Abuse charges against four eldercare workers underscore gaps in state oversight

by Bryant Furlow

Four New Mexico caregivers have been criminally charged for abusing elderly residents at assisted living, group home and home care facilities in Rio Rancho, Las Vegas and Santa Fe, following investigations by the state’s Department of Justice (NMDOJ). 

In three of the cases, the alleged assaults were caught on video. Such dramatic evidence of alleged eldercare abuse is rare, one national expert told New Mexico In Depth on Wednesday, adding that abuse often goes unreported and unaddressed, in part because there are gaps in oversight of such facilities. 

The four defendants are Salomon Sanchez, 20, a worker at Community Options, Inc.’s facility in Santa Fe; Lee Carrizales, 64, an employee at Pacifica Senior Living in Santa Fe; Edwards D. Bonilla-Aguinada, 34, of MorningStar of Rio Rancho Assisted Living; and Linda Romero, 52, a paid home caregiver who allegedly repeatedly struck a developmentally disabled patient in front of witnesses, according to court filings.

Each of the four is charged with abuse of a resident, a petty misdemeanor punishable with up to six months in jail. Two of the facilities told New Mexico In Depth on Wednesday the charged employees had been fired. 

“These charges send a clear message that abuse of vulnerable New Mexicans will not be tolerated,” Attorney General Raúl Torrez said Tuesday in a press release. 

The NMDOJ disclosed videos of two of the incidents, involving Sanchez and Carrizales, but did not publicly release video of Bonilla-Aguinada’s alleged assault of an 89-year-old woman with Alzheimer’s, out of sensitivity for the victim, who had soiled herself, according to spokeswoman Lauren Rodriguez. The incident with Romero was not recorded. 

On May 11, 2024, two videos — one taken shortly after the other at Community Options, Inc.’s Camino Esquina group home for people with developmental disabilities, in Santa Fe — show a person identified as Sanchez slapping, grabbing and shoving a wheelchair-bound resident. At one point he grabbed the resident from behind, forcing their head down.

“No one’s taking you to the bathroom, fool – no one,” he can be heard saying in the video. “Play with your toys. No bathroom!”

In a May 5, 2024 video taken at MorningStar of Rio Rancho Assisted Living, which was not released by NMDOJ, a person identified as Bonilla-Aguinada is seen aggressively forcing an 89-year-old resident with Alzheimer’s to disrobe after soiling herself, according to a NMDOJ court filing: The defendant pushed the victim onto the bed, snapping her head backwards, then aggressively removed her clothes, forcing the victim off the bed and onto the floor.

Pacifica’s caregiver, Lee Carrizales, is charged with verbally assaulting two different residents on January 4, 2024. A video of the first incident shows a person identified as Lee yelling in the face of one resident who was sitting in a wheelchair at Pacifica’s Memory Care Unit. “Stop your (expletive) crying already, stop it!,” Lee can be heard yelling. “You’re on your own now, I’m not dealing with you anymore!” A second video shows Lee yelling and cursing at another resident in the Memory Care Unit, later that day. The first victim could not recall the incident and “seemed confused,” according to NMDOJ court filings; the second victim told an investigator she was scared of Lee.

“[S]omeone who is not going to be able to remember or is not going to be able to communicate well, is a prime target,” Richard Mollot, executive director of the Long Term Care Community Coalition (LTCCC), a New York-based patient advocacy group, said in a telephone interview Wednesday. 

Community Options and Pacifica have been sued by residents and their families, court records indicate. In an April 9, 2024 news story in the Santa Fe New Mexican, family members of another Pacifica resident described living conditions at the facility as substandard, alleging, the paper wrote, “constant staff turnover and a lack of medical care.” 

The publicly released videos are “horrific,” Mollot said. 

Mollot has testified before Congress on elder care, including testimony given before the Senate Special Committee on Aging in January. The committee’s hearings focused on quality of care, patient safety, and the assisted living industry’s lack of accountability or federal regulatory oversight. 

“It’s a nightmare to be in a situation like that,” Mollot said. “Living at these facilities, you are vulnerable and count on people that are paid and that are trained.”

The situation is worse at assisted living facilities than more regulated skilled nursing homes, Mollot noted. The federal government requires regular inspections of nursing homes. But no such requirements for assisted living centers exist, meaning oversight falls to states.

New Mexico has struggled to fill that gap. A New Mexico In Depth review of complaint investigations, inspection reports, and court filings for 215 facilities with nearly 6,000 beds found that many assisted living centers across the state have fallen short of the mark on resident safety, and instances of neglect and delayed medical attention are prevalent.

An agency spokesman told New Mexico In Depth in March the Division of Health Improvement is tasked with inspections when a new facility applies for a license or when ownership changes hands, or to investigate complaints. The division also requires facilities to report critical incidents, which then spur investigations. 

But unlike their approach with skilled nursing homes, state inspectors do not conduct regularly scheduled onsite compliance inspections of assisted living centers. 

Administrators at Pacifica Senior Living in Santa Fe and defendant Romero, the paid caregiver accused of striking a developmentally disabled patient repeatedly in front of witnesses, could not be reached for comment. 

A spokesperson for MorningStar said in an email that immediately after learning of the assault, the facility investigated, and fired Bonilla-Aguinada the following day.

“When in July the [state] Department of Justice called our executive director as part of its continuing investigation, we cooperated fully,” the spokesperson said. “There is no higher priority at MorningStar than that of resident safety and quality of compassionate care.”

Noemi Rivera, New Mexico state director for Community Options, responded to an email from New Mexico In Depth, writing that the company is “committed to providing safe and supportive housing for people with disabilities and has a zero-tolerance policy for abuse or mistreatment of any kind.” 

“Upon learning of the incident, the employee was immediately suspended and subsequently terminated,” Rivera’s email stated. “We are fully cooperating with authorities to ensure that justice is served.”

But changing systemic problems at eldercare facilities can require more than firing an abusive caregiver, Mollot emphasized. “You have to go up the chain of command because that’s what is going to make a difference,” he explained. “Too often, we see something horrific and they get rid of an employee, but that doesn’t solve the problem by itself. What helps address the problem is when you are actually going after the operator [administrator]. They have ultimate responsibility.”

For now, the NMDOJ is focusing on prosecuting the defendants for their behavior, not pursuing additional investigations into their employers, according to Medicaid Fraud and Elder Abuse Division Director Joseph Martinez, in a phone call Wednesday. 

It’s also crucial that the state conduct unscheduled on-site inspections at eldercare facilities, Mollot said.

“There’s nothing more important,” he told New Mexico In Depth. “It’s critical that you have inspectors coming in, in a way that it’s not predictable for the provider, because you want to see what is going on there. You don’t want it to be sugar coated or problems including abuse or neglect being covered up — and we know those happen.”

The NMDOJ separately charged a fifth caregiver of abuse earlier this year, Rodriguez said. She did not have the details before New Mexico In Depth published this story. 

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Abuse charges against four eldercare workers underscore gaps in state oversight