From late 2006 to early 2009, the state Health Department found more than 830 violations at residential care group homes for the mentally ill and elderly, according to a joint investigation by the Tulsa World and The Oklahoman.
Violations include 30 cases of inappropriate medical care and 24 cases of client abuse or neglect, four involving the death of a resident.
Inspectors documented residents who were covered in feces, stolen from, or left to sleep on dirty mattresses.
Some were supervised by felons. Others lived in buildings infested with ants, cockroaches and mice.
At least two people were allegedly raped.
During an inspection in late 2006, a developmentally disabled woman living at Prague's Royal Living Care Center told a state official she didn't like three of the home's male residents.
One hurt her the previous night, she said.
"Hits me. Hurts me. Hurts me," she said, pointing to her crotch. "I don't like it when he hurts me there."
The home's administrator said she had seen the resident with a lot of the home's men. She called the girl "easy," reports state.
"I suspect some of them were even doing anal sex to her because she acts like she's in a lot of pain the way she can't sit still and rocks back and forth," the administrator said.
That evening, the Health Department removed the girl from the home.
Officials from the home declined to comment.
‘Oversight is really critical'
The state inspects residential care homes once every two years. That's not enough, said Tamie Hopp,director of government relations and advocacy for Voice of the Retarded, a national non-profit organization.
"These are folks who are the most vulnerable in our society, and the oversight is really critical," Hopp said.
Dorya Huser, the state Health Department's chief of long-term care services, said the standards, including the frequency of inspections, are set by state law.
"It (a change) would have to be motivated by a legislator or request," Huser said.
To qualify for a residential home, a person must be ambulatory and able to live without routine skilled nursing care. Injections or frequent assessments are given, however.
"A lot of times, it's a medication issue," said Mary Fleming, director of surveys for the state Health Department. "They should be essentially capable of managing their own affairs. If (the homes) maintained the population they ought to have, it wouldn't be a big thing."
‘To be protected'
During the nearly three-year span studied by the World and The Oklahoman, at least three people died after wandering away from Oklahoma residential care facilities, the papers' investigation found.
In one instance last year, an 82-year-old man, prone to hallucinations, climbed out of his window at Early Autumns Residential Care Homein Stillwater before falling off a cliff and dying face-down in a nearby creek.
The home failed to properly care for the man, Health Department reports state.
The man's family members said they placed him in the home because they thought it was an assisted-living center, and they wanted 24-hour supervision.
"I took him there to be protected," a family member told inspectors.
Sharral Tye,Early Autumns administrator, declined to comment.
Others died in similar instances, records show:
In April 2008, 19-year-old William Eugene Hurst, a resident of the now-closed Green Country Residential in Fairland, was hit by a truck and died after he wandered from the facility. Hurst was mentally ill and had previously walked away from the home seven times in 37 days. Owners of the home — Greg and Cindy Bedford — gave up the license and agreed not to open a residental care home, officials said. In April 2009, the couple were cited for operating unlicensed residential homes in Ottawa and fined $6,750. The couple couldn't be reached for comment.
In May 2008 a 54-year-old schizophrenic resident wandered away from Edna Lee's Residential Care in Vinita. He was found seven days later dead from dehydration.
A male resident died in 2007 after officials at North Fork Residential Care in Checotah failed to treat his infection.
"The cause of death was felt to be directly traceable to his sepsis and shock," a Health Department report states.
State law requires the state Health Department to be notified when a person in a residential care home goes missing, dies or is assaulted.
But that doesn't always happen.
In one instance, Green Country Residential failed to notify the state after a resident ran away on five different occasions, according to inspection reports. The home also failed to notify the state of four resident-on-resident assaults, an incident in which a resident hopped a fence of a nearby child-care center into the play area and when a resident punched a window, cutting herself, after she was threatened with eviction.