2003Investigative Reporting

BROKEN HOMES | A FINAL DESTINATION

For Mentally Ill, Death and Misery
By: 
Clifford J. Levy
April 28, 2002

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Randolph Maddix, a schizophrenic who lived at a private home for the mentally ill in Brooklyn, was often left alone to suffer seizures, his body crumpling to the floor of his squalid room. The home, Seaport Manor, is responsible for 325 starkly ill people, yet many of its workers could barely qualify for fast-food jobs. So it was no surprise that Mr. Maddix, 51, was dead for more than 12 hours before an aide finally checked on him. His back, curled and stiff with rigor mortis, had to be broken to fit him into a body bag.

At Anna Erika, a similar adult home in Staten Island entrusted by the state to care for the mentally ill, three other residents had previously jumped to their deaths when a distraught Lisa Valante, 37, sought help. But it was after 5 p.m. and, as usual, the residents, some so sick they cannot tie their shoes, were expected to fend for themselves. No one stopped Ms. Valante, then, from flinging herself out a seventh-floor window.

Sometimes at these homes, the greatest threat can be the person who sleeps in the next bed. Despite a history of violent behavior, Erik Chapman was accepted at Park Manor in Brooklyn. After four years of roaming the place with a knife, Mr. Chapman stabbed his roommate, Gregory Ridges, more than 20 times. At last, Mr. Chapman was sent to a secure psychiatric facility. Mr. Ridges was sent to Cypress Hills Cemetery at the age of 35.

Every day, New Yorkers come face to face with the mentally ill who have ended up on the streets since the state began closing its disgraced psychiatric wards more than a generation ago. Mr. Maddix, Ms. Valante and Mr. Ridges were among thousands more who ended up in dozens of privately run and state-regulated adult homes in New York City.

Oceanview Manor

Broken elevators are part of the landscape at adult homes like Oceanview Manor in Brooklyn.
Nicole Bengiveno/The New York Times

A yearlong reporting effort by The New York Times, drawing upon more than 5,000 pages of annual state inspection reports, 200 interviews with workers, residents and family members, and three dozen visits to the homes show that many of them have devolved into places of misery and neglect, just like the psychiatric institutions before them.

But if The Times's investigation found that the state's own files over the years have chronicled a stunning array of disorder and abuse at many of the homes, it discovered that the state has not kept track of what could be the greatest indicator of how broken the homes are: how many residents are dying, under what circumstances and at what ages.

The Times's investigation has produced the first full accounting of deaths of adult home residents. At 26 of the largest and most troubled homes in the city, which collectively shelter some 5,000 mentally ill people, The Times documented 946 deaths from 1995 through 2001. Of those, 326 were of people under 60, including 126 in their 20's, 30's and 40's.

At two of the largest homes, Leben Home in Queens and Seaport Manor in Brooklyn, roughly a quarter of the 145 residents who died were under 50. The Times's analysis of the deaths used Social Security, state, court and coroner's records, as well as psychiatric and medical files.

The analysis shows that some residents died roasting in their rooms during heat waves. Others threw themselves from rooftops, making up some of at least 14 suicides in that seven-year period. Still more, lacking the most basic care, succumbed to routinely treatable ailments, from burst appendixes to seizures.

Some of the hundreds of deaths undoubtedly stemmed from natural causes and were unavoidable. Studies have found that the mentally ill typically have shorter life expectancies than the general population, because they have difficulty caring for themselves and are more prone to health problems. The average age of death in the overall survey was 63.

There are few extensive studies on death rates of the mentally ill in facilities like adult homes. But Dr. E. Fuller Torrey, a psychiatrist who is a nationally recognized expert on mental illness and mortality, called The Times's analysis disturbing.

"It would certainly suggest a fair number of deaths that were premature," said Dr. Torrey, who is executive director of the Stanley Medical Research Institute in Bethesda, Md., and is familiar with the adult home system in New York City. "There is no question that if these people were getting better care and more skilled care, they would be living longer. And this poor care leading to death is going to cut right across the age population. It also means that people who are 70 are dying prematurely."

In the end, whether the residents were in their 20's or 70's, it is impossible to know just how many of their deaths could have been prevented. The only other accounting of the dead seems to be on Hart Island in the East River, where scores of adult home residents are buried in the mass graves of potter's field.

Officials at the State Department of Health, which regulates the homes, acknowledge that they have never enforced a 1994 law that requires the homes to report all deaths to the state. Asked for records of any investigations into deaths at the homes, the department produced files on only 3 of the nearly 1,000 deaths.

None of the suicides were among the three. Even the fatal stabbing of Mr. Ridges at Park Manor went unexamined by the department. The city medical examiner's office said it had not received a single inquiry in recent memory from state inspectors regarding an autopsy of an adult home resident.

Neither Gov. George E. Pataki nor his health commissioner, Dr. Antonia C. Novello, would comment on The Times's investigation. Their aides said a deputy health commissioner would speak for the administration.

Presented with The Times's findings, the deputy health commissioner, Robert R. Hinckley, said the department would examine "ways to better investigate those deaths that are reported to us."

To that end, Mr. Hinckley said the state would issue a regulation alerting the homes that it would strictly enforce the 1994 law on reporting deaths.

"We want facilities to follow the law, and we are redoubling our efforts to get them to report all deaths," he said.

As of Friday, seven weeks after Mr. Hinckley's promise, the department had still not issued the regulation.

About 15,000 mentally ill adults -- most of them poor, many of them black and Hispanic -- reside in more than 100 adult homes in the state, the majority in the city and its suburbs. Some are now larger than most psychiatric hospitals in the nation.

The reality of the homes is far from what was envisioned. In the 1960's, New York, like other states, decided to shutter or sharply scale back its psychiatric wards, where patients often languished for decades.

When the profit-making adult homes offered to shelter the discharged patients, the state embraced the idea. Federal disability money was used to pay the homes, which would provide meals, activities and supervision. The homes would bring in outside providers for psychiatric and medical care.

The state was responsible for making sure it all went well.

But from the start, problems surfaced. No one knew about them better than the state itself, which for 30 years has issued damning inspection reports and then all but ignored them.

State investigators across those three decades described many of the homes as little more than psychiatric flophouses, with negligent supervision and incompetent distribution of crucial medication. At one, Brooklyn Manor, the staffing was so sparse that a resident was put in charge of the entire place on one evening, a routine 2001 state inspection report shows.

In more than 100 inspection reports from 1995 through 2001, investigators frequently noted filthy and vermin-ridden rooms in some homes, and disheveled and unbathed residents in others. They cited administrators for poor, sometimes fraudulent, record-keeping involving residents' money and care. A 2001 state inspection of Garden of Eden in Brooklyn found the operator to be "routinely threatening residents."

In a 1990 overview of adult homes, the Commission on Quality of Care for the Mentally Disabled, a small state watchdog agency, rated half of the homes that it surveyed in the city as poor. Ten years later, the agency came to the same conclusion.

But the formal reports get at only part of the system's failures, according to The Times's investigation.

The investigation reveals several of the homes to be medical mills where the operators and health care providers pressure residents to undergo treatment -- even surgical operations -- they neither need nor understand in order to earn Medicaid and Medicare billings.

The homes are typically run by businessmen with no mental-health training. A 1999 audit by the State Comptroller's Office aimed at evaluating the regulation of adult homes found that the Department of Health had done little to scrutinize the people it licensed to run them.

The homes are staffed largely by $6-an-hour workers who dispense thousands of pills of complex psychotropic drugs each day. At one home, Ocean House in Queens, social workers said a medication worker was basically illiterate.

The homes are not required to have professional staff on duty overnight. Multiple visits reveal that often only the janitors, and possibly a guard or two, remain.

Nathaniel Miles, a former porter at Surf Manor, a 200-bed home in Coney Island, recounted two scenes last year that he called typical: on one night, he had to stanch the heavy bleeding of a resident who had had a seizure and fallen in a bathtub. Down in the lobby on another night, he had to chase after a woman who had threatened to kill herself and had run from the home.

Surf Manor

Nights at the city's adult homes, such as Surf Manor in Brooklyn, are the starkest, when only a janitor or a guard or two remain.
(Nicole Bengiveno/The New York Times)

The notion that residents would be limited to those who might, with help, enter the work force or join a community was abandoned almost from the outset. The state's own files show that the residents include severe schizophrenics, manic-depressives and others who have no hope of achieving self-sufficiency. Visits to the homes reveal that some residents hole up in their rooms for days at a time. Others can be found in smoking rooms or hallways, suffering psychotic episodes. Some are shuttled back and forth to psychiatric wards.

And many, it is clear, do not survive.

At the largest homes, one person died every three to eight weeks on average from 1995 through 2001, The Times's analysis shows. At the 361-bed Leben Home, 14 of the 66 dead were under 50 years old. At the 346-bed Seaport Manor, 24 of the 79 dead were under 50.

"Seaport is no more than a warehouse," a 50-year-old resident wrote to her sister on Christmas Day, 1998. "There are an unusual number of deaths among middle-aged people here."

Less than two months later, the resident scrawled "Evil wins" on the wall of her room, swallowed an overdose of pills and placed a plastic bag over her head, according to toxicology reports from the medical examiner's office and interviews with Seaport workers. The home's report to the state shows that Seaport failed to disclose the true details of her suicide, saying only that she was discovered dead in her bed. The state never looked into it anyway, according to its own files.

To do an inventory of the deaths, though, is to appreciate residents who had passions and triumphs and who had strived to find their own place in the world.

Jonathan Miller, sweet and gentle, traded baseball cards from his room at an adult home in Queens called King Solomon. He died there, of a heart attack, during a heat wave in July 1999. Mr. Miller, 35, was not discovered until the smell brought a worker to his door. The home waited until night to remove his body, workers said, then they cleared his room of the baseball cards he loved. At his wake, his family wept in front of a coffin that had to be closed to hide what had happened to his corpse.

"These people are just given little value by either the state or the adult homes or the mental health providers," said George Gitlitz, who has spent a decade visiting the homes and urging the state to improve conditions on behalf of the Coalition of Institutionalized Aged and Disabled, one of the few advocacy groups for adult home residents. "They are seen as dollar signs -- as property -- and not as human beings."

The sorry history of New York's adult homes and their oversight extends over decades and multiple administrations. And New York is not entirely alone. Other states placed discharged mental patients in similar facilities. In 1989, after surveying homes in several states, a Congressional committee called them "a national tragedy."

Not all the dozens of homes in New York City are disastrous. Some are clean and staffed by kindly people who try to help the mentally ill find their way. Yet all the places are troubled by the same systemic problems, like untrained workers and gaps in supervision.

The homes are also costly. The government spends an average of $40,000 a year on each resident through federal disability and Medicare and Medicaid payments. That adds up to $600 million annually in taxpayer money.

Yet even as public money pours into the system, the government does little to hold the homes accountable. Over the years, few operators have been meaningfully punished, despite amassing records of misconduct, state inspection reports and interviews show. Albany, lawmakers concede, has consistently chosen to avoid the looming question: If you close the homes, where will the mentally ill live?

And so for decades, thousands of them have been living in broken-down former hotels and rooming houses. Police and fire department records make clear that emergency workers are frequent visitors, routinely responding to 911 calls about psychotic episodes, unfettered chaos and dead bodies.

Merciless Season

A Sweltering Summer, Rooms Like Ovens The summer of 1999 was one of the most oppressive in memory in New York City, day after day of soaring temperatures and pleas from health officials for the public to take precautions.

At the Leben Home for Adults, a brick building on 45th Avenue in Elmhurst, Queens, the rooms could heat up like a furnace. Originally built to house offices for an airline parts factory, the structure is poorly ventilated, making it hotter inside than outside in the summer.

The more than 350 residents at Leben, like many mentally ill people, are vulnerable to the heat because of their medication and poor general health. Most also had no income beyond their modest monthly disability checks, and could not afford to buy air-conditioners or pay the additional fees that Leben's operator, Jacob Rubin, charged to run them.

Mr. Rubin received more than $3 million a year in government money to operate the home, even though state inspections deemed it neglect-ridden. As Mr. Rubin ran the air-conditioner in his office there, closing the door to keep it cool, workers said, many residents went without fans.

It was an exceptionally tough summer for Michael Bonner, who had taken to hiding away in his room for days at a time, with no one at the home trying to coax him out.

Mr. Bonner had schizophrenia and depression and had been in and out of homeless shelters, psychiatric wards and adult homes for much of his 52 years. There had been times when he found stability. He had worked as a porter at La Guardia Airport and as a clerk at a department store. He had liked to show up at his uncle's home in the Bronx. "Surprise!" he would say before bounding in. But his disease always seemed to win out.

By 1999, it had become overwhelming.

For weeks at Leben that summer, workers said, they appealed in vain to Mr. Rubin to install new air-conditioners and fix broken ones. The rooms were suffocating, and resident after resident was getting sick.

Mr. Bonner remained in his room all day on Aug. 16, when the outdoor temperature reached the mid-80's. At some point, Mr. Bonner's roommate saw that he was in distress and ran into the hallway looking for help. Dennis Lloyd, the director of security and recreation at the time, responded.

"The man is in convulsions, foaming from the mouth," Mr. Lloyd said in an interview. "His body had to be like 108 degrees, 109 degrees, such a fever. It was hot that day. To touch him, oh my God. His body was burning up. When E.M.S. came in, we were ordered to soak towels in cold water, to wrap his body. But it was too late. He died in the hospital."

After working at Leben for 14 years, Mr. Lloyd left last year and took a job at a nursing home. He said he agreed to be interviewed about Leben because he felt the public needed to know about the conditions there.

In Mr. Bonner's case file at Leben, it was scrawled only that he had hyperthermia, a spike in body temperature. His uncle, Nathan Goods, said an administrator had told him that Mr. Bonner had died of a heart attack.

Leben never notified the State Department of Health about the death. That was not surprising. Instead of enforcing the 1994 law requiring the homes to report all deaths, the department asks the homes to report deaths only from "other than natural causes." The homes, which have no medical credentials, get to make that determination, and they usually determine deaths to be natural.

Mr. Goods eventually went to Leben to pick up his nephew's few possessions, which the home had put into a trash bag. "He was just another poor soul who didn't have a family with money who could watch him and protect him," Mr. Goods said.

His death at Leben was not unique, though. July and August were the deadliest months at the 26 adult homes in The Times's survey in four of the seven years. As at Leben, most of the other homes do not run air-conditioning unless residents pay an extra $25 to $150 a month. The operators say the state does not pay them enough to provide it free.

Few months took as great a toll as July 1999, when 17 residents died.

Three weeks before Mr. Bonner died, Stephanie Dinardi, 40, was found by her roommate naked on the floor at Leben and was dead when the ambulance arrived.

But the ambulance workers knew they would be back. "During the summers, we were constantly at Leben for heat cases," said Chris Jute, one of the workers who responded that day.

The state knew the reasons. Psychotropic drugs can reduce sensitivity to heat and the ability to sweat. The mentally ill are also less likely to take precautions, such as drinking fluids, and are prone to diabetes and other diseases aggravated by heat. One of the state's own psychiatrists, Dr. Nigel Bark, found in a study that psychiatric patients had twice the risk of dying during heat waves as the general population. He concluded that the "risk can be eliminated" with air-conditioning and other precautions.

The State Office of Mental Health has provided air-conditioning in the state's psychiatric hospitals for more than two decades. The office, the agency with the most expertise in addressing the needs of the mentally ill, has little role in overseeing the adult homes, which shelter three times more mentally ill people than the psychiatric hospitals.

Asked why the adult homes were not air-conditioned and what precautions were taken by the Department of Health in the summer, Mr. Hinckley, the deputy health commissioner, said regulations required the operators to ensure that residents "remain comfortable" when the temperature is above 85 degrees.

While many hospitals and nursing homes run air-conditioners, Mr. Hinckley pointed out that the state did not require them to do so, either.

Mr. Rubin would not comment. In May 2001, after The Times published two articles detailing malfeasance at Leben, the state forced him to surrender his license and leave the industry. The home, under new management, was recently renamed Queens Adult Care.

Muriel Sachs, who endured a quarter-century at Leben, would not live to see Mr. Rubin go. Ms. Sachs, 71, had respiratory problems and the misfortune of being assigned a room on Leben's third floor, its highest and hottest.

She was a fixture at the home, wandering the halls and showing off an old photograph of herself with a dapper man she imagined was her husband. She had survived a lobotomy and more than two decades in psychiatric wards before the state shut them down. "We have no other alternative than referring her to you," a social worker wrote to the newly opened Leben in 1974.

She would grow old at the home. Then, on July 6, 1999, several things conspired against her in Room A317. The outside temperature hit 101 degrees and Mr. Lloyd, the longtime security director, said the workers on duty that night refused to check on the residents on the third floor because it was stifling.

Room A317 not only lacked air-conditioning. The fan also did not work because the room's electricity had accidentally been shut off, Mr. Lloyd and other current and former workers said.

In the middle of the night, Ms. Sachs got out of her bed, perhaps to seek help. She did not get far. At 6:50 a.m., she was found face down on the floor of her room, dead of heart failure, according to police records.

"She passed away because of the suffocating heat," recalled a former janitor, Arsenio Cabrera, who was on duty that morning.

Mr. Cabrera, Mr. Lloyd and other former Leben workers said they kept silent because they feared losing their jobs. "Everything was covered up," Mr. Lloyd said.

Mr. Rubin notified the Health Department about Ms. Sachs's death, without mentioning the heat, according to department records. A state inspector wrote a note saying that she could not follow up anyway because she was too busy, the records show.

Ms. Sachs was Jewish, and occasionally attended religious services. A group called the Hebrew Free Burial Association will provide a proper Jewish burial in the city for anyone who cannot afford it. It requires a phone call. Ms. Sachs was sent to potter's field. No mourners or headstone or prayers. Only a burial number, 34943.

Threat to Themselves
A Trail of Suicide, a Lack of Answers

Both Melvin Ryan and Lisa Valante had long been besieged by schizophrenia. Their voluminous psychiatric records told of histories of bizarre behavior, of an inability to care for themselves, of periods of depression so relentless they could not pull themselves out of bed for days.

They had already tried to kill themselves when they were sent by a state hospital, Rockland Psychiatric Center, to the Anna Erika home in Staten Island within two months of each other in the late 1990's. Less than two years later at the home -- deemed by the state to be the appropriate place for them to live -- the two would finally succeed in ending their lives.

Mr. Ryan, 51, jumped out a seventh-floor window. Less than three weeks later, Ms. Valante, 37, did the same. They were the third and fourth residents of the home to commit suicide that way in four years. After Ms. Valante's death, the operator of the home installed guards on some windows, he said, but not on others, including the one that Ms. Valante had jumped from.

In the state's headlong drive to make its psychiatric wards obsolete, officials have publicly maintained for 30 years that the adult homes are a satisfactory substitute. The thinking is this: with psychotropic drugs, residents do not need close supervision. They will see therapists regularly, and when a crisis arises, they will be sent to a psychiatric ward.

In the wake of that thinking lies a roll call of suicides that, in recent years, includes but is not limited to:

  • Vadim Sapojnikov, 26, who left Park Manor, went to his family's home for a visit and leapt from a fourth-floor window.
  • Eliezer Sulsona, 42, Sherri Cohen, 38, and Joan Ciancimeno, 49, who jumped from New Haven Manor, Sanford Home and Park Inn in Queens.
  • Robert Tricarico, 41, who leapt from Lakeside Manor in Staten Island.
  • Lavar Murphy, 22, and Charles Osdin, 83, who hanged themselves at Wavecrest in Queens and Riverdale Manor in the Bronx.
  • Myrna Millington, 61, and Fu Jun Ho, 45, who jumped from Anna Erika before Ms. Valante and Mr. Ryan.
All these suicides went uninvestigated by the state inspectors who regulate the homes, according to their records. Had the suicides occurred at a psychiatric hospital or even a prison, they would have routinely prompted inquiries.

Ms. Valante had been sick since her 20's and was estranged at times from her parents, who live in Florida. As her illness worsened, she often refused to bathe and insisted on wearing only one set of clothing, a printed housedress over a long black outfit.

Mr. Ryan had lived with his elderly parents in Harlem for years, until they could no longer care for him. Despite his battles with schizophrenia and drug abuse, he had the face of a mama's boy, angelic and unlined, and a sinewy body that harked back to his days as a high school track star.

By the time they got to Rockland Psychiatric Center in 1997 and 1998, the two had been hospitalized numerous times after psychotic, often suicidal, episodes, and it seemed clear that their chances of leading stable lives were slim.

Mr. Ryan was put on a suicide watch at one point at Rockland, and often told his psychiatrist that he heard voices threatening to lynch him, according to his treatment records.

Ms. Valante wrote all over the walls of her hospital room, a paranoic graffiti about death and evil. A psychiatrist quoted her in her treatment records as saying, "I wish I could just die and rest in peace and eternity."

Still, Mr. Ryan and Ms. Valante could not remain there forever. The state encourages hospitals to save money by stabilizing patients and discharging them. With few exceptions, New York does not want to provide long-term psychiatric care.

So the two were sent to Anna Erika to stay.

Like many adult homes, Anna Erika has been cited by state inspectors for serious violations in recent years. The home is one of the largest in New York, with 427 beds, including a significant population of elderly people, some without mental illness. But at one point, inspectors charged that it did not have a single qualified case manager to supervise residents, according to a 1999 state report.

The therapists who came to Anna Erika to treat residents did what they could, but there were not enough of them and the home could also easily get rid of them if they complained about conditions.

Soon after Mr. Ryan and Ms. Valante began living there, they hunkered down in their rooms. Over the next year and a half, both had psychotic episodes, were hospitalized and then were determined well enough to return to the home.

By the summer of 2000, Mr. Ryan was refusing medication, and his therapists considered hospitalizing him again. He asked to move from a room on the second floor to one on the seventh. The home agreed.

He told his social worker on Sept. 13 that he was afraid to get out of bed and was considering voluntarily going to a psychiatric ward, according to his treatment records. Two days later, at 7:20 a.m., the police said, he opened the window in his room and stood on the ledge. Then he jumped.

Less than three weeks later, Ms. Valante would follow. Her psychiatrist had also been considering hospitalizing her, according to her treatment records. Shortly after 8:30 p.m. on Oct. 3, Ms. Valante went to see her social worker, who had an office on the seventh floor, according to interviews and records. As usual after business hours, no one was there. She paced the hallway, then walked into a room, opened the window and jumped.

Vincent Sirangelo, Anna Erika's operator, said the home had done nothing wrong in caring for the two.

When asked for evidence to show that the home had been closely monitoring Mr. Ryan and Ms. Valante or had even known that they were in crisis, he declined to provide any. He said Anna Erika "had fulfilled its obligations."

"We did our own internal investigation," he said. "There was no reason that surfaced why they committed suicide."

The Ryan and Valante families heard nothing from state officials after the suicides, and got only a single phone call from Anna Erika administrators.

"They said, `We just wanted you to know that your daughter is dead,"' recalled Ms. Valante's mother, Gertrude. "Just like that. I went out of my mind when it happened. And they wouldn't give me any answers."

Threat to Others
A Stabbing Ends a Rebuilt Life

Gregory Ridges, 35, called his mother every morning from Park Manor, a storefront home on Coney Island Avenue near Prospect Park in Brooklyn. He loved to tell her that he was setting off for his part-time job as a custodian. "I'm going to make the doughnuts!" he would exclaim, riffing on that old television commercial. Then he would put on his uniform and shoes, which he had carefully laid out the night before.

When he returned to the home he would let his mother know that the doughnuts had been made, a routine she cherished. Once plagued by paranoia about himself and his family, her son had slowly gotten better. He was one of the few adult home residents who held a job, and he took great pride in it.

The first boy of 10 siblings, Mr. Ridges had a special place in his mother's heart. She called him Big G, and loved his sense of humor. So did workers and residents at Park Manor, a home for 62 mentally ill people.

In the late 1990's, Mr. Ridges lived there with two other men in a dusky room not much bigger than a sleeper on an Amtrak train. He and Sanford Lall got along. Their other roommate, Erik Chapman, had an obsession with knives and threatened to kill them both.

Mr. Chapman was as feared around the home as Mr. Ridges was liked. One worker refused to be alone with him. Other residents recalled violent outbursts when he used illegal drugs and rejected his psychotropic medication.

Even his family was afraid of him. Before going to Park Manor, he stabbed his sister and stepfather, beat up his brother and attacked his father-in-law so viciously he was in the hospital for weeks. Psychiatrists had noted Mr. Chapman's violent tendencies, yet he was accepted at Park Manor in the mid-1990's and stayed for four years.

If people like Ms. Valante and Mr. Ryan did not belong at adult homes because they were a threat to themselves, Mr. Chapman exemplified a different sort of danger.

The screening of residents can be lax at the homes, in part because it is at the discretion of operators who have no mental health training and are running commercial enterprises. Since an empty bed means no money, some homes are willing to accept almost anyone, records and interviews show.

As a result, fighting among residents and other violence in the homes are not uncommon. Killings are, yet when they have occurred, they have gone unexplored. In 1989, for example, two women were killed in separate cases at Leben, and their deaths were not classified as homicides for months. The crimes were never solved.

At Park Manor, everyone immediately knew who the killer was. What went unexamined was why he had been able to remain at the home despite ample evidence that he was dangerous.

Mr. Chapman, now 33, began having psychotic episodes in the early 1990's while living with his family in Brooklyn. "He used to always carry a knife and brass knuckles," said his brother, Charles Chapman. "Was I scared of him? Most definitely. He just likes to physically attack you."

In 1994, after stabbing his sister, Erik Chapman was hospitalized at Kings County Hospital Center. "Patient remains very guarded and evasive," a psychiatrist wrote in his records. "This together with history of violent assaultiveness suggest he is a risk and dangerous to others." Less than two months later, Kings County discharged him.

From 1996 through 2000, Mr. Chapman lived at Park Manor. After one psychotic episode in late 1998, he went to Maimonides Medical Center, where psychiatrists repeatedly noted his hostility toward his roommates and his refusal to return to the home, according to his treatment records.

"Admits to possibly wanting to hurt men," a psychiatrist at the hospital wrote. Asked on a form whether Mr. Chapman had homicidal tendencies, another psychiatrist wrote a question mark and then, "Suggested hurting his perceived persecutors." Among his delusions: he believed his Park Manor roommates were coughing up blood on him.

After two months at the hospital, he was discharged back to Park Manor. Soon after, inspectors cited the home's operators for doing almost nothing to examine his psychiatric history or address his needs, according to a June 1999 state report. But the inspectors never followed up.

That was not out of the ordinary. As with other homes, inspection reports portrayed Park Manor as in disarray, to no avail. At one point, they noted, a college student was volunteering as the home's case manager for all 60 or so residents.

It was a testament to Mr. Ridges that he had been able to turn his life around there. He arrived at Park Manor in 1994 after several psychiatric hospitalizations. After a shaky start, he settled in. In the last year of his life, he focused on everyday issues such as how to budget his paycheck -- his doughnut money, he called it -- so he would not spend it all at once.

But he did have to contend with his roommate. His mother, Hattie Fee Ridges, said that her son often complained that the home would not do anything about Mr. Chapman. Mr. Ridges told her that he had asked for his room to be switched, but had been turned down.

Mr. Lall, their other roommate, said Mr. Chapman often instigated arguments with him and Mr. Ridges. Mr. Lall recalled in an interview how Mr. Chapman once shoved him against a wall and held a knife to him. "He said, `If you don't behave yourself, I'm going to kill you,' " Mr. Lall said.

On a Thursday in June 2000, Mr. Ridges returned from his job and went to his room. He encountered Mr. Chapman and the two apparently argued over rap music, the police said. Mr. Chapman pulled out a brown and gold folding knife. He lunged, stabbing Mr. Ridges more than 20 times in the neck, sternum and arm.

"Me and Greg Ridges didn't get along," Mr. Chapman told the detectives who arrested him.

When Mrs. Ridges did not receive her customary phone call from her son that day, she called the home. An employee told her everything was fine. Wary, Mrs. Ridges went to the home that night, and no one would let her in. Several hours later, police officers showed up at her apartment and told her what had happened.

A few days later, she locked the door to her son's former room in her apartment. To this day, she rarely enters it. "I just can't bring myself right now to part with his things," she said recently. "I miss him."

Nearly two years after the killing, no one in an official capacity has delved into the home's role. Not the State Health Department, which regulates the home, nor the police, nor the Brooklyn district attorney's office, which focused only on prosecuting Mr. Chapman, who was found unfit for trial and sent to a psychiatric facility.

Otis Cue, Mr. Chapman's stepfather, said that he felt great sorrow for Mr. Ridges's family and that he hoped some lessons could be learned that might help prevent violence at the homes. But Mr. Cue added that no officials had contacted him about his stepson's history.

For now, there are only denials.

Park Manor's operator, Simon Halpert, said Mr. Chapman had no history of violence, was well liked at the home and had never caused the slightest trouble. "Anybody and everybody who comes in this door has had a thorough screening," Mr. Halpert said.

He said Mr. Ridges had never asked to have his room changed.

Maimonides Medical Center, which treated Mr. Chapman during his last hospitalization, said it never discharged patients who were a threat.

The only state agency saying it looked into the killing was the Office of Mental Health. It did so, it said, because therapists who worked at a clinic run by the office treated Mr. Chapman at the home. The office said it agreed with Mr. Halpert. It would not release a copy of its investigation, saying it was protecting the privacy of the mentally ill.

"We never had a problem with him in his behavior," Mr. Halpert said of Mr. Chapman. "He was very polite, always polite."

Casualties of Care
Ignoring the Signs Pointing to Trouble

On a spring Sunday in 2000, Ann Marie Thomas began to die at Elm-York, a 286-bed home tucked away near a ramp to La Guardia Airport.

Ms. Thomas, 60, was having chest pains and trouble breathing, according to interviews and records, and the workers there told her to relax. The next day, a nurse who visited the home told Ms. Thomas she was having an anxiety attack. By that night, the vice grip around her chest had tightened.

"She kept saying, `I can't breathe, I can't breathe,' and clutching her chest in pain," said Terry Lipiro, a resident of the home at the time. Several workers confirmed her account.

Until then, Ms. Thomas had been relatively sturdy, the home's hallway Ann Landers, a gush of gossip and advice. Her delusions quelled by medication, she grasped at a normal life, doting on a boyfriend named Harvey, ordering in Chinese food and listening to Elvis Presley.

On Tuesday, Ms. Thomas saw a medical doctor, Mathaiah Ramaiah, who also diagnosed anxiety, and Ms. Thomas received no treatment, according to interviews and records.

"She had these chest pains, and they should have paid more attention to her," said Dhandai Dhanraj, a worker at the home at that time.

By Tuesday night, a roommate, Elizabeth Szalkiewicz, became alarmed and called Ms. Thomas's sister for her.

"I think I'm having a heart attack and they don't believe me," Ann Marie Thomas told her sister, Josephine, on the phone. "I think that I'm dying."

Josephine Thomas said she then called employees at the home, who assured her that her sister was fine.

A short while later, Ann Marie Thomas lay down on the floor of her room and removed all her clothes, hoping to find relief from the sensation that she was suffocating, according to interviews with residents and workers. Ms. Thomas stayed there, naked, and began to feebly pray.

The next morning, Ms. Thomas was found dead of heart failure, still in the same undignified position.

In interviews, executives of Elm-York said workers had closely monitored Ms. Thomas and reported that she was not in distress. They would not say which workers, or provide records detailing when they checked on her. "If there had been chest pains, 911 would have been called," said Robert Amsel, the home's administrator.

Mr. Amsel said the home provided such good care that "less than 10" residents died from 1995 through 2001.

The Times documented roughly 110 deaths of Elm-York residents in that period, largely from death records kept by the Social Security Administration.

After being given a list of those names, Mr. Amsel said that many of them were of people who were no longer residents when they died. He would not say which people he was referring to.

Dr. Ramaiah would not comment.

Josephine Thomas complained to the State Commission on Quality of Care for the Mentally Disabled, the small watchdog agency. She charged that her sister would have lived had she received proper supervision.

Thirteen months later, without interviewing her, the agency told her that it could find no evidence that the home had done anything wrong or that Ann Marie Thomas had ever complained of chest pain.

The commission might have found some evidence if it had examined the report filed by the ambulance workers who responded to the home. "Patient's roommate states that patient collapsed last night, 12 hours ago, but no one at the facility responded to her calls for help until this a.m.," the report said.

In a way, Ms. Thomas's death underscores the most basic shortcomings in supervision and care found by The Times's investigation at many of the homes. Yet she was certainly not alone. John Miller and Randolph Maddix were just two more residents who died unattended after signs of distress were ignored, records and interviews show.

Mr. Miller, 47, a resident of Park Inn in Queens, died of a ruptured gangrenous appendix in 1997 after complaining of pain for three days, according to his brother. The state took no action; his family is suing the home in State Supreme Court in Queens, charging that neglect led to his death. The home's lawyers would not comment.

At Seaport Manor in Canarsie, Brooklyn, even the untrained workers realized that Randolph Maddix was too sick to be there. During his two years at Seaport, ambulances took him to Brookdale University Hospital and Medical Center more than 40 times after he had seizures at the home, according to hospital records.

But whenever the workers said they suggested to the home's administrators that he be sent to a nursing home, the administrators demurred. It would mean an empty bed. And profits always seemed to trump other considerations at Seaport, which the state has long rated one of the city's worst adult homes.

Less than a year after Mr. Maddix entered Seaport, a therapist wrote in his case file that he should be placed in a "more suitable environment" because he was paranoid and refusing to eat.

State inspectors also suspected that Mr. Maddix should not be there. In an inspection report in July 1999, they cited the home for failing to address his problems and send him to a facility with a "higher level of care," but did nothing else.

So Mr. Maddix stayed, and suffered. On several occasions, workers said he had seizures while watching television in the smoking room, then writhed and tumbled to the floor. He broke his elbow. He smashed his face. He bloodied his eye.

"He couldn't do anything on his own," said Andy Cadet, a former Seaport worker. "As time went by, the seizures started increasing, and getting worse and worse."

Seaport's operators would not comment. Last year, after The Times began an investigation of Seaport, the state said it would move against the home, even though it had known for decades about grievous problems there. Last month, the operators agreed to surrender their license, and the state is now considering whether to try to install a new operator or close the home.

Mr. Maddix had had seizure disorder since he was a teenager. One of the few things that gave him pleasure was smoking cigars and drinking coffee on the Coney Island Boardwalk as he stared at the water. But for much of his life, he could barely function.

He occasionally had an aide assigned to him at Seaport during the day, but the aide left before dinner. He was then deposited in his room, where he sometimes suffered seizures alone, in the dark. His roommate, who was partly blind and often delusional, sat by, unknowing.

"There wasn't anybody there at nighttime to watch out for him," said his mother, Mildred Maddix. "There wasn't anybody. Just him and God."

His last visit to the hospital was on Oct. 9, 1999. After a seizure, he was found unconscious in his wheelchair. Dried blood from a finger-length laceration crusted the right side of his face. As always, he was returned to the home.

Less than two weeks later, he went to the bathroom connected to his room in the early evening and had another seizure, falling between the toilet and the bathtub, workers said. He was discovered dead the next morning still next to the toilet.

At Seaport, the discovery of a dead resident was almost routine. The usual practice was followed: the home reported only that Mr. Maddix was found unresponsive and then pronounced dead, never telling the state the full details of what had happened.

As with the deaths of so many other mentally ill residents of adult homes, the state never investigated anyway.