Before dawn at the Jacksonville Terrace nursing home, a nurse’s aide found Gladys Tipsword, 69, unconscious in the shower room, her naked body slumped in a pool of blood, her skull fractured by a metal chain still embedded in her head. Patients at the Downstate facility bolted from their beds as police sirens wailed. Employees raced along hallways, flinging open bedroom doors and searching dark closets, quickly confirming that patient Victor Reyes, a 20-year-old schizophrenic, was on the loose. Again.
Everyone in the nursing home feared the youthful Reyes. He had two personalities, one gentle, and one so violent that he once warned a therapist, “If the violent person was present right now, I would pull out your windpipe.”
Authorities would learn that Reyes had attacked Tipsword after she had resisted his sexual advances. He then went on a violent spree outside the nursing home that left one man dead and two others seriously injured.
Reyes’ rampage was not the inexplicable behavior of a man gone berserk.
The tragedy that erupted in Jacksonville on May 25, 1997, was the result of a little-known state strategy to dump psychiatric patients into hundreds of geriatric nursing homes.
Since 1995, a change in state policy allowing placement of psychiatric patients in any nursing home transformed refuges for the aged into for-profit mental institutions.
Faced with unprecedented vacancy rates resulting from health-care alternatives for the elderly, nursing home owners–particularly a group of politically savvy Chicago businessmen–have capitalized on the state-supplied flow of mentally ill patients.
Despite this influx of psychiatric patients, nursing homes still have a lot of empty beds. Dozens of nursing homes have even employed agents to search the streets and psychiatric hospitals for new patients.
The result in Illinois, as well as in other states, has been the mixing of two vulnerable populations–the elderly and the mentally ill–often with disastrous results.
Although Tipsword survived the attack and now lives in a Pana, Ill., nursing home, she is unable to speak or feed herself because of her injuries.
After Reyes escaped the nursing home in Jacksonville, Ill., on the morning of the attack, he walked for several miles and broke into a home, where he ate several pieces of cold pizza and stole a 1987 Oldsmobile, police said.
Just outside of Jacksonville, a town of 19,000 about 30 miles southwest of Springfield, he mowed down three bicycle riders with the car, killing one of them, before crashing into a tree. Reyes was convicted of murder and attempted murder in August and is awaiting sentencing.
Reyes’ case, while extreme, reflects a troubling pattern.
In hundreds of incidents since 1995, the elderly have suffered abuse at the hands of psychiatric patients, many of them untreated and unsupervised, according to a Tribune review of state records.
Nursing home staffs often lack training to deal with volatile patients. At Jacksonville Terrace, for example, Reyes was to receive seven medications to control his flare-ups. In the wake of the attack on Tipsword, state investigators found that over a five-month period, the drugs were not administered on 37 occasions, “resulting in violence towards other residents.”
When nursing homes attempt to merge the elderly and the mentally ill populations without enough training, staff or government oversight, basic care for all patients deteriorates, a Tribune analysis of state Department of Public Health records shows.
“It’s a big and disastrous problem,” said Elma Holder, founding director of the Washington D.C.-based national Citizens’ Coalition for Nursing Home Reform. “You have the desperate needs of the mentally ill who are going to nursing homes, but most places just don’t provide good mental health care.”
The winners in this dramatic reordering of health care are nursing home owners who, according to nursing home financial records, are reaping hundreds of millions of tax dollars as they fill beds without always considering patients’ age or diagnosis.
Among the owners who reaped financial benefits from Jacksonville Terrace is a former state legislator who heads the main nursing home lobbying and advocacy group.
For the first time, more mentally ill patients in Illinois live in nursing homes than state psychiatric institutions. As of January, about 12,000 patients diagnosed with mental illnesses were living in 562 nursing homes. Dementia and Alzheimer’s disease are not classified as mental illnesses by the state and are counted separately.
Nationally, the estimated number of psychiatric patients treated in nursing homes has significantly increased, based on the record level of Medicaid and Medicare bills for treatment of mental illnesses, according to inspector general reports at the U.S. Department of Health and Human Services.
Mental health experts say there is nothing unsafe about placing patients diagnosed with mental illnesses in nursing homes, provided the facilities conform to health and safety regulations. But inspection reports show that dozens of nursing homes with the highest concentration of mentally ill patients have failed to meet even minimum standards.
Despite the undisputed needs of mentally ill patients, the state does not require nursing homes to provide psychiatric training for nursing home staffs. Most often, these employees are minimum-wage nurse’s aides. Within the last two years, at least two legislative committees, consisting of mental health advocates and lawmakers, have unsuccessfully recommended increased training requirements.
A Tribune review of computer databases maintained by the Departments of Public Health and Public Aid, along with Medicaid financial records and court, property and state inspector general files, revealed that:
– On May 20 this year, state inspectors uncovered evidence that a man diagnosed with mental disorders had fondled the private parts or was found naked with at least three female residents, two with Alzheimer’s disease, at Greenwood Manor West in Jerseyville, Ill.
In an effort to slow the frequency of attacks–which peaked at 13 a month– untrained nurse’s aides recorded behavioral goals that would slowly wean–not immediately stop–the man from accosting women. The man was told he could be involved in no more than three incidents monthly, according to nursing home records.
“Goal: Decrease fondling to 3x monthly by 4/15/98,” the employees wrote in their notes. After criticism from state inspectors, the employees informed the patient that he was not to molest any woman.
– After being admitted to Litchfield Terrace nursing home in Downstate Litchfield, a 45-year-old man, diagnosed with schizophrenia and a long history of violence, committed dozens of sexual assaults last year. The patient, identified in state records only as “R-9,” was transferred to the home in 1996 from a state psychiatric facility. The attacks, which targeted elderly women, reached a violent pitch in February 1997, when there were only four days that month that R-9 did not commit a sexual assault.
Criminal charges, which are pursued on a case-by-case basis, were never sought, Public Health officials said.
Even when potential crimes are reported to police, prosecutors typically are reluctant to spend time and resources on cases in which suspects are mentally ill and would likely face no jail time if convicted, said Steve Orr, an attorney and chief of Public Health’s enforcement division.
Records also show that the Litchfield facility, in which 52 of the 65 beds were occupied by psychiatric patients, housed at least 13 undernourished patients– among them elderly and mentally ill–who were up to 65 pounds underweight. The residents were not receiving prescribed levels of calories and vitamins or necessary high-protein supplements, state inspectors found.
– On July 28, a 36-year-old mentally ill man was witnessed dragging a 60-year-old female patient into a bedroom at the Winston Manor Convalescent & Nursing Home in Chicago. The woman began screaming as the man ripped her clothes off, “then laid on top of her,” a state investigation found.
Although an employee found the pair naked, no internal investigation was conducted and police were not called. The victim–largely unable to communicate due to schizophrenia–was never examined by a doctor, nor was she taken to the hospital to determine if a rape had occurred, even though she complained of “pain down there,” inspectors found.
An employee told other residents that the couple were just wrestling. Although state citations were issued for failure to investigate the attack and for failure to provide medical treatment, the home was neither fined nor disciplined.
In all three cases, the state relied on nursing home files to document many of the deficiencies. The homes corrected the problems, subsequent state inspections found.
Despite such failures statewide, nursing homes are typically not fined or disciplined for violations in an industry that government tightly regulates but whose standards it loosely enforces.
In most incidents, the elderly have been victims of minor physical assaults and molestation, typically resulting from patients whose mental illness has not been properly treated, public health and nursing home records show.
Incidents detailed in state inspection reports include: patients dumped from wheelchairs, medical equipment tampered with or disconnected, fistfights over food, theft of clothing, death threats for reporting incidents, and sexual fondling of women too feeble to ward off attackers.
A troubled past
State records reveal a system that not only failed Victor Reyes, but also his many victims.
Reyes’ psychiatric history portrays him as doomed from the start. He was born with fetal alcohol syndrome, and in 1981 at age 5, Reyes became an orphan.
His mother left six children alone in a Chicago basement apartment that was gutted by a fire sparked by an electrical short-circuit. Reyes’ six siblings died, trapped in the apartment by security bars and a dead-bolted door. He would have been home that night, but he was already in the hospital being treated for a broken leg, possibly the result of abuse. His mother was jailed briefly, then died on the streets, succumbing to long-held drug and alcohol addictions, state records show.
As a ward of the Department of Children and Family Services, Reyes ambled through foster and group homes and psychiatric hospitals. He frequently set fires and fantasized about killing people, health records show. By his teen years he was diagnosed with schizophrenia.
In December 1996, he was hospitalized for slamming his fist through a window at a group home, which refused to take Reyes back because of many previous violent incidents, state records show.
So in January 1997, DCFS approved Reyes’ placement in Jacksonville Terrace, where 50 of the 90 patients were diagnosed with mental illness.
A DCFS employee later told Public Health inspectors that the child-protection agency refused to follow its own caseworker’s recommendation to institutionalize Reyes, state records show. A DCFS spokeswoman said recently that officials wanted to put Reyes in a state facility, but he was deemed stable at the time, so he was transferred to a nursing home.
Within 24 hours of arriving at Jacksonville, Reyes punched out his roommate and threatened to kill him, state inspection records show. At 5 feet 8 inches tall and 191 pounds, he had no trouble imposing his will.
Two days later, he dumped an elderly man from a wheelchair, inspection records show. After another two days, at about 11 p.m., he ran away, carrying his most prized possession: a videotape of the movie “Batman.”
By law, nursing homes are not allowed to lock residents inside the homes, but facilities are required to track the comings and goings of patients, usually with door alarms or buzzers.
Reyes, who had broken open a locked window, was found by police and returned to the home about an hour later, records show. Once again, within an hour of his return, he threatened an older patient in a wheelchair, yelling, “I will pound him to pieces. I’ll kill him.”
As nurses tried to restrain Reyes, he lunged for the patient’s throat. Police responded to an employee’s 911 call, and Reyes was tranquilized with an injection of Haldol, a psychotropic drug used to dampen emotions, state records show.
After the incident, the home made arrangements for a psychiatrist to evaluate Reyes.
The examination led to an ominous conclusion: “Mild risk to self and severe risk to others,” the doctor wrote. The evaluation was included in Reyes’ nursing home file, but at least three nursing staff employees later acknowledged that they had not read the file or were unaware of the warning.
Explosive combination
In his role as executive director of the Illinois Council for Long Term Care, the chief lobbying group for nursing homes, Pete Peters says facilities should not mix younger people with mental illnesses and older, frailer patients.
“I don’t know how you end up caring for people who are old, who need rehabilitation, and have schizophrenic paranoids running around the home,” Peters said, terming such combinations potential “explosions.”
Yet Reyes’ rampage occurred in Jacksonville Terrace, where Peters is part-owner.
Peters dismissed state findings that the home failed to provide proper protection and care for Reyes and a half dozen other mentally ill patients accused of assaulting each other or older patients.
“The `could’ve, would’ve and should’ve’ is the big problem with all this,” he said.
Peters said no one could have predicted Reyes’ violence.
The politically powerful council, a lobbying arm of the nursing home industry, was established by nursing home magnate Leon Shlofrock, although his name does not appear on the council’s letterhead.
Likewise, Peters’ name does not appear in the state’s computer database of registered nursing home owners, which is available to the public. The database identifies only owners whose holdings are 5 percent or more.
But Medicaid records reveal that Peters has 2 percent stakes in Jacksonville and at Litchfield Terrace, where the string of sexual attacks was documented.
Secretary of state records show the Long Term Care Council and its members, consisting of about 400 homes, have contributed hundreds of thousands of dollars to legislators of both parties, while successfully lobbying for higher state and federal subsidies and allowing more facilities to accept the mentally ill.
The nursing home industry, based on total contributions, ranks among the top five most powerful political action groups in Illinois, behind manufacturing and labor groups.
After the Jacksonville investigation, the Department of Public Health levied a $10,000 fine and began efforts to revoke the home’s license.
Both actions were dismissed earlier this year because state officials said that the Jacksonville owners agreed to pay
a $60,000 federal fine based on state
findings.
Gary Weintraub, a Jacksonville Terrace owner who is also the facility’s attorney, said, “We take the position that we didn’t do anything wrong.”
The state’s findings of missed medications, he said, should be tempered with the fact that Reyes sometimes refused to take prescribed psychotropic drugs, which is his right as a patient.
Jacksonville Terrace–and all nursing homes–must walk a thin line between controlling patients and guaranteeing their legal rights, he said. Although employees recognized problems with Reyes, he had calmed down considerably in the month preceding the attack, he said.
Once patients are admitted, nursing homes have to undergo a complicated and lengthy legal battle to have patients removed or involuntarily transferred to another facility.
“We can’t tell patients to hit the road,” he said.
Reyes represents a broader problem, he said, as the State of Illinois continues to use nursing homes as mental institutions as a way to further downsize its costly psychiatric facilities.
“As far as I’m concerned, this goes beyond this case,” he said. “This is a societal problem.”
An attorney for Gladys Tipsword’s family said her relatives were unaware that Jackson Terrace accepted young psychiatric patients.
When Reyes was admitted to the home, handwritten notes from state investigative files obtained by the Tribune show that few questions were asked by nursing home employees. The facility’s head nurse admitted Reyes without meeting with him.
Typically, other nursing administrators said, a personal visit is made, especially with psychiatric patients, in order to assess their compatibility with other patients.
A further breakdown of protocol and communication occurred inside the home, state records show. Often, employees were unaware of Reyes’ violent history and, remarkably, had even failed to read his care plan, a medical blueprint outlining treatment strategies and goals.
An employee, on duty the morning Tipsword was found in the shower room, stated he did not know what information was contained in Reyes’ files, explaining to investigators, “It would take awhile to read all the care plans here.”
Deadly outburst
By March 1997, in addition to violent episodes, Reyes began to sexually harass the staff, records show. In one case, Reyes approached a nurse and demanded sex in graphic and vulgar language. In others, he repeatedly pinched female employees on their buttocks, nursing home records show.
On May 6, Reyes told employees that he wanted to be sexually active, a right guaranteed by federal law that is subject to nursing home rules.
A staff member “explained and demonstrated use of a condom,” according to state records, noting that Reyes was also told that if a partner said no, at any time, he “must be a gentleman and respectfully stop any activity.” Condoms were available at the nurses’ station, he was informed.
On May 25, Reyes sat quietly beside Gladys Tipsword in the far corner of an otherwise vacant dining room. At first, according to witnesses, his gentle side was on display.
Reyes talked and laughed as he gently massaged Tipsword’s bare feet, a nurse’s aide reported. When Reyes asked for a foot massage, Tipsword obliged, nursing records show.
They made an odd couple–Tipsword a brittle-boned St. Louis widow, a hostage of age and disease, who couldn’t remember the day or date, and Reyes, almost five decades her junior, whose actions twisted as suddenly as a remote control changed channels.
The nursing staff took little notice and was unconcerned, state records show. About 1:40 a.m., nurses’ notes show, Reyes grabbed Tipsword’s hand and directed her to the shower room not far from the nurses’ station.
An aide, who saw the couple enter the shower room, did not intervene because the home’s policy was to allow residents to engage in consensual sex. However, Tipsword’s files showed that she didn’t have the capacity to consent, state investigative records show.
Less than two hours later, an aide looked in the shower room and discovered Tipsword’s naked body, slumped against the wall and on the floor.
In his confession to police, Reyes denied the attack at first, then smiled suddenly and said, “I guess you want me to spill my guts.”
According to Reyes’ confession, he became enraged when denied sex and Tipsword began screaming. He then choked her, beat her head against the floor tile and grabbed a metal chain used to secure a shower curtain and began whipping Tipsword’s prone body, especially her head.
“I did it,” he told police. “I tried to kill her.”
Reyes’ violence escalated outside the home.
After beating Tipsword, he casually walked to his room and changed clothes, then threatened to kill his roommate if he informed on Reyes, records show. Next, Reyes is believed to have disconnected a battery-powered alarm to a courtyard door, then walked outside and climbed a fence.
From there, Reyes meandered for a few miles through Jacksonville. About 8 a.m., after breaking into a home and stealing a car, he sped down Old Route 36. Ahead of him were three bicyclists, all well-known residents: Charles Grojean, 35, a Realtor, led the pack, followed by Gary Vaughan, 42, a state administrator for Public Aid, and Dietolf Rothfuss, 61, a pathologist.
Reyes aimed the car across the center line and plowed into the bikers, sending them flying along the roadway, police said. The stolen car slammed directly into Vaughan, who was instantly killed, his left leg torn from the impact and hurled 50 yards away. The other two men suffered serious injuries, but both have recuperated.
“I saw his eyes,” recalled Grojean. “He looked straight at us, then turned the car.”
Today, the men and the victim’s family, who’ve filed a lawsuit against the nursing home, still ponder how Reyes was dispatched to live in a nursing home in a quiet town where even the names of traffic violators are read over a local radio station.
Standing within the courthouse where Reyes was convicted, the same building where sentencing will be handed down in October, Grojean summed up the survivors’ feelings:
“We don’t blame Reyes as much as we blame the home,” Grojean said. “I don’t think there is an excuse for what happened inside that home.”
