Early one afternoon in March 2015, an authoritative knock stirred Mark Allen Keeney into answering the door to Room 6 of a motel in southeast Missouri.
A sheriff’s deputy and police chief wanted to know who was with him. They found empty beer cans and two women, both described in a state health report as mentally ill and under the care of a guardian.
The women, in their mid-40s, also were residents of Keeney Country Homes, a state-licensed residential care facility that Keeney owned in the neighboring county.
Before the day was over, Missouri inspectors were wrapping up their investigation. Within a week, the state had revoked Keeney’s licenses to operate that home and another he owned, both in Poplar Bluff, Mo.
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It wasn’t until 18 months later that Keeney, 61, was charged with rape and sodomy. That case was dismissed, but prosecutors refiled in February. He has pleaded not guilty.
Sexual abuse of residents in long-term care facilities, assisted-living centers and nursing homes is a largely hidden problem nationwide.
It hides behind reporting systems that fail to catalog such complaints separately from other forms of abuse that afflict the elderly and disabled. It hides behind business incentives that drive facility owners to conceal abuse.
It hides behind apathy and the reluctance of family, friends and visitors who know or suspect something has happened but don’t want to get involved. It hides behind the failure to believe victims.
“People don’t even think that an older person would be sexually assaulted, would be raped, would be a victim,” said Edwin Walker, once the head of Missouri’s former department on aging and now a deputy assistant secretary at the federal Administration on Aging.
Yet inspection reports, regulatory notices and court documents describe many instances of sexual abuse of long-term care residents. One federal program has cataloged more than 20,000 complaints of sexual abuse at long-term care facilities over 20 years — a rate of nearly three such complaints a day.
That disturbing total, however, is incomplete. It ignores, for example, cases in which one resident sexually assaults another resident.
Truth is, no one knows how much of this goes on.
That leaves regulators, advocates and prosecutors struggling to prevent abuse and respond when it happens.
Missouri regulators reacted quickly and decisively to close Keeney Country Homes.
But care advocates complain that regulators too often fail to do enough in the face of abusive situations and fall short of their obligations to stop abuse in the first place.
In the Keeney Country Homes case, the state notified Keeney five days after the March 21, 2015, incident that it was revoking his license for the facility. A second notice revoking the license for his Maple Crest Residential Care Facility came five days after that. Keeney did not appeal.
According to those letters and an inspection report: Keeney had taken both women, along with their medications, from Keeney Country Homes. Keeney drove around looking for a motel room and picked up a 30-pack of beer. Both women took “several oxycodone pills,” and each had a history of drug or alcohol abuse. At the Leerjack Motel in Ellsinore, Mo., Keeney had sexual intercourse with one and “made” each perform oral sex on him.
In five years, Missouri had revoked licenses for only eight other long-term care facilities, said Dean Linneman, director of regulation and licensure within the Missouri Department of Health and Senior Services.
“This was something very egregious and did place imminent danger to the residents of the facility,” Linneman said of the Keeney case.
Regulators and advocates helped the residents of Keeney’s Country Home relocate to other facilities. That protected the dozen or so residents but also disrupted their lives, something caregivers say can be traumatic. Maple Crest, Keeney’s other facility, stayed open after a quick sale to new owners who operate it under a different name.
Home operators also can be fined for violations and their businesses cut off from Medicare and Medicaid reimbursements as both a financial punishment and incentive to address problems. Missouri has seen an increase in the frequency and amounts of penalties, according to a spokeswoman for the Missouri Department of Health and Senior Services.
But too few homes face such penalties and only in severe cases, said Mitzi McFatrich, executive director of Kansas Advocates for Better Care.
McFatrich said state inspectors in Kansas, who are trained to spot problems that could lead to abusive situations, also fail to meet their own schedule to visit long-term care facilities each year. Visits come roughly every 16 months, McFatrich said. A specific complaint also can trigger an inspection.
The agency is short nine inspectors, said Angela de Rocha, spokeswoman for the Kansas Department for Aging and Disability Services, which is in charge of those inspections. It is a demanding job that requires a nursing license and travel around the state.
“We’re barely holding the line,” de Rocha said.
When sexual abuse is discovered in care facilities, regulators usually take milder actions aimed at preventing further abuse.
Publicly available deficiency reports document that the home violated regulations — “failure to keep residents free from abuse” — and require the operator to offer a plan of correction.
This was the case in 2012 when the staff of a Macon, Mo., care facility witnessed one resident “unclothed, in bed, and on top of a resident with cognitive impairment, in a sexual act,” according to the state’s notice to the facility.
The letter said the staff told each resident’s guardian but “conducted no further investigation” and provided “no further monitoring” of the unclothed resident who “continued to reside at the facility” and “continues to exhibit unwanted attention toward an additional resident with cognitive impairment.”
In Missouri and Kansas, advocates see no legislation in the works that will help stop the abuse.
One Missouri bill would require long-term care facilities to report suspected abuse to law enforcement. But Chad Jordon, of the Missouri Coalition for Quality Care, said the bill would change little and he doesn’t expect it to become law.
Missouri lawmakers debated a bill in 2009 that might have prevented a recent situation in a Marshfield, Mo., nursing home.
In January 2016, the state cited the home because it “failed to provide supervision of one resident, who had a history of inappropriate sexual behavior,” or develop interventions to address the resident’s “inappropriate sexual behaviors toward other residents.”
The bill Missouri lawmakers debated would have required care facilities to run background checks on residents, just as they’re required to when hiring staff. The bill passed but not before being watered down to a voluntary option.
Where regulators fall short, citizens need to step in.
Hundreds of volunteers already visit nursing homes and other long-term care facilities under a federally mandated ombudsman program in each state. Vetted and trained volunteers visit with and advocate for residents.
Barbara Hickert, the program’s long-term care ombudsman in Kansas, said she assigns each of roughly 100 volunteers to specific homes. It’s not enough.
There are about 800 care facilities in the state, which means most never see an ombudsman volunteer. In Missouri, the ombudsman program had 233 volunteers last year to cover 1,144 long-term care facilities.
Even ombudsman volunteers face limits on what they can do. Some victims are unable to say what happened to them because of severe dementia. Others are simply too embarrassed.
“People don’t tell us or tell anyone,” Hickert said. “There’s a lot of abuse out there that goes unreported.”
The upshot is that discovering and confronting abuse is everyone’s job.
It requires citizens to take action, to talk with residents of care facilities, watch for signs of abuse and heed complaints about sexual abuse that too often are dismissed.
Walker, the deputy assistant secretary at the federal Administration on Aging, said it requires citizens to see abuse as a crime instead of a family issue.
Be alert, for the sake not only of loved ones but also for other facility residents who may be left alone.
Citizen action helped unmask Keeney’s motel hideaway.
One of the women he’d taken from Keeney Country Homes used Keeney’s credit card to check into the motel. Then, they overstayed the 11 a.m. check out.
Motel employee Tiffany Voyles dutifully called the phone number the woman had left at check-in. Instead of a cellphone, it turned out to be a business. But Voyles heard a familiar voice at the other end.
“Tiffany, this is Janet,” said a woman Voyles knew from church who happened to be at work — at Keeney Country Homes. Something was wrong. Voyles called the sheriff.
Donna Norviel, a nurse who worked at both of Keeney’s care facilities, at first assumed the resident had stolen Keeney’s card. Then she sent her husband to find out.
Was Keeney’s car there?
It was, and Derick Norviel told law enforcement what they might expect to find inside Room 6.
The incident still haunts Donna Norviel, whose voice broke as she spoke about that day.
“It’s been over two years, and it’s like it was just yesterday,” she said.
Tracking sexual abuse of long-term care residents remains an unfinished job.
Extensive abuse data is collected by the Centers for Medicare & Medicaid Services, but it doesn’t track sexual abuse as a separate category.
The most specific data available come from the 50 state ombudsman programs and are collected by the Administration for Community Living in Washington, D.C. This was the source of the 20,000 complaints of sexual abuse in the last 20 years.
But that doesn’t include resident-on-resident abuse, which is obscured within a larger category of abuse between residents.
That means the 20,000 figure misses cases such as a 2013 incident at a Linn, Mo., facility.
A female resident said a male resident “forced himself on me” after she’d told him to stop, according to a state notice sent to the facility. It said a hospital assessment found “signs of trauma, including vaginal bleeding,” and the male resident was taken into police custody. Still, when he returned to the home, the staff “did not take any action to ensure the safety of other residents,” the state notice said.
Other cases aren’t reported because an ombudsman has respected a victim’s wish not to pursue a complaint. Federal law exempts a volunteer from the mandatory reporting requirements that cover nurses, caregivers, administrators and others.
Walker said the data fail to give a true measure of abuse.
“Until we can get that nailed down, we can’t effectively determine the best interventions and best approaches to preventing the problem, or getting the necessary resources to respond to the problem,” he said.
A solution may be at hand by the end of 2019.
The Administration for Community Living is working on a more uniform reporting system for state agencies. Called National Adult Maltreatment Reporting System, it would create more complete data totals nationally and include totals for sexual abuse.
While regulators moved quickly against Keeney, criminal prosecution stalled.
With a deputy on the scene, the Carter County sheriff’s office investigated, talking with Keeney and both women, as well as their guardian.
Records show the women were sent to a nearby hospital and to forensic interviews, which can help establish evidence when a victim is mentally impaired or a child.
The case landed on the desk of Carter County’s part-time prosecutor. Ernie Richardson had the case until his retirement in June 2016. It is not clear why he did not bring charges, which waited until his successor was named last fall.
In contrast to the Keeney case, law enforcement often never learns about sexual abuse complaints.
In 2012, a resident of a Moberly, Mo., care facility reported being raped by another resident. Facility staff had received the complaint but failed to put interventions in place and “failed to notify law enforcement of the allegation,” the state’s notice to the facility said.
Facility owners with a regulatory problem face strong financial incentives to avoid triggering a criminal investigation, said Paul Greenwood, head of the elder abuse unit of the San Diego County, Calif., district attorney’s office.
For starters, it’s bad for business to call the police.
“They don’t want the black-and-white unit sitting in their parking lot,” Greenwood said.
He said a criminal case also can stoke an owner’s fears of a costly civil lawsuit.
“I’m very concerned that crimes generally are occurring in facilities that never ever get to traditional law enforcement. Something has to be done,” Greenwood said.
Greenwood was among the first prosecutors in the country to specialize in elder abuse. Others around the country followed.
In 2006, an abuse scandal at a Newton, Kan., group home for adults spurred the creation of the Kansas Attorney General’s Abuse, Neglect and Exploitation Unit.
After years of collecting statistics on abuse of children and adults, the attorney general last year persuaded lawmakers to let state prosecutors focus on investigating and prosecuting adult abuse. In its last fiscal year, the office counted 360 instances of adult abuse. The reports do not separately track sexual abuse of adults.
The attorney general tried but failed to get the Kansas Legislature to pass a law prohibiting caregivers in long-term care facilities from having sex with residents, regardless of the person’s ability to give consent.
Missouri law prohibits an owner of a skilled nursing facility from “sexual conduct” with a facility resident.
Last March, the U.S. attorney’s office in Kansas announced the creation of a federal task force on elder abuse.
The task force is meant to bring together federal, state and local law enforcement, along with social services agencies, to combat “grossly substandard care” in nursing homes. It is one of 10 such task forces the Justice Department created around the country.
But more than a year later, the Kansas-based task force has yet to bring a case.
Carter County is on its second attempt at prosecuting rape and sodomy charges against Mark Keeney from the March 2015 incident.
The first charges were filed last September by the new county prosecutor, Amanda Oesch, who has declined requests for an interview.
At a preliminary hearing in January, one of the women testified that she had sex with Keeney because she was afraid to say no, according to the Daily American Republic newspaper in Poplar Bluff. It said Oesch’s complaint had charged that the woman “was incapable of consent because of a lack of mental capacity,” but that Oesch changed it during the hearing to “forcible compulsion.”
On Feb. 7, Associate Judge Michael Ligons dismissed the charges, finding insufficient evidence of forcible compulsion. The file has been removed from public records.
Oesch refiled charges eight days later. The new complaint again charged Keeney with sodomy and rape “by the use of forcible compulsion.”
In court Thursday, Keeney pleaded not guilty. He is scheduled to appear in court again May 18.
Symptoms and signs of sexual abuse
New difficulty sitting or walking
Torn, stained, bloody clothing, especially undergarments
Bruises, particularly in inner thigh, genital areas
Unexplained genital infection, vaginal or anal bleeding
Unexpected agitation or withdrawal from social interactions
Unusual behavior or stress when near a specific person