LADDER OF CARE
Types of residential facilities for the aged in Tennessee:
* Nursing home: Room and board, daily living assistance, intermediate to skilled medical care 24 hours a day and often rehabilitation and social programs.
Facilities and beds available:
Hamilton: 11, 1,659
Tennessee: 326, 37,382
* Assisted living: Room and board, daily living assistance plus nonmedical and some medical care, including some medication administration.
Facilities and beds available:
Hamilton: 15, 1,010
Tennessee: 250, 15,219
* Home for the aged: Room and board, daily living assistance.
Facilities and beds available:
Hamilton: 11, 252
Tennessee: 89, 1,623
Source: Tennessee Department of Health: Health Care Facilities
PAYING THE BILL
Average nursing home charge (semiprivate room)
State // Daily // Annual
* Tennessee // $174 // $63,510
* Georgia // 167 // 60,955
* Alabama // 176 // 64,240
* U.S. // 214 // 78,110
Average assisted living charge
State // Monthly // Annual
* Tennessee // $3,494 // $32,328
* Georgia // 2,915 // 34,980
* Alabama // 2,694 // 32,328
*U.S. // 3,477 // 41,724
Source: Metlife 2011 market survey of long-term care costs
As he thumbed through records at the kitchen table of his Ooltewah home Thursday, David Machoka said he had never had any safety violations on his state inspections at Moraa's Assisted Living Home for Seniors.
Machoka and his wife, Agnes, said the six-bed home for elderly women they operate in Collegedale is their ministry.
"Our family ties are so close, and when we grew up in Kenya, we were brought up on the biblical principle to respect your parents," David Machoka said. "As long as they are the age of my father and above, they are my parent. We never neglected anybody. We never abused anybody."
"If we were abusive, we would not have had this place for five years," added Agnes Machoka.
That's not what investigators with the Collegedale Police Department and Tennessee's Adult Protective Services say.
On Tuesday, they charged the Machokas and their employee, Margaret "Maggie" Adhiambo, with two counts each of physical abuse and gross negligence, and six counts each of willful abuse, neglect or exploitation.
The investigation began after family members took 96-year-old Gertrude Moore from the home to a hospital, where doctors found she was dehydrated, had a urinary tract infection and that there were no traces of her required medication in her blood. She had bruises on her legs and ankles where she said a caregiver had shaken her.
Though state law says the home only can accept people who can move on their own and take their own medications, the investigators found that none of the residents fit the criteria. Two had Parkinson's disease, and several were in various stages of dementia. None had the power to get out of the house on their own, as required by fire codes.
Families were called to move the six elderly women residents, ages 66 to 101, to other facilities.
"The [Machokas] cannot care for these patients with these needs. They're not licensed to, they're not trained to," said Detective Kat Cooper with the Collegedale Police Department.
Trudy Mott, the long-term care ombudsman for Southeast Tennessee who was part of the investigation, said the Machokas should have told the families their loved ones needed a higher level of care than the home could provide.
But, she said, "everybody's looking for their dollar. Everybody's trying to keep them in place so they can keep that dollar. ... It's still all about the money."
Families with elderly loved ones sometimes don't have many choices, Mott said.
"Unfortunately, what happens is because most assisted living, all over, is so expensive, people of lower incomes cannot afford it. You end up with a residential home for the aged. The regulations are not as strict."
And, with a graying population, the needs are increasing, she said.
"We need homes that are regulated, we need homes that provide good care, that have the people in place that have the training. With the population growing as fast as it is with the seniors, we're not ready for it."
In Tennessee, a home for the aged may house residents who are ambulatory, mentally aware of their surroundings and able to medicate themselves.
Where assisted living centers offer medical and nonmedical care and nursing homes provide skilled or intermediate nursing care full time, homes for the aged are basically boardinghouses.
Requirements to become a licensed administrator of a home for the aged are simple: have a high school diploma or GED, pass a test, pay a $180 fee and complete 24 hours of continuing education every two years.
No medical knowledge is required for administrator or staff. The state's standards include six pages of specifications for licensing, ownership and administration, and seven pages of requirements for construction and safety standards.
But staff specifications are only vaguely defined: "Each home for the aged shall have an identified responsible attendant and a sufficient number of employees to meet the needs of the residents." There's no definition of what it means to meet residents' needs.
The investigators said Adhiambo, who has no state certification of any kind, was the sole caregiver for the six women.
David Machoka disputed the investigators' findings.
"My wife is there always," he said. "We don't go anywhere. I don't have another job. There's always two or more people there, unless we are running an errand."
The Machokas say they never received any safety violations in yearly state inspections, and never had any complaints of abuse or neglect over the four years they ran the home.
The Tennessee Department of Health did not respond to telephone and email requests Wednesday and Thursday for copies of the home's state inspection reports or to questions whether it has opened an investigation. Late Friday afternoon, spokeswoman Shelley Walker said in an email that the reports weren't available in electronic form and would be provided when she receives a copy from the regional office.
Agnes Machoka said the couple started Moraa's Home, named after Agnes' mother, in 2009. Agnes had been working for Life Care as a nurse when the couple found they could outfit their own small care facility. She is a state-licensed nurse's aide. David Machoka says on a blog that he has a master's degree from University of Phoenix.
Some family members said the couple provided excellent care. For about $2,000 to $3,000 a month, their loved ones got three meals a day, toileting, laundry, bathing and other basic care. That cost is well below the more than $5,000 it costs on average for nursing home care in Tennessee.
Medications were typically provided and packaged by each family, and the caregivers would distribute them according to each family's instructions so the residents could take them.
Mary Barrow, who shares power of attorney for 101-year-old resident Maggie Smart, said finding Moraa's one year ago was a relief after a bad experience at a more expensive nursing home. Prices kept rising there, and Smart's health kept declining.
Once she went to Moraa's, things got better.
"We watched improvements," said Barrow. "She started feeding herself. She started gaining weight. She received very good care. I've been up there at all different times, and I've never seen anything like abuse. I was floored when [the police] called me this week. Maggie was probably just as floored as we were. She's the type who will let you know if she's been mistreated."
Yolanda Cullins said she read all the licensure information for Moraa's Home and studied inspection reports before setting her mother, Queen Crossing, up there.
She knew that her mother, who had Alzheimer's, fell under a tricky category in state law, but Moraa's seemed like a close enough fit. It was very clean, and Cullins liked the Machokas' philosophy about "not throwing our old people away."
"People are desperate. I read the regulations and I knew she was supposed to take her own medicine and things like that," Cullins said. "But I'd rather her be there in a family setting than a nursing center at this point."
But Cullins acknowledged that she saw most of the care was being provided by only one person.
"I do think it is a lot of work for one person," she said. "And I think it would have been better if there was another person there. There were complaints about the way they lifted people, that it should be a two-man job."
Moore's granddaughter, Haley McDonald, said she saw a caregiver roughly hoist an elderly woman out of a wheelchair and throw her onto a bed.
"I started crying, and I didn't even know the lady," McDonald said.
Cooper, the Collegedale detective, said her specialty is child sex crimes, and she sees similarities among those cases and this one.
"It's the ones that are nonverbal, that you can't communicate with, they can't verbalize when abuse is happening to them, and they make the perfect victim," she said.
The difference, Cooper said, is that there aren't as many resources for investigating and responding to allegations of elder abuse.
"After you work a few child abuse cases you find there's a protocol, and there's hundreds of people with resources for children," she said. "But those things aren't as much in place with these types of cases."
The Machokas appear to have made a comfortable living in the four years they've run Moraa's. Their Ooltewah home and about 5.5 acres of land is valued at around $375,000.
They rent the space housing Moraa's at 8616 Apison Pike from Bryan and Jill Giacomozzi. The couple's address is listed as a post office box in Collegedale, and no phone number could be found for them. County property records show the Giacomozzis owe three years of back taxes on the building.
The Machokas and Adhiambo posted $15,000 bonds each after their arrests and face court dates.
Agnes Machoka said they intend to keep the home open.
"We are not giving up. We feel called to this work," she said.
Judy Walton has worked 25 years at the Chattanooga Times and the Times Free Press as an editor and reporter focusing on government coverage and investigations. At various times she has been an assistant metro editor, region reporter and editor, county government reporter, government-beat team leader, features editor and page designer. Originally from California, Walton was brought up in a military family and attended a dozen schools across the country. She earned a journalism degree ...