and there’s no talk about caring for the elderly,” says Clement. “When you read their records, you think that this is a real-estate company.”

7. AND KEEP THE BACK DOOR SHUT
Emeritus actually had an in-house policy dubbed “KEEP THE BACK DOOR SHUT,” which was all about how to discourage residents from leaving the facilities. Some employees testified that the idea behind these actions was to literally retain residents as long as they were alive.

Under oath, CEO Granger Cobb testified that the name of program refers to “trying to do everything we can — in situations where residents want to stay with us, family want their loved one to stay with us — to be able to keep them.

“Families usually want their loved ones to stay with us as long as possible, as opposed to skilled nursing in a very institutional environment,” he continued. “And so, we try to work with the families and do all we can to, ya know, accommodate that.”

8. A HISTORY OF COMPLAINTS (AND OF GETTING OFF EASILY)
According to Frontline, Emeritus has the highest per-bed complaint ratio in all of California, where the largest number of its facilities are located. These include things like accepting patients who were too ill to be in assisted living facilities.

Then there are deaths, like that of Chicago Bears Hall of Fame running back George McAfee, who died shortly after wandering out of his room at an Emeritus facility and drinking a bottle of industrial strength detergent. Though Emeritus settled with his family, the state of Georgia only fined the company $601 over the incident.

“Had this been a daycare facility where a child died, the place would have been shut down,” points out one of his daughters.

In an interview with Frontline, Emeritus CEO Cobb chalked this up to human error and called it “the exception to the rule.”

What about the Mississippi woman who was only at an Emeritus facility for 9 days when she packed up a bag, told a staffer she was leaving and then went up to the second floor, pried open a window and jumped out?

Her daughters arrived as their mom was being taken to the hospital where she would eventually die from her injuries. They claim that not a single person from the facility was outside helping their mother and no one spoke to the family about what had happened.

In this case, state regulators did not even cite or fine Emeritus.

“That was one where we actually followed our policies and procedures,” explains Cobb. “They had checked all the windows in the community to make sure that none of them opened past 12 inches, which is the regulation… It’s so difficult sometimes with our residents that may have some memory impairment; sometimes their behavior is unpredictable and catches staff off-guard, even when they think they’re doing all the right things.”

The woman’s daughters are currently suing Emeritus, but say they don’t want the money.

“I say ‘Shut the facility down, put the people in jail, we’ll drop the lawsuit,'” one daughter tells Frontline. “It’s not the money, it’s truly not the money, but the money is all that matters to Emeritus… it’s the only way to hurt them, and believe me I want to hurt them.”

9. MAKING IT STING
Elder care attorney Clement recently represented a family whose mother died after only a few months in the care of Emeritus. The 81-year-old resident fell down one day flat on her face and had to be taken to the hospital.

“She was taken to the hospital alone,” says Clement. “This woman suffered from dementia. They didn’t have enough care-giving staff to put someone in the ambulance with her who could be her voice and talk for her at the hospital.”

When the woman returned to the assisted living facility, Clement says that Emeritus allowed her to sit idle and develop sores and wounds that allegedly led to the resident’s death — after they were discovered in a real hospital.

She had eight different areas of skin damage,” explains the lawyer. “Pressure ulcers, dead skin that goes through muscle tissue; you can see into her body.”

The woman’s family sued Emeritus, alleging that the company — among other things — violated state law by allowing her to sit with open wounds without receiving medical care.

Jenny, the $10/hour medicine-room employee we mentioned earlier, testified that she attempted to clean some of the wounds. When her boss found out, she says his only response was “Just don’t let anybody know.”

Emeritus has its own medical experts claiming that the woman’s death was not a result of the wounds but of a combination of Alzheimer’s and stroke-related damage. Even so, it offered her family a sizable settlement — $3.3 million.

The family’s issue was not with the dollar figure, but with the strings attached to it.

“That’s a substantial amount of money,” admits her son, “but that also came with basically a gag order, an order that we wouldn’t have been able to talk; we would not have been able to share my mom’s story. They wanted us to turn over all of our investigative [materials] and they knew we had a lot of stuff that had been uncovered.”

Not willing to be hushed by Emeritus, the case went to trial, where the jury found the company liable and awarded the late resident’s family more than $22 million in punitive damages — a figure arrived at by combining the annual income of Cobb and the Emeritus chairman.

“This is about everyone who has Alzheimer’s or dementia,” says Clement. “This is about every senior who has any type of physical disability and is dependent on staff for help.”

Emeritus maintains it is not liable in this case. Its first attempt at an appeal was denied, but the company says it will continue.

Clement laments that this tragic case is “typical of the resident population in assisted living today. This is the population that they’re marketing for. This is the population that they’re going after. This is the population that’s going to make them a lot of money.

10. TICKING TIME-BOMB?
Though the Frontline episode specifically deals with issues and incidents involving Emeritus, Texas A&M’s Hawes cautions not to think these problems are relegated to one company.

“The head of a state licensing agency once told me, ‘Assisted living is the rock we don’t want to look under,'” says Hawes. “They know there’s a problem, but they don’t have the resources. When it’s nursing homes, we have federal support for a huge amount of surveys and inspections and complaint investigations… none of that exists for inspection and regulation of assisted living.

“We’re creating an industry with a million people in it who are becoming more frail, who are poorly regulated by the state,” she continues. “That’s why I talk about it as a ticking time-bomb, because we’re gonna see more deaths, more injuries. And families are gonna be so shocked, because they think they’ve made a good decision. They think they’ve made a safe decision.”

Frontline’s “Life and Death in Assisted Living” begins airing tonight on PBS. Click that link for showtimes and stations. It will also eventually be available for streaming online, along with supplemental material on ProPublica.org.

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