Hunter had been supervising the man, who suffers from Alzheimer's disease, after escorting him to the smoking room. But another patient pressed her call button for help and Hunter was the only aide who could respond.

When she returned to the smoking room, the man had vanished.

Hunter was panic-stricken. Just two weeks before, another patient had walked out the front door of the same home and was struck by a car and severely injured.

"I asked the nurse at the nurse's station, 'Where did George go?' " Hunter said.

Minutes later, George was found wandering in the street in front of the home. Luckily, this time, a passing motorist retrieved him before he was hurt.

"There are times when you just feel like throwing up your hands and saying, 'I quit,' " said Hunter, a 23-year-old Dayton resident who has been a nursing assistant for six years.

"I have bills to pay or I wouldn't work there. They're very understaffed ... but when something happens, the blame always falls back on us."

Hunter's lament is common among nursing home aides, who make between $7 and $10 per hour, usually with limited benefits.

With as many as 15 or more patients to care for on their own, aides say they are understaffed, overworked, underpaid and under-appreciated.

Nationally, the turnover rate among aides in a typical nursing home exceeds 100 percent in a single year, according to the National Academy of Sciences, a private non-profit group in Washington, D.C., that advises Congress on science, technology and medicine.

"The nursing home industry is putting profits before patient care, by keeping staffing levels to the bare minimum," says a lobbying brochure produced by the Service Employees International Union, which represents thousands of nursing home aides and nurses across the country.

Nursing homes, once primarily run by churches, government agencies and other non-profit organizations, are now dominated by for-profit companies; four-fifths of Ohio's 938 nursing homes are private, for-profit companies, and an increasing number are chain-owned.

There are some excellent for-profit nursing homes, but overall their staffs have a higher patient load, a Daily News analysis of staffing ratios shows.

For-profit homes typically have 15 residents per registered nurse, compared to 13 per nurse at non-profits.

For-profits also average about 1.5 residents for every member of the nursing staff on all shifts, including aides, compared to about 1.3 per nursing staff member at non-profits, the data show.

The staffing disparity may be hurting patient care. The Daily News analysis found for-profit homes averaged twice as many serious health and safety violations than non-profits, and they are nearly four times as likely to have three or more serious violations.

"There are a lot more violations in the for-profit homes," said Charlene Harrington, a nationally known researcher at the University of California at San Francisco who has examined national data on nursing homes over the past five years.

"They're trying to cut corners too much."

But the Ohio Health Care Association, which represents primarily for profit homes, says a study it conducted comparing state and federal data on Ohio nursing homes shows for-profit and non-profit homes had "very similar" violation rates in 1998-99.

"In some ways, non-profits get more citations," said Van Runkle, the chief legal counsel to the health care association.

Clay Reedy of Springboro, a nursing student who has worked three and a half years as a nurse's aide in four nursing homes, said reduced staffing is a problem in the for-profit homes he's worked in, particularly on nights and weekends.

"When you're short-handed, sometimes you have as many as 20 people (to care for) on second shift," he said. "It's intense all the time. It's just shut up and move on . . . . You can work all day and you don't feel like you've accomplished anything when you walk out of there."

A nurse who quit working at a for-profit nursing home in Kettering this year said poor staffing levels there left as many as 43 patients in the care of a single nurse and nurse's aide.

"I've seen patients lying in urine overnight and stuck in wet diapers for most of the day," she said. "And many of them are not getting proper nutrition and hydration. You can tell just by looking at them -- their skin is dry and flaky and their eyes are sunken."

For the frail elderly, dehydration can kill.

Barbara Frantz of West Milton, a registered nurse, said fluids could have saved her husband's 100-year-old grandmother, Helen Bice.

After breaking her hip in a fall at home, Bice entered Carriage Inn of Dayton Nursing Center last February.

Carriage Inn is operated by Integrated Health Services Inc. of Maryland, one of the largest for-profit chains in the country.

Bice was still alert and otherwise healthy when she entered the home, Frantz said, but two weeks later, and just hours before her death, it was a different story.

"I never saw anyone so dehydrated in my life," Frantz said. "She was pasty. Her oral (cavity) was dry. Everything about her was dry."

Carriage Inn of Dayton officials would not comment on Bice's care but defended the quality of the home.

"The care we have here is exceptional," said Dan Like, who took over as administrator of the home in September.

"We are well-staffed, and that's rare for a long-term-care facility in this day and age."

'NOTHING WAS EVER DONE'

Under federal regulations, the Ohio Department of Health can use three main penalties to enforce standards in nursing homes: deny government payments for new patients, impose fines or terminate a home's eligibility for Medicare and Medicaid payments, effectively closing the facility.

However, in nearly all cases, homes can escape penalties if they correct their problems within an allotted period of time, usually 50 days.

Critics say that's the crux of the problem. "It's no enforcement system at all if all you're doing is saying, 'Gee, do better next time, guys,' " said Toby Edelman of the National Senior Law Center, a non-profit advocacy group in Washington, D.C.

Between May 1994 and September of this year, the state began enforcement actions against nursing homes 1,251 times.

In four of five cases, no fines were imposed, primarily because problems were fixed in time.

Even when homes were fined, the typical amount -- $7,963 -- was less than what many homes receive in state Medicaid payments in a single day.

Weak enforcement leads to a yo-yo pattern among bad homes.

A recent national study by the General Accounting Office, the investigative arm of Congress, found that although most homes corrected their problems to avoid sanctions, nearly half -- 40 percent -- again showed serious violations within three years.

Lenore Kiln of Centerville complained to state authorities about the care of an 88-year-old friend at Manor Care in Centerville. Kiln said her friend was sometimes left to lie for hours in a soiled bed and developed bed sores that were rarely bandaged.

"I filed a complaint with the Ohio Department of Health, and other than an inspection (of the home), nothing was ever done," Kiln said.

Health department officials say the home was cited, and the state recommended a denial of Medicare and Medicaid funds. But the home corrected its problems in time and escaped any penalty.

HCR-Manor Care, the for-profit chain that owns Manor Care, declined comment on the case.

'SHE COULD BE ALIVE TODAY'

In the living room of his West Carrollton home, Victor Blankenship keeps a framed picture of his mother Grace, looking the way he would like to remember her.

The vivacious smile, he said, captures what she was like at age 79: an active, outgoing woman who loved to cook, entertain and crochet, who faithfully supported her church and who regularly made the rounds of garage sales and flea markets. Like Grandma Moses, she had begun painting oil pictures for the first time in her life the year before.

"She was so active it was unbelievable," Blankenship said. "I could hardly keep up with her myself."

The photo was taken more than a year before Grace Blankenship was transferred from an assisted living wing to a nursing home unit for severely demented residents at Wood Glen Nursing Center.

It was there on the morning of June 20, 1993, that the staff failed to notice when a male resident -- a man who had been a boxer in his youth and who had a history of fighting with other residents -- wandered into her room. In the confrontation that ensued, Grace Blankenship, who weighed just 112 pounds, got the worst of it, including three broken ribs.

To help control the pain, Blankenship's physician prescribed 100 milligrams of Darvocet to be repeated every four hours. However, there was a standing order to notify him if she became nauseous or began vomiting.

At 5 p.m. on July 4 -- a holiday -- she complained of pain in her right side, according to a state investigator's report. Then at 10 p.m., and again at 11 p.m., she began vomiting large amounts of fluid.

Exactly how many times she vomited that night is unclear, but by midnight, she was cold, clammy and unable to walk without help. By 6 a.m., her blood pressure had plummeted to dangerous levels and her speech was slurred, the report states.

During those eight hours in which her condition had changed dramatically, no one at the home called her family or her physician for a consultation or to order a transfer to a hospital emergency room, state investigators found.

Nor was she given fluids that might have prevented the severe dehydration that sent her into shock and killed her at 6:40 a.m. that same morning, according to the home's nursing notes.

Marietta Houchins, the nurse's aide assigned to care for Blankenship starting at 11 p.m. that night, said she was told by her supervising nurse when she came on duty that, "Grace is dying, and I want you to stay with her the whole night on your shift." But at no time during her shift did Houchins give Blankenship fluids or did the nurse start an IV, she said.

Houchins said Blankenship never asked for water. "She was dying. I always know when they're dying. Before people die, they talk about the people they've seen, or they're going to see," she said. "They're not wanting anything to drink."

Greg Nelson, president of the Kettering-based Centurion Management Group and owner and operator of Wood Glen at the time, said the home was not responsible for Blankenship's death.

He said her family had placed a "no code" order in her file, asking that she be given only "care and comfort measures" in the event of a sudden downturn.

"A no code order is a no code order," he said. "We allowed her to die with dignity."

A statement released by Nelson's attorney, Brant Poling, also said that Blankenship's "medical and mental condition had progressed to the stage that she required nursing home care. She was seen and evaluated by her physician prior to admission in the nursing center."

"Grace Blankenship died suddenly of natural causes on July 5, 1993," the statement says.

Victor Blankenship insists he never signed a no-code order. Such a request wouldn't have applied to his mother anyway, he said, because simple, not heroic, measures could have saved her.

And he said he knows of no doctor's evaluation prior to her transfer to the nursing home unit for severe dementia patients.

Blankenship said it was understood when his mother entered her apartment at the assisted living wing that she would be transferred to a nursing home bed when her savings ran out. But, he said, he assumed she would be placed in a unit for residents with the lowest severity of dementia. Instead, she was moved to a vacant bed in Wood Glen's Pine unit, where many of the home's most confused and combative patients resided.

"She was very uncomfortable in that setting and was quick to say so," Blankenship said.

Billy Stratton, an aide who cared for her on second shift and no longer works at the home, agreed that Grace Blankenship did not suffer from dementia.

"She was as lucid as we are," Stratton said. "We used to talk about the Cincinnati Reds. She knew all the players' names and how they were doing."

The state fined Wood Glen $5,842 for violations in the handling of Grace Blankenship's death. Victor Blankenship said that's not enough of a penalty.

He filed a $30 million lawsuit in Montgomery County Common Pleas Court against the former owners and managers of the home, including two of Nelson's firms, Centurion Management Group and GNWT Inc. A trial date has been set for early next year.

Blankenship said much of his bitterness is aimed at Ohio's system of elder care, a system that he feels gave his mother only one choice -- a nursing home unit where she didn't belong and where she didn't get the care or protection she needed.

"All I know," he said, "is that with some very simple treatment she could be alive today."

Sidebars:

Some area facilities in touch with residents

Hiring qualified staff a serious challenge for homes

Determine what your elder care needs are

Books on aging

Part Two:

Penalties few for poor care
  Nursing homes usually prepare for 'the game'