Jones & Jones at 7804 and 7806 Forest Hill Ave. in Richmond is largely shielded from view by a line of tall trees.

It’s been more than 20 years since Michel Burke-Barnes and Margaret Burke last saw their brother. But in that time, they thought and prayed about him a lot. They wondered: Was he okay? Was somebody taking care of him?

They knew he was living at Jones & Jones Assisted Living in Richmond, but little else. They never knew why he left San Antonio so long ago. They never understood why he never wanted to come home.

And when he died at the age of 51 on the morning of July 2 at Jones & Jones, reportedly by his own hand, his death became yet another unanswered question.

But for the Virginia Department of Social Services, Kevin Hammock’s death, along with that of another resident in May, became two of the many reasons for why it decided to revoke Jones & Jones’ license on Sept. 12.

The lengthy list of violations at Jones & Jones reflects not just a facility where residents sometimes die in preventable ways, according to the state.

It is also a window into a system that is meant to act as a safety net for vulnerable people with complicated medical and mental needs, who cannot afford to find a home anywhere else but who too often don’t get the care they need.

And it exposes the limits of state oversight, since nearly 100 people still live at Jones & Jones’ facilities, despite the fact that both the properties and the owner and administrator have had licenses revoked.

WHERE DO THEY GO?

While assisted living facilities are commonly home to elderly residents, many of those who live at Jones & Jones, and the hundreds of similar facilities across the state, are physically disabled, have serious mental illness, or both. They’re often in their 40s or 50s.

This is the second time that Jones & Jones has had a license revoked. The facility has two buildings at 7806 and 7804 Forest Hill Ave., and a separate license for each building. A renewal of a license for the first, where residents complained about filthy conditions, was denied in March, but the facility hasn’t yet closed because the decision was appealed.

The state upheld its decision to deny the first license during an informal conference in April, but it was appealed again.

The same months-long appeal battle seems likely for this second license revocation, as Mable Jones, the facility’s owner and former administrator, appealed the decision Tuesday. She said in a brief interview last week that all the claims DSS sets forth in the hefty, 44-page statement of allegations are unfounded and have not been proven.

Jones lost her license in April, after the Board of Long-Term Care Administrators found she had used residents’ Social Security money to gamble at casinos and go on vacations. Since then, the facility has been operating without an administrator, a violation of Virginia law.

DSS ordered Jones & Jones to “cease operation” because “dangerous conditions and practices exist at the facility such that further delay in closing the facility poses an imminent and substantial threat to the health, safety and welfare of the residents.”

But the notice also outlines the appeal process, which can take months.

State inspections paint a picture of a facility where residents often go without their medication, must share a common supply of clothes, are not given their appropriate monthly allowances designated by the state and sometimes go years without mental health treatment.

It alleges that Jones & Jones failed to comply with numerous laws and regulations and that “this lack of compliance may have resulted in the death of a resident and has adversely impacted the health, safety and welfare” of others.

But many of the claims the state lays before the facility aren’t new. Over at least the past four years, Jones & Jones has racked up several hundred violations from DSS. Those public inspection reports describe a living environment rife with blood-stained linens, soiled sheets, unlabeled medication bottles and bedbugs that skitter across the walls.

And DSS isn’t the only one looking into Jones & Jones. Richmond Commonwealth’s Attorney Michael Herring is also investigating Jones and the facility, along with the Richmond Police Department. A lawyer in Herring’s office would not comment on the investigation.

The long-running violations at Jones & Jones raise a slew of questions about the safety net for Virginia’s most vulnerable residents and the level of oversight over their caretakers.

Why was Jones & Jones permitted to stay open for five months without an administrator, a span of time in which two residents died in preventable circumstances, as the state alleges? Why, after years of repeat violations, has it taken so long for the state to step in and take action against the facility?

Tara Ragland, adult licensing program director with DSS, turned down an interview request for this story.

And perhaps the most pressing question of all: If the state upholds its decision to revoke the facility’s licenses, where will the residents go?

Jones has said in past interviews that 95 percent of the residents at Jones & Jones have a mental illness. Too often in Virginia and other states, people with serious mental illness find themselves cycling between the hospital, the criminal justice system and jail.

Many of the residents at Jones & Jones, where 98 people currently live, have said that it was the only place that would take them. They have stories of hopping around from facility to facility, sometimes violating the rules, possibly due in part to their mental illness.

“Absolutely, we don’t want people living in places like Jones & Jones,” said Anna Mendez, executive director of Partners for Mental Health, a Charlottesville nonprofit. “But at the end of the day, when the Jones & Joneses of the day close, where do they go? And my concern is that they end up on the street, because you only end up at a Jones & Jones because there’s nowhere else for you to go.”

PREVENTABLE DEATHS?

Before Hammock died in July, another resident died on May 7. According to the statement of allegations that DSS sent Jones & Jones in mid-September, the resident’s day program caseworker had called the Jones & Jones staff to tell them the unidentified man needed immediate medical care.

But the staff did not call emergency services and that afternoon the resident collapsed and died.

“A reasonable person, much less trained staff, would have judged the caseworker’s observations, particularly of Resident 1’s breathing, to be indicative of a serious illness or medical condition that required immediate medical attention,” the statement of allegations reads.

In Hammock’s case, the problems that the state outlines aren’t about his immediate medical care before he died. DSS claims that, during the seven years  he lived there, he had 46 psychiatric hospitalizations for paranoid schizophrenia. In many of those cases, he requested to go to the hospital himself.

According to the statement of allegations, “he complained of hearing voices telling him to hurt himself and/or others, thoughts of suicide and thoughts of hurting people before they hurt him.”

DSS says Hammock’s record did not include adequate plans for follow-up care by a qualified mental health professional. A note in his record from March 2017 said he hadn’t had a regular appointment with a psychiatrist since February 2015.

The facility “failed to demonstrate an understanding of its responsibility for ensuring consistent and collective delivery of services for residents who do not possess the ability to reason logically, make appropriate decisions or engage in purposeful behavior,” according to DSS.

He was moved from the 7804 Forest Hill Ave. location to the adjacent one at 7806 Forest Hill Ave. in April. Just moving him there was a violation, DSS said, because the facility accepted him even though it could not provide adequate care due to his known history of “suicidal ideation,” or suicidal thoughts.

Kevin Hammock, in his grandmother’s home in San Antonio, Texas, about 25 years ago. (Photo courtesy Michel Burke-Barnes)

Burke-Barnes and Burke, Hammock’s sisters, still live in Texas, where the siblings had grown up. Though they called Hammock on the phone and sometimes sent him money, they said he didn’t give them a sense that he was not being treated well or that he wanted to come home.

Usually, they said, he would keep their conversations brief.

But still, they worried. And now they say Jones & Jones should have done more to provide care for him.

“I believe they contributed to his death,” Burke-Barnes said.

Jones points to the fact that Hammock did not complain to staff often and that he would usually go to the hospital on his own without their knowing.

“Well, how can you stop somebody from taking their own life?” Jones said.

DSS does regular visits to assisted living facilities, usually once a year when the facility is requesting a new license, but in cases like Jones & Jones — where there have been 18 complaints against the facility in the past four years, the vast majority of them resulting in violations — inspectors visit much more often, usually every few months.

Recently, they’ve been showing up multiple times a month.

In all that time, they evidently didn’t recognize that Hammock was not getting the consistent mental health care he required.

“The inspection process requires a sampling of records,” a DSS spokeswoman said in response to a question on why inspectors never realized Hammock wasn’t getting the necessary care. “Because it is a random sample, licensing staff are not always able to inspect all the records that are on site.”

REGULATORY HURDLES

The regulations that govern DSS do not necessarily make it easy to step in on cases like Jones & Jones.

The state’s inspection rules are set up so that, when considering a facility’s license, inspectors can only look at that license year. It cannot consider previous years, even if the place has been operating for 20 years or more.

That might be a good practice for assisted-living facilities that improve in response to violations, so inspectors can’t use the past against them. But for those like Jones & Jones, where, year after year, repeat violations surface, it limits the state’s ability to consider the bigger picture.

Even if DSS steps in and revokes a license, there are other, massive hurdles that make closing a place down anything but simple. There are a lot of moving parts for the primary agencies, DSS and the Department for Aging and Rehabilitative Services, explained Joani Latimer, the state’s long-term care ombudsman.

She said DSS has been working to monitor Jones & Jones and make sure the residents have their up-to-date assessments, “so that when there’s word of which way this is going, they’ll be ready to move forward.”

The assisted living facility has the primary responsibility of creating a plan of discharge and safe relocation for the residents, she said, “but you can’t always count on that happening.”

Closures only happen a few times a year, she estimated. They can occur either because the facility has had its license revoked or because it is voluntarily closing.

And they’re especially difficult for facilities like Jones & Jones, because there are fewer beds available.

Jones & Jones relies on state funds, known as the Auxiliary Grant program, to pay for its residents. The program gives people who already receive Supplemental Security Income from the federal government additional funds to cover their assisted living stays, though it only provides about $1,200 per month, per resident.

Fewer than 300 of the 580 licensed assisted living facilities across the state accept residents with Auxiliary Grant funding, according to the Department for Aging and Rehabilitative Services, which administers the program.

And of those facilities, some only accept a handful of such residents, relying mostly on private pay. Not all have operations like Jones & Jones, where on average 80 percent of its residents rely on the Auxiliary Grant program, according to DARS.

So there are fewer places to send residents, Latimer said, and sometimes they have to be moved across the state.

‘SOMETHING CHANGED’

 When Hammock was growing up, he and his sister, Burke, were close. They’d play in their grandmother’s backyard, going down to a little creek and catching crawfish.

“But something changed as we got older,” she said.

His sisters were never entirely sure if he really did have schizophrenia, but their grandmother was, they said. She told them that some family members had similar diagnoses. She always worried about Hammock, according to Burke and Burke-Barnes.

And when she died around 2010, they asked Hammock if he wanted to come home. But he didn’t.

Staff called Burke-Barnes and told her that he went to a psychiatric hospital only once during his stay at Jones & Jones, so she thought it happened just that one time, definitely not 46 times.

When he died, Hammock’s remains were mailed back to San Antonio. Burke took them to the cemetery where his grandmother was buried, and poured the ashes over her grave.

“I felt better about that,” she said. “About doing it that way.”