01:00 AM EDT on Sunday, August 22, 2004

BY JENNIFER LEVITZ
Journal Staff Writer

The Rhode Island Health Department first saw "Resident #1" last November, during an inspection at Hillside Health Center, a nursing home in Providence.

She was lying in urine, with a bedsore on her left buttock.

Bedsores are wounds of the bedbound. When you can't move, the weight of your body wears away your skin. Bedsores can be wounds of neglect.

For the next 16 weeks, Health Department inspectors watched Hillside's Resident #1 deteriorate.

Hillside kept promising to take care of her. The Health Department kept giving more time.

By February, Resident #1's bedsore had worsened from Stage 2 to Stage 4, to a bloody crater, like someone had taken a hook and gouged her tissue and muscle. A state inspector decided that Resident #1 was in "immediate jeopardy" -- in danger of being gravely hurt, or of dying.

The Health Department gave Hillside more time.

Finally, on Feb. 28, 2004, a Saturday, 117 days after discovering her first bedsore, and after 11 documented visits, state health inspectors ordered that Resident #1 be taken out of Hillside Health Center.

She was one of some 9,200 people in Rhode Island who live in nursing homes and who rely on the Health Department regulatory system to ensure their safety.

It is a system, a Journal investigation has found, in which regulators are reluctant to close poorly performing nursing homes, and where fines are frequently threatened, then forgiven.

It is a system in which regulators are afraid of alienating the nursing home interests, and where public access to inspection reports is delayed.

It is a system, and philosophy, that turned Resident #1 into a number.

She was 87. She had raised two children. She had four grandchildren, and two great grandchildren. She had broken her hip dancing to Christmas music.

Her name was Germaine Morsilli.

The Rhode Island Department of Health licenses and regulates the 101 nursing homes in the state.

For five years, beginning in 1993, the department scrutinized the proposal for Hillside.

Dr. Patricia A. Nolan, the director of the Health Department, was concerned about the scale of the project and the finances of the applicant, Antonio L. Giordano, and Consultants Inc., the firm he founded.

A public housing developer, Giordano was sued as one of the delinquent borrowers who had helped precipitate the collapse of the Rhode Island credit unions in 1991.

Giordano winnowed his proposal from 234 beds to 150. He opened Hillside in 1999, in an elegant brick building on Providence's East Side. It was his third nursing home, financed with a mortgage insured by the U.S. Department of Housing and Urban Development.

The year before Hillside opened, a resident set himself on fire and suffered deep burns at Coventry Health Center, partly owned by Giordano. Health inspectors, according to inspection reports, found that Coventry Health was letting dementia patients smoke without supervision and hadn't addressed bedsores.

Donald C. Williams, the state's associate director for health services regulation, said, "We were nervous about it. There was always the feeling that because of his involvement in facilities that have had problems before that, there might be a problem with this facility."

Hillside, Williams said, was "a problem from day one."

In April 2001, Hillside's monthly employee bulletin said the nursing home had eliminated "all unit manager positions in an effort to contain costs."

Sarah Paul, a nurse's aide at Hillside, said, "We would walk in and there would be two of us for 48 residents on the floor."

In July 2001, Roberta M. Hawkins, Rhode Island's ombudsman for the elderly, checked up on Hillside after complaints about the Alzheimer's floor. The state has a contract with Hawkins to serve as a resource for the elderly.

Hawkins said her staff saw residents wandering around unwashed, a patient lying in feces, and heard call bells that weren't being answered by the sparse staff. Hawkins sent a two-page complaint to the Health Department.

In August 2001, inspectors investigated after a Hillside resident was rushed to an emergency room. According to state records, the hospital had called the Health Department, which found that the woman had been eating and drinking little for two months, yet as she declined, Hillside had not intervened.

Nor had a nurse ordered lab tests after noting that the woman wet herself with strong, foul smelling urine, according to the report of the investigation.

That was a week before she was taken to the hospital, in apparent shock with an infection.

On Oct. 28, 2002, according to state records, a spot check of 20 residents showed serious flaws at Hillside.

Resident #3 had lost 16 pounds in 18 days, and was no longer eating by mouth. Resident #14 had lost 22 pounds in six months. The nursing home had not brought in a dietician.

Resident #20 had dementia, and her care plan said she needed help eating. Inspectors wrote that three times over two days her tray came, and no one helped her; uneaten food was taken away, hot cereal still covered. She was down to 96 pounds.

Three diabetics needed evening snacks. They weren't getting them.

Resident #10 had a Stage 4 bedsore, the most serious stage.

The staff was skipping doses of medicine for four residents.

One man was going without his seizure medication. A worker told inspectors that Hillside had been out of the drug for almost two months, according to the inspection report.

Arthur A. Pullano, principal surveyor in the Health Department's facilities regulation division, said Hillside had "16 pages of deficiencies" from the October 2002 inspection. "Plus we had a bunch of complaints," he said, referring to calls from Hillside families.

Pullano threatened Hillside with a fine of $800 per day.

Hillside's administrator, James D. Janetakos, hand-delivered a plan to correct everything, Pullano said.

"He'd say, 'Arthur, I'm doing the best I can. I'm doing this. I'm doing that.' "

Pullano sent an inspector to Hillside to follow up; he rescinded the fine.

"It's not my job to close these places," said Pullano. "I don't want them to close because what do residents do? It's a big trauma.

"I try to help them out, bring them into compliance."

The next month, November 2002, at Hillside, Germaine Morsilli broke her hip.

Five feet tall, with short, snowy curls, Germaine had been a factory worker, a soldier's mother, and a hostess who held square dances in her finished basement in Pawtucket.

She'd been widowed, remarried, and separated. She was still proud of her appearance. She wore glasses with pink and purple frames and kept her cheeks pink with Covergirl.

She didn't like the way the pillow flattened her hairdo, so she kept a hand mirror in her night stand and fluffed her hair before leaving her room, her daughter said.

From her bed at Hillside, Germaine told her daughter, Diane Gobin, a 59-year-old receptionist, how she used to ring her bell -- and no one would come. Germaine claimed that Hillside's workers told her to stop ringing.

"I think about that now and my heart breaks," Gobin said, "because I don't know how true it might have been.

"My mother suffered from dementia. Every so often she would call me, she always remembered my phone number, she would call me on the phone and say -- I don't know where I am. I don't know what these people are doing to me."

In October 2003, Diane Gobin said she noticed a red spot on her mother, Germaine.

"I was washing her and turned her over and her skin was all red," Gobin said. "I called it to the attention of the nurse and she said, 'Oh, we'll put some dressing on it and take special care of that so it will get better.' "

That didn't happen.

On Nov. 4, 2003, Rhode Island's health inspectors went to Hillside for an annual inspection. They looked at 23 people.

Six had bedsores, also called "pressure ulcers."

Germaine Morsilli had a Stage 2 bedsore on her left buttock.

At Stage 2, the first layer of skin is broken, said Madeline Vincent, a public health nurse at the Health Department. "It's like a blister. You're still not in a lot of trouble. When it gets to Stage 3, you're in a lot of trouble."

She said that at a nursing home: "No one should develop a pressure ulcer if they didn't already have one."

There was no dressing on Germaine's wound and she was lying in her urine. The risk of infection goes up if a sore is contaminated by urine or feces.

The nursing assistant told inspectors she had just washed Germaine and would inform the nurse later that the dressing wasn't on the bedsore.

Inspectors wrote that they later followed up with the nurse, who said she had not been told that Germaine needed dressing.

Hillside was notified that it would be fined $250 per day, and that its Medicare and Medicaid funding could be eliminated in six months, by June 2004.

Barring federal and state funding is tantamount to closing a nursing home. In Rhode Island, an average of two-thirds of the revenue that flows into nursing homes comes from Medicaid, the insurance program for the low-income.

Janetakos, the administrator at Hillside, filed a plan of correction on Dec. 5, 2003, saying he would comply with state regulations.

That is what state regulators wanted to hear.

Williams, associate director for health services regulation, said he tells regulators: "Seek compliance, that's the mantra."

"We can't put everyone out of business," Williams said. "We try to be instructive. If they close, it's no good. We can't be draconian, we need to find appropriate balance.

"In the case of Hillside, I'm sure this department will be questioned whether the balance was appropriate or not."

On Dec. 16, 2003, health inspectors returned to Hillside.

Nine out of 13 people in the sample had bedsores. One woman, who didn't speak English, whimpered and cried, according to inspection reports.

Two were in wet beds.

The inspectors visited Germaine twice that day. On the first visit, around 7:30 a.m., inspectors wrote that the bedsore on her buttock was Stage 2, and that a "new Stage 2 pressure ulcer" was at the base of her spine. Inspectors noted "excoriation," meaning Germaine's skin was worn off.

There were no dressings on her bedsores.

Inspectors came back at 8:40 a.m. "The resident was found lying in urine/feces and there was a strong odor of feces/urine in the room."

Inspectors returned one day later, Dec. 17.

They visited Germaine. It was 1:15 p.m.

Inspectors found another bedsore, Stage 2, on the lower part of Germaine's left buttock.

"This resident now had three Stage 2 pressure ulcers on this day."

Again, there were no dressings on her bedsores.

Hillside's staff told inspectors that they typically used a "coversite," a particular type of bedsore dressing, on Germaine, but that the dressing had not been available.

Adele Renzulli, a registered nurse with the Health Department, was one of the inspectors.

"They still had a system problem," she said. "They couldn't, for some reason, get a handle on it. It was not to the point . . . I mean, people were OK, people were OK. You say, how can they be? But they were."

Renzulli said: "Germaine never seemed frightened. Germaine never complained about not being cared for because we asked those questions. She never, ever complained to us, because we did speak to her. How are things going? Fine. Are you scared? No. Did anyone mistreat you? No."

When it comes to inspecting nursing homes, Rhode Island follows a national model adopted by Congress in 1987 in response to horrific abuses in the industry.

The model requires one thorough annual inspection of every nursing home that receives Medicare and Medicaid. Richard Shaw, a regional official for the Centers for Medicare & Medicaid Services, said, "We rely on states to be our eyes and ears."

Rhode Island received $1.9 million in federal money last year to inspect the 93 nursing homes in the state that accept Medicaid and Medicare; the state, which pays 43 percent of Medicaid reimbursements, contributed an additional $600,000.

During the annual inspections, the state inspectors also ensure that the nursing homes meet state regulations, said principal surveyor Arthur Pullano.

Some states say an annual inspection is not enough since nursing homes residents today are sicker than ever.

The fittest of the elderly are going to assisted-living arrangements. Hospital stays are shorter, and patients are often discharged into nursing homes.

In Rhode Island, two-thirds of nursing home residents now need skilled nursing care, said Dr. David R. Gifford, assistant professor of medicine and community health at Brown University School of Medicine.

In Rhode Island's annual inspections done for Medicare and Medicaid, teams of three or four inspectors look only at a sample of residents, perhaps 25 people for a nursing home of 150 people.

The inspectors assign grades to violations. The worse the grade, the bigger the potential penalty.

A 2003 report by the federal General Accounting Office said the agency had studied annual inspections from 16 states and found that 39 percent of the inspections had understated problems that should have been classified as "actual harm" -- including avoidable bedsores, severe weight loss, and multiple falls resulting in injuries.

Rhode Island was not part of that study, but it has had examples of how "actual harm" is not easily defined.

In July 2002, at Hillside Health Center, an 80-year-old man tumbled down the stairs in his wheelchair. A security guard spotted him at 1 a.m. lying in the stairwell in blood. He'd left the Alzheimer's unit, which was supposed to be secured.

The Health Department investigated and found that the man had fallen six times before. His chart showed a history of wandering. The nursing home insisted it had a full staff in the unit that night and couldn't explain why no one heard the alarms on his chair or in his room.

The inspectors wrote that Hillside had not provided supervision to keep the man safe.

According to inspectors, this was not a Grade G -- a case of "actual harm."

Shown the report about the wheelchair fall, Shaw, the New England director for the Centers for Medicare & Medicaid Services and a former inspector, said: "In reading it out of context, it seems like, what happened to this guy? It should have been a G."

Madeline Vincent, the public health nurse at Rhode Island's Health Department, reviews nursing-home inspections.

In an interview, she read the report about the 80-year-old man and laughed with recognition. She said she remembered the incident well, because it had reminded her of an old Richard Widmark movie in which the actor pushed an elderly woman down the stairs in a wheelchair.

She said anytime she comes across a report about a person falling down the stairs, "it's like 'Oh my God, this is a bad Richard Widmark movie.' " She said inspectors had been correct in not finding actual harm because the man in the wheelchair hadn't had his lifestyle compromised.

Renzulli, the nurse who has worked for the Health Department as an inspector for six years, explained: "You might think of harm as something very different than what harm really is in the world of regulation."

"Let me give you an example. Someone doesn't walk, OK? They fall and break a limb. Is that a level of harm? No. You know why? Because it didn't impede . . . they couldn't walk anyway. Now, I know that sounds like, 'Oh my God,' but you have to . . . that's the regulatory process. To the public, to a loved one, it's 'Oh my God, my mother's arm is broken.' Yeah, but that's not how it is in regulatory."

Raymond Rusin, chief of facilities regulation in the Health Department, said that the industry complains about "overzealous surveyors, nitpicking."

"I've got to do what I've got to do to meet standards to provide care," Rusin said. "But I'm cognizant of the fact that if I royally piss off the industry, they are going to go around me to the legislature."

Rusin meets once a month with the Health Care Association, an independent organization that represents and lobbies for most of the state's for-profit nursing homes.

Alfred Santos, the group's president, said he e-mails "issues to Ray, and then we go in to Ray, and he knows what the issues are going to be."

Asked what nursing home operators think about the inspection system, Santos said: "We love it."

Under the federal model, a nursing home operator is allowed to file a plan of correction after each inspection. The Health Department then sends out an inspector to re-check the exact violations, such as a filthy kitchen or a bedsore.

The state is allowed to be an enforcer, recommending to the federal government when nursing homes should be fined or cut off from federal and state Medicaid money -- likely closing the home.

The enforcement is not done with a heavy hand.

"The system is designed for trying to motivate the owner to do the right thing," said Rusin, of facilities regulation.

"There is a bottom line where we say, 'You can't fall below standards,' " he said. "But we prefer to cajole and motivate a provider to do what it has to do."

Said Vincent, public health nurse for the Health Department: "We never [close a home] capriciously or arbitrarily. We try to make sure that they can't come into compliance.

"There is a lot built into the process that allows the facility to come out of the hole."

There is "due process," she said.

State records show some examples.

Before Edmund Place in East Providence was ordered closed by the state and federal government in 2000, it was threatened with fines or the denial of Medicaid reimbursements five times between 1996 and 1999. The nursing home was finally fined in 1999, when a check of 18 residents found that 12 of them had bedsores.

The Health Department twice threatened to cut off Medicaid reimbursements to Coventry Health -- partly owned by Giordano -- before the nursing home finally went into receivership in 2001.

Last year, Pullano, principal surveyor at the Health Department, threatened 12 nursing homes with fines; four paid.

The department had three times threatened Hillside with either heavy fines or a loss of Medicaid funding -- and three times rescinded -- by last fall.

The December 2003 inspection at Hillside -- which took place from Dec. 16 to Dec. 19 -- had found widespread bedsores, medication mixups, and wrong foods being fed to patients at risk of choking.

Nolan, the health director, froze new admissions to Hillside.

Pullano wrote to five attending doctors of Hillside patients who had bedsores in the December inspection.

He essentially wrote, he said, that "that home is screwed up."

The families of the other Hillside residents weren't told that.

Why?

Williams, associate director for health services regulation, said sounding alarms can make a troubled home worse. Residents move; new patients stay away. The census drops, and so does revenue, further hurting the quality of care.

"What if we started sending notices to every family? 'The home your loved one is in is problematic,' " said Williams. "You better be damned sure about it, because you're going to kill the business."

He said Hillside, by regulation, was supposed to post its recent inspections, or a sign saying where those inspections could be found.

"According to our information, they weren't posted," he said.

By December 2003, Pullano, the principal surveyor, was getting calls from Hillside employees: their checks were bouncing and vendors would only deliver food and supplies if paid cash up front.

Pullano investigated.

"The supply stuff had to be done on a cash and carry basis," said Pullano. "Maybe in November or December or earlier. You investigate it. Naturally you investigate all kinds of complaints. The administrator came back and said, 'Arthur, I'm doing this here on cash-only basis with the dietary suppliers.' "

"He said the reason why checks couldn't be cashed was because the employees were trying to cash their checks too early in the morning.

"I don't know what happened over there. We would tell him to fix something and go back tomorrow and something else would break."

Pullano said he knew Hillside had staffing problems. "I guess they couldn't get anyone. Who would want to work up there when you've got this cloud over the place?"

Hillside administrator Janetakos, in a letter to the Health Department last month, said that the owner of Hillside was not providing sufficient funds to pay the temp agencies on sooner and said that he tried to boost staffing through newspaper ads. He said that while residents' units might have been short on supplies at times, he believes that the main supply closet was always fully stocked. He said the owner rejected his proposal to bring in a new management firm to correct Hillside's problems.

The owners, Antonio L. Giordano and Consultants Inc., declined to be interviewed for this story.

Three weeks after the December inspection, in which the Health Department had visited Germaine Morsilli three times, and had noted her bedsore, plus two new ones -- Diane Gobin found her mother screaming for help.

It was Jan. 9, 2004.

Gobin had just had heart surgery for two blocked arteries. Her brother, who lives in Florida, had undergone open-heart surgery the year before.

Gobin recalls how she went to see her mother at 4:30 p.m.

"I found her in her bed, frantic, with her slacks pulled down to her thighs. She was covered in feces from the back of her knees to the middle of her back.

"She was screaming, and screaming for help. She put her arms out to me, like 'Save me!' "

Gobin asked questions, and was told that an aide had come in around 2:30 or 3 p.m. and had found Germaine in a mess. The worker's shift was up. She was supposed to tell her replacement that Germaine needed to be changed, and that her bedsore needed to be cleaned. She did not, Gobin was told.

"I just tried to calm her down and reassure her that I would be back the next day. I didn't know what to do about it, didn't know what to say."

On her lunch hour the next day, Jan. 10, Gobin typed up a letter to the nursing home administrator requesting an investigation. She sent another letter to the Health Department. She said she never heard back from the Health Department, but she knows her complaint was forwarded to the attorney general. The attorney general's department would not comment on the complaint.

Gobin didn't know that health inspectors were already monitoring Germaine's wounds.

On Jan. 14, Hillside filed another plan of correction with the Health Department.

On Jan. 20 -- 11 days after Gobin found her mother in her own waste -- the Health Department inspectors returned to Hillside. It was 10:45 a.m.

Hillside's new director of nursing was present.

Germaine was again lying in bed without dressings on her Stage 2 bedsores.

The nursing assistant caring for Germaine told inspectors that she had completed her care of Germaine more than an hour earlier, at 9:30 a.m. She said she had informed a nurse at that time that Germaine did not have dressings on.

Inspectors went to the nurse, who said she had just been told, at 10:30 a.m., that Germaine needed dressing.

The director of nursing told inspectors that there were supposed to be two nurses on Germaine's unit -- but that there had been a problem keeping two nurses on. The nursing director said, inspectors wrote, that one nurse could not keep up with all that needed to be done.

Nine days later, on Jan. 29, inspectors went back to Hillside.

It was 8:30 a.m.

The bedsore on Germaine's left buttock had gone from Stage 2 to Stage 3, invading layers of skin, and damaging tissue.

At Stage 3 -- you're in trouble.

There was no dressing on Germaine's wounds.

At 9 a.m., inspectors checked on Germaine again.

Now, the Stage 3 bedsore had dressing on it, but the Stage 2 bedsore at the base of Germaine's spine did not. Nor did the third Stage 2 bedsore at the lower part of her left buttock.

Inspectors looked at Germaine's chart and saw that a nurse had written that Germaine's wounds had "increased in depth."

So why leave Germaine in Hillside -- or allow the same staff to continue caring for her?

Why not rule "immediate jeopardy," the designation that allows the Health Department to simply move a resident from a home?

"You can't rush to judgment on things," said Renzulli, the nurse who was part of the inspection team that was monitoring Hillside. "Unless it's so egregious and someone is being harmed right in front of you, you're uprooting people from their homes and until you can prove harm you just can't call an [immediate jeopardy] and you don't call it independently. Facilities have a right to that.

"Basically, regulators and the nursing home staff, we do the same things, but we do it in different ways," Renzulli said. "They're caring for people and we're caring for people, so basically we should work together and we do. I want to say, 9 out of 10 times, we're working together."

By the end of January 2004, inspectors had found Germaine Morsilli without dressing on her bedsores five times.

The nursing home still hadn't lost credibility with Renzulli.

"I always assume everything has been corrected, because if you go in negative, then you're already biased against the facility. It's not up to us to make judgment, it's up to us to follow regulatory process and language.

"I'm not just blowing hot air; I always go in assuming compliance."

At 7:45 a.m. on Feb. 13, health inspectors returned to Hillside to check on Germaine and a handful of other patients who had bedsores.

By 8 a.m., inspectors were by Germaine's bed, a single by the window. In her nightstand, according to her daughter, she had a photo album, 27 pages of her life: her finished basement in Pawtucket, her son who fought in Korea, and the time Germaine dressed up in a nurse's uniform to care for her first husband after his heart attack.

Now, she weighed less than 80 pounds.

According to an inspection report, she was lying on her back, on her bedsores.

An inspector asked to see Germaine's wounds.

"I have not put a dressing on her yet," the nurse said, according to the inspection report.

Let me see the old dressing, an inspector ordered.

The charge nurse referred the inspector to a nurse's aide, who said: "There was no dressing on her when I cleaned her at 7:15 this morning."

The inspectors looked at Germaine's wounds.

The bedsore on Germaine's left buttock was Stage 4, the worst stage, when the wound goes through layers of decayed skin and is into muscle and bone. Infections can invade the blood stream.

Nurse Renzulli, who was on the inspection team that day, recalls what Germaine's Stage 4 bedsore looked like: "It's going through layers of skin. It's nine centimeters long, five wide, and three centimeters deep. Deep, and it had a bloody discharge and large area of redness."

The charge nurse at Hillside told inspectors, according to the report: "I have not dressed this wound before."

And then she attempted to dress Germaine's wounds.

She put tape on Germaine's skin.

An inspector told the nurse to look at Germaine's chart, which contained a doctor's order for how to treat Germaine's bedsores. The chart said a dressing was to be used, not tape.

"So at that point," said Renzulli, "I called my supervisor. I called in and the decision was made she was to be moved from the facility."

The inspectors declared "immediate jeopardy."

The designation carries a fine of $5,000 per day. In Rhode Island, there had been just four cases of immediate jeopardy since 1973, according to Pullano, the principal surveyor.

Germaine still wasn't moved from Hillside.

Instead Pullano said he told Hillside: "They had two or three days to tell us how they were going to correct this."

The nursing home returned with a plan to move Germaine from the third floor to the fourth floor, to a skilled nursing unit.

Ray Rusin, chief of facilities regulation, said his first thought was, "This is problematic; why aren't we moving this person?"

Because it was a rare case of immediate jeopardy, Rusin had to inform Nolan, the health director.

"She's a doctor, she may come down and say, 'I don't care what they think they can do. Get her out of there.' "

He said he and Nolan accepted the nursing home's proposal to keep Germaine Morsilli in Hillside, as long as she was in the skilled nursing unit.

"That sounded reasonable to us," Rusin said.

He said that "lots of people with bedsores" were getting appropriate treatment at Hillside.

Asked if he was nervous about leaving Germaine in Hillside, Rusin said: "Yes, because I knew I'd be standing in front of you answering these questions."

On Feb. 14 and 15, health inspectors checked in on Germaine.

On Feb. 15, she was in a new room on the skilled nursing unit.

On Feb. 19, health inspectors checked in again and reported that the nursing home was taking proper care of her bedsores. Hillside, on Feb. 20, filed yet another plan of correction. But the improvements didn't last, according to the Health Department.

On Feb. 28, inspectors went to Hillside at 7:45 a.m. and checked on Germaine in the skilled nursing unit. They learned that she had fallen out of her bed the night before.

Her dressing was old, "three-quarters off," and soaked with feces and drainage from her wound, Pullano said.

An inspector asked the aide who had been tending to Germaine why she had not changed Germaine's dressing. "She stated, 'I only work here every other weekend and didn't know she had a dressing,' " Pullano said.

The inspector called in the nursing supervisor, who said she didn't know how to use the wound-care products Germaine needed. She asked the inspector for help, Pullano said.

Diane Gobin, Germaine's daughter, got a call from the Health Department: Her mother had to leave Hillside; the nursing home could not care for her.

Gobin said she wished she'd moved her mother sooner. She'd thought about it often, she said, but she hadn't wanted to separate Germaine from her sister, Lucille, who had lived at Hillside. Lucille died last fall, but Gobin didn't want to put her mother through the trauma of being moved. Plus, she said, "I kept thinking, they're going to do what they say they're gonna do, you know? You don't know how much worse the next nursing home might be if it's your first experience with this."

Gobin learned that February day, for the first time, that the Health Department had been monitoring her mother's wounds.

On Sunday, Feb. 29, Gobin went to get her mother out of Hillside.

Diane said she sat at the end of the bed in a chair and watched her mother sleep.

Germaine woke, and according to Gobin, said: "I know I shouldn't ask, but just let me die."

"I can't live like this."

"Well, Mom," Gobin said she responded. "God's not going to come for you, but we're taking you somewhere else. We're taking you to another nursing home."

Her daughter said Germaine clapped her hands: "Oh, thank God."

At Orchard View nursing home in East Providence, Germaine settled into her new room.

She asked for a manicure for her 88th birthday.

Six weeks after leaving Hillside, Germaine Morsilli died.

She had a bad heart.

"I think my mother hung on and hung on so she wouldn't die in that awful place," said Gobin.

On March 3, the owner put Hillside into receivership, the state version of bankruptcy.

The court appointed a receiver, who couldn't salvage the nursing home, which owed more than $3 million to vendors, and $2 million to the Internal Revenue Service.

In May, Hillside closed.

The 80 residents left at Hillside had to be moved to other nursing homes. Hillside left unpaid $82,250 in fines for its poor care.

The federal government is unsure if it will be able to collect the money.

"We'll see," said Shaw, regional director for the Centers for Medicare & Medicaid Services.

In July, the Health Department revoked Janetakos' nursing home administrator's license, and, in a July 29 administrative order, pinned the problems at Hillside on him. Janetakos responded in a letter that it seemed he was being made a scapegoat.

Some family members question the role of the Health Department. Why had regulators allowed Hillside to get so bad?

In one of two interviews in July, Health Director Patricia Nolan said: "I don't have the luxury of going down the street and saying: These people are really lousy, I'm not going to let them run a nursing home.

"I have to prove they are really lousy."

One woman, Jacqueline Wallace of Providence, whose mother had lived at Hillside, told The Journal in an interview that it seemed that a person could be punished more for brawling in downtown Providence than for neglecting an elderly person's bedsore.

Asked for her comment on that observation, Nolan said: "Are you suggesting we should arrest the nursing home staff? That's not how it works. We were, in fact, fining this facility. The idea that we should punish individual nurses for abuse and neglect -- there has to be intent."

Nolan said it is the Health Department's job to tell a nursing home what it is doing wrong, and then ask the home to correct the problem. She said most nursing homes in Rhode Island fix flaws, and keep them fixed.

Nolan said she does not believe it's good public policy for the Health Department to punish problem nursing homes with increasingly heavy fines, because the lost money might take away from patient care.

Rhode Island law allows the Health Department to step in and ask the court to appoint a receiver for a nursing home -- though it has never happened.

Nolan said the "rescue concept" concerns her because she doesn't know what it would mean for the state and the residents.

Who would run the nursing home, and what liability would the state take on?

"Say something happens, a resident falls out of the window. Where is the liability, and is the state protected?"

Nolan said the Health Department would prefer to get nursing homes to deliver quality of care and sustain it. When one closes, families have to quickly find a new home. While there is not a shortage of nursing home beds in Rhode Island, it can be hard for people with specialized needs to find slots, she said.

"Ordering a person to be evicted from a home is really a tough decision. It's easier to order a facility to get with it, and take care of a person."

What about Resident #1, Germaine Morsilli, who'd been ordered removed from Hillside, after inspectors watched her bedsore go from Stage 2 to Stage 4?

Nolan said it's rare for the Health Department to take action on an individual patient and that she is involved when the Health Department declares a case of "immediate jeopardy." She said she remembers Ray Rusin, chief of facilities regulation, coming to her "about a patient" in February.

That was Resident #1, Germaine Morsilli.

Nolan said she didn't want to discuss a particular patient and say "we should have done X." In any case, she said she didn't remember the details of Germaine Morsilli.

Offered the paperwork, she pushed it back across the table.

"Sorry, you'll have to go with what Ray says."

Nolan said she signs a number of orders in her job, and the one about Hillside Resident #1 did not stand out. "It's sort of like remembering: Did you clean your teeth that day? It was a long time ago."

Jennifer Levitz can be reached at 277-7931 or jlevitz [at] projo.com