Man's death at group home illustrates challenges of meting out justice when suspect has intellectual disability

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Herbert “Herbie” Rohloff wasn’t expected to live to 53 years old.

He was born with Down syndrome, and doctors said they did not think Rohloff would survive past his second birthday, according to relatives. As a teen, he wasn’t expected to make it to adulthood. As he reached middle age, his brother worried that the biggest threat to his life was the busy intersection outside his group home in the West Rogers Park neighborhood.

But his family never thought his life would end violently. Last October, a fight with another resident over Halloween candy turned physical, and two weeks later Herbert Rohloff was dead. Chicago police closed the homicide case by exception, meaning detectives know who committed the killing but aren’t pursuing charges because of the person’s mental capacity, said Anthony Guglielmi, spokesman for the department, in an email. The Cook County state’s attorney’s office declined to comment.

The homicide case, among hundreds in Chicago last year, was complicated from the start because of the suspect’s intellectual disabilities. The legal community has discussed for years how to mete out justice in such cases. Now an approach known as an individualized justice plan is gaining some traction as a way to hold people with intellectual disabilities accountable while providing alternatives to traditional forms of punishment. Last year, Illinois lawmakers agreed to create a task force to look at the issue.

Charging people with intellectual disabilities can be complex because it’s unclear whether they could formulate the intent to kill, said Hugh Mundy, an associate professor at the John Marshall Law School.

“Every criminal (offense), or virtually every criminal offense, required a mental state in order to prove the element,” Mundy said. “It’s not just the act itself.”

Rohloff’s brother, Michael, and his sister-in-law, Maria, have been grappling with who should be held accountable. They described him as someone who liked to eat fried chicken, listen to Prince and watch “Rocky” movies. They’ve filed a wrongful death lawsuit against Lutheran Social Services of Illinois, the organization that runs the group home where Herbert Rohloff spent his entire adult life.

“You know, I don’t think it serves a purpose for (the person of interest) to be put in jail because he will not understand,” Maria Rohloff said. “But he needs to be put where he can’t hurt anyone else.”

‘Killed over a candy bar’

Last November, Michael Rohloff got a call from his mother telling him Herbert Rohloff had been hospitalized in Evanston. He found his brother struggling to breathe, with a black eye and bruises to the head, Michael Rohloff recalled in an interview with the Tribune.


Michael Rohloff holds a childhood photo of his brother, Herbert, at his home in Indian Head Park. Michael said his brother "looked just like this except with a snowy white beard" when he was killed in 2017 by a fellow housemate at a group home. (Stacey Wescott/Chicago Tribune)

“He looked at me, his face lit up, like it always does, and he was like, ‘Michael,’” he said.

The last thing Herbert Rohloff told his brother was that his ribs hurt. He would spend the next few weeks at Presence St. Francis Hospital in Evanston, heavily sedated, before he died. He suffered his injuries Oct. 31 when another resident beat him up over Halloween candy, but he wasn’t taken to the hospital until the next day, according to the family and reports from Chicago police and the Cook County medical examiner’s office.

An autopsy determined Herbert Rohloff died Nov. 16 from complications of multiple injuries and from congestive heart failure, according to the Cook County medical examiner’s office. He had rib fractures and multiple injuries to his spine.

“You know, it’s ridiculous,” Michael Rohloff said. “Of all the things, I was sitting there worried about him living too close to Devon and Western because the traffic is hectic, and (there are) so many strangers in the area. And you essentially get killed over a candy bar.”

‘It’s not about pointing fingers’

There aren’t data on how many people with intellectual developmental disabilities have been charged with serious felonies, but The Arc, a national advocacy organization for people with disabilities, is trying to get funding to fill that void in research, said Leigh Ann Davis, director of its criminal justice initiatives.

There have been cases of those with intellectual disabilities being prosecuted for, and being victims of, serious crimes, Davis said. That’s why it’s important for police agencies and the courts to understand the needs of those with disabilities, she said.

“What we’ve seen happen is that law enforcement (officers) don’t decipher that there is a difference, necessarily, between people with mental illnesses and intellectual developmental disabilities, and how that’s important because they may need to provide different services for someone or they may need a different referral depending on what type of disability the person has,” Davis said. “And the more that they (officers) know about the person’s disability, the more likely they can de-escalate a situation.”

In Illinois, advocates for those with intellectual disabilities are working with local prosecutors to find a middle road that provides alternatives to traditional criminal punishment. Amy Newell, executive director for The Arc’s branch in Rockford, said the group is pushing for courts to use personal justice plans that lay out the person’s diagnosis, limitations and recommendations.

“It’s not about pointing fingers, shaming people or any of that,” Newell said. “It’s about having an open conversation and really doing what’s best and safest for everyone.”

Last year, lawmakers created a task force to examine how those with disabilities are confined in jails, how they are represented in criminal cases and how police interact with them.

Michael Rohloff said he was worried about his brother, Herbert, living near a busy Chicago intersection. His brother's fatal beating over Halloween candy was shocking. (Stacey Wescott/Chicago Tribune)

In Herbert Rohloff’s case, police believe a resident of the group home caused the injuries and the person was taken to a local psychiatric facility for treatment, said Guglielmi, the police spokesman. Police aren’t moving forward with any criminal charges because of the person of interest’s mental capacity, he said in an email.

Cook County State’s Attorney Kim Foxx’s office did not return multiple requests for comment.

Mark Heyrman, a clinical law professor at the University of Chicago Law School, said not pursuing charges in the case was probably a wise choice, because it would be difficult for prosecutors to secure a conviction if they couldn’t prove the person of interest comprehended what he did.

“He may have a limited understanding of what actually happened,” Heyrman said.

Herbert Rohloff, who had Down syndrome, was beaten during a dispute over candy by a fellow resident of their group home in Chicago's West Rogers Park neighborhood. (Stacey Wescott/Chicago Tribune)

A family seeks justice

The Rohloff family suspects a worker supervising the residents was preoccupied giving another resident a bath when the fight unfolded, said Craig Hoffman, an attorney representing the family. Even so, the family isn’t sure why Herbert wasn’t taken to the hospital the same day he was injured. In the lawsuit against the home, the family notes that Herbert Rohloff was taken to the hospital the next day and in a private vehicle by a worker rather than in an ambulance.

The home where Herbert Rohloff lived, in the 6200 block of North Artesian Avenue in West Rogers Park, remains open, according to a statement from Lutheran Social Services of Illinois. It opened in 1983, and many of the residents have lived there since then, according to the statement.

“At Lutheran Social Services of Illinois, we consider the people who live in our CILA (Community Integrated Living Arrangement) homes family, so of course we mourn the loss of any of these individuals as that of a family member,” the statement read. “Legally, the Illinois Mental Health and Developmental Disabilities Confidentiality Act precludes us from divulging any information on our residents.”

The civil case remains pending, and the family expects it could take years before it’s concluded.

Holidays and birthdays without Herbert Rohloff keep coming and going. This summer, Michael Rohloff had the words “my favorite” tattooed on his arm in the same font used in the “Rocky” movies.

Herbert Rohloff stopped intellectually developing when he was 5, and he couldn’t express himself beyond simple sentences. “My favorite” was something Michael Rohloff often heard his brother say, and “Rocky” was one of Herbert’s favorite movies.

Michael Rohloff also has found himself regularly wearing the T-shirt that he wore to the hospital the day his brother died.

“It’s odd what you connect and stay with,” he said as he teared up. “I was wearing this shirt when he passed, and I was just saying today, ‘I’m never going to get rid of this shirt.’”

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Man's death at group home illustrates challenges of meting out justice when suspect has intellectual disability

Randolph killing underscores dilemma for nursing homes

The Randolph nursing home where Walter D. Rice Jr. is accused of killing his roommate.

RANDOLPH — Walter D. Rice Jr. was growing increasingly aggressive and paranoid.

Throughout the summer, the burly, 58-year-old nursing home resident, who suffered from brain damage as well as dementia, complained that a friend was trying to kill him and rape his wife. He yanked pictures off walls, smashed glass, and wandered into other residents’ rooms, taking their food and belongings.

A nurse practitioner prescribed mood-stabilizing medication, which seemed to help for a while, state records show. But then the staff at CareOne at Randolph neglected to give him the drugs for an entire month, setting the stage for tragedy, according to inspection reports from the Massachusetts Department of Public Health.

Rice allegedly beat his 86-year-old roommate over the head with a heavy ceramic flower pot as the victim lay in bed on Sept. 5. James Schappell, an Army veteran who served in the Korean War, died the following day of severe head trauma.

Now, Rice is facing a murder charge, something his wife said is unfair. The nursing home is to blame, she said.

“They didn’t take care of him,” Regenia Rice said Friday before her husband’s arraignment. “He doesn’t deserve this.”

The case marks the second time in two years that CareOne has faced sharp criticism after a younger resident killed an older one at one of its Massachusetts nursing homes. The New Jersey-based company declined to comment on the specifics of the Randolph homicide or an earlier one in Lowell, but said in a prepared statement that the safety, security, and well-being of its residents are a priority.

The deaths highlight a troubling nationwide pattern of violent and sometimes deadly confrontations between nursing home residents, among them cases in which younger, stronger men attack and sometimes kill their older, more frail roommates. The attacks frequently involve people suffering from dementia or mental illness, separated by generations and living in close quarters with each other.

In North Carolina, an 89-year-old resident died after being attacked in August by a 50-year-old. In Baltimore, a 61-year-old fatally beat an 84-year-old last year. And in Houston, a 56-year-old with a mental illness bludgeoned his two roommates — 77 and 51 — with a wheelchair armrest three years ago, killing them both.

James Schappell, who was killed by his roommate at a Randolph nursing home, in a Facebook photo with one of his daughters.

State and federal regulators say fatal encounters between residents at nursing homes are rare, but reports of violent encounters between nursing home residents in Massachusetts are on the rise at a time when the number of younger, stronger residents is also climbing. Researchers say the true number of violent incidents involving residents under the age of 65 is impossible to know, because government agencies don’t track them.

“This is a taboo topic, because the industry doesn’t want to talk about patients with serious mental disease, like Alzheimer’s, harming each other,” said Eilon Caspi, a Minnesota researcher who has spent more than a decade studying confrontations between nursing home residents in the United States and Canada. He said the lack of reporting is a major public health problem.

“I know of a lot of incidents where the family was told your father fell, and a closer look reveals one resident was pushed by another resident,” Caspi said.

In fact, the US Health and Human Services inspector general’s office recently warned that nursing homes are failing to report a significant number of assaults on residents that resulted in someone getting treatment at a hospital emergency room.

Caspi reviewed 100 fatal encounters between nursing home residents over the past three decades and found the attackers were, on average, about nine years younger than their victims. In all of the cases, at least one of the residents had dementia.

Nursing home leaders say they face a daunting task, expected to provide care for a growing number of patients with drug addictions and other complex needs while state funding has not kept pace. Tara Gregorio, president of the Massachusetts Senior Care Association, an industry trade group, said nursing home administrators “consistently engage in abuse prevention training,” including how to minimize resident-on-resident abuse.

“Nursing facilities are increasingly being asked by hospitals and physician organizations to care for a younger population with significant needs,” Gregorio said. “With fewer resources, this is an emerging and critical issue for our members.”

Elder advocates have increasingly raised concerns about much younger residents with mental health problems being admitted to nursing homes that do not have adequate staff and training to sufficiently care for them. In Massachusetts, 13 percent of nursing home residents are now under the age of 65, up from about 10 percent a decade ago. The increase is modest, but, in a challenged industry, many nursing home staffs feel overburdened already.

“Facilities are admitting residents that they simply don’t know how to meet their needs, especially younger residents who have mental health issues. That’s an underlying root cause” of many resident altercations, said Amity Overall-Laib, director of the National Long-Term Care Ombudsman Resource Center, which helps state ombudsman programs track complaints about nursing homes.

In Massachusetts, the number of resident-on-resident incidents reported to the state has declined — from 2,070 in 2012 to 1,836 last year — but the number of incidents involving more serious outcomes is growing. Confrontations ending with broken bones increased from 13 in 2012 to 20 last year. The number of sexual incidents rose from 64 in 2012 to 79 last year, while confrontations in which one resident inflicted pain on another jumped from zero reported incidents in 2012 to 32 last year.

Unfortunately, state officials do not track the ages of the attackers.

The state’s data show no deaths reported from resident confrontations during the past five years, except for 2015. In that year, state public health officials indicated there was at least one and perhaps as many as five deaths, but declined to disclose how many, saying it would violate patient confidentiality to do so.

Caspi, the Minnesota researcher, said regulators need a system for tracking such cases, because “if you really want to tackle this phenomenon, you need to capture it.”

David L. Ryan/Globe Staff

Regenia Rice (above), the wife of defendant Walter Rice, was in Quincy District Court on Friday for a hearing on the case.

The experience at CareOne facilities in Massachusetts in recent years, which includes two homicides and a rape, suggests that resident-on-resident violence is a serious challenge, and that staffs struggle to manage the outbursts.

An inspection report by Massachusetts regulators detailed a July 2015 episode in which a 41-year-old resident of the CareOne facility in Lowell knocked 66-year-old Anthony Mazzurco to the ground, striking his head on the floor. Mazzurco died hours later. The report indicates that, after Mazzurco struck his head on the floor, staff waited 85 minutes to notify a doctor. Regulators found that CareOne at Lowell repeatedly failed to properly supervise residents, including Mazzurco and the resident who pushed him. Both residents were “known to have behavior issues and had previously engaged in physical altercations,” according to investigators’ findings.

After Mazzurco’s death, the Centers for Medicare & Medicaid Services imposed a fine of $109,396 on the Lowell facility for a list of failures, including providing substandard care and a critical delay in notifying a doctor.

Separately, CareOne paid a $92,077 fine for failing to investigate allegations of sexual abuse and to prevent the rape of one resident by another at the same Lowell nursing home this past February.

In that case, a resident diagnosed with HIV, schizophrenia, dementia, and bipolar disorder was accused by his roommate of forcing oral and anal sex on him, according to state documents. The documents noted that the alleged attacker had also been accused of sexually assaulting two other residents last year and had frequently been observed masturbating in his room while watching pornography.

In a statement to the Globe, CareOne said accusations in the state’s report that staff waited 85 minutes to notify a doctor about Mazzurco’s head injuries were “inaccurate and false.” It also contested the accuracy of the state findings after the investigation into the alleged rape, but did not elaborate.

State health inspectors cited CareOne at Randolph for numerous failings after Schappell’s death last month. He leaves three daughters, nine grandchildren, and 11 great-grandchildren. He raised his family in Lawrence Township, N.J., where he owned a service station and was an avid bowler, according to his obituary.

State inspectors indicated that Rice had been aggressive and agitated for months prior to the attack. He underwent a psychiatric evaluation at a hospital in December 2016 because he was suffering from hallucinations and paranoia and tried to jump out a window, according to records. The following month, he was readmitted to the Randolph nursing home, where he failed to get adequate care as he became increasingly aggressive and agitated, state inspectors found.

On Aug. 6, mood-stabilizing medication that Rice had been taking for a month, resulting in an improvement in his behavior, was “stopped in error,” according to documents. Rice did not get his prescribed a medication again until Sept. 5, just 20 minutes before he attacked his roommate, state inspectors found.

State officials faulted CareOne for failing to give Rice medications and for not providing adequate services or monitoring his escalating behaviors in the month before the attack. Federal regulators have yet to determine financial penalties for CareOne as a result of Schappell’s death.

Barry Chin/Globe Staff

Walter Rice was arraigned Friday at Morton Hospital in Taunton, with defense attorney James Murphy at his side.

Timothy Hodges, chief strategy officer for CareOne, which runs more than a dozen nursing homes in Massachusetts, declined to comment on allegations that staff neglected to give Rice his medication, citing patient privacy. But he said the company follows industry best practices and state and federal guidelines.

“We are deeply saddened by this recent incident, and our thoughts are with the families of those affected as well as our residents, our dedicated staff, the entire CareOne at Randolph community and all those coping with the realities of dementia,” Hodges said in a statement.

Nursing home companies are rarely criminally prosecuted for failing to protect residents from violence, said David Hoey, a Reading attorney who has represented families in civil lawsuits against nursing homes for more than two decades. He said prosecutors often are reluctant to pursue abuse, neglect, and related charges against nursing homes, given the complexity and cost of such cases.

“A lot of these nursing home companies are out-of-state companies, so now you are in federal court and it’s a major production,” said Hoey.

In most fatal resident altercations, prosecutors don’t pursue charges against the attackers either, usually because the attacker suffers from dementia or mental illness and is not competent to stand trial.

But the Norfolk district attorney’s office is pursuing murder and assault charges against Rice, who was arraigned Friday in his bed in the intensive care unit at Morton Hospital in Taunton because he was deemed too ill to appear in court He kept his eyes closed and never spoke as a court clerk read the charges and entered not-guilty pleas on his behalf.

Attorney James Murphy stood beside his client and told a judge that Bridgewater State Hospital had declared Rice competent to stand trial after a mental health evaluation, even though paperwork provided by staff appeared to contradict that finding. He said a doctor’s report indicated that Rice does not have and never will have “rational or sufficient understanding of court proceedings in this case.”

Rice, who has no prior criminal record, has not been the same since he was diagnosed with a brain tumor at age 50, according to his wife. The man charged with killing his roommate, she said, “This isn’t him.”

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Randolph killing underscores dilemma for nursing homes

State: Nursing home’s failure to ‘provide adequate care’ led to beating death

BUFFALO, N.Y. (WIVB) — The New York State Department of Health cited Emerald South Nursing and Rehabilitation Center for failing to provide adequate care to its residents, specifically, the 84-year-old dementia patient who beat Ruth Murray to death last August.

Those are regulations are in place to keep residents, like the 82-year-old Murray safe.

Instead, the department of health says the nursing home’s negligence is the reason Murray was attacked after wandering into the man’s room on Aug. 26.

As a result of its investigation, the state leveled its stiffest fine — $10,000 — against the facility.

News 4 is not naming Murray’s attacker because he was never charged with a crime.

Mike Scinta, of the Brown Chiari law firm, represents the Murray family.

“What we see here is they failed both residents,” Scinta said. “They failed not only Ms. Murray, who suffered the fatal injuries, but they also failed the attacker because he was supposed to be watched as well every 15 minutes, which clearly did not happen.”

A News 4 investigation into Murray’s death found Emerald South repeatedly violated state and federal regulations, which led to the facility’s one-star rating.

But the vast majority of residents at the home on Delaware Avenue receive Medicaid or Medicare, and former employees say the facility has a heads-in-beds approach — keep the rooms full and the money flowing.

An investigation into the beating death of Murray by the department of health found multiple deficiencies.

“This family has been devastated by the manner in which their mother died,” Scinta said. “And to see a report like this, and to know that there’s ongoing systemic problems in the facility, it makes them very angry and very frustrated with the fact that this facility can do this time and time again.”

The department of health found Emerald South did not ensure each resident received adequate supervision to prevent accidents. As one example, they failed to check on Murray’s attacker every 15 minutes, which was part of his care plan.

The department’s investigation found the CNA (Certified Nurse Assistant) who was assigned to Murray’s attacker on the day of the beating was out of the building running an errand for her team leader, and the next time she laid eyes on the man was after the incident.

“The facility chooses to under staff itself,” Scinta said. “They don’t have enough hands on deck to take care of the residents, and in turn what happens is things get missed or ignored, and simply not done. And people aren’t protected. Because of their failures, Ms. Murray is now dead.”

When it came to reporting the fatal beating to authorities, Emerald South failed three as well, the state report showed.

The department of health wasn’t notified about the incident until Aug. 28th, two days after it happened — when the report said they should have been notified within 24 hours.

Buffalo attorney Richard Sullivan represents Emerald South, but has not returned repeated calls for comment about the state’s investigation or the impending lawsuit by attorneys representing Murray’s family.

Willie Faulkner lived across the street from the 84-year-old man.

Faulkner cared for his neighbor, and was ultimately one of the reasons why he was sent to Emerald South after he could no longer care for himself.

“That’s not the type of facility that I would go to if I had to go to one,” said Faulkner, who visited his neighbor and other residents at Emerald South.

It’s a place Faulkner says he remembered all too well for all the wrong reasons.

“The day that I went in, he was in the room with nothing,” Faulkner said of his visit with his neighbor. “He didn’t have anything. There was nothing on the bed. He may have had a pillow behind him, but it didn’t have a pillow case on it. It didn’t have no sheets on the bed, no nothing on the bed. No dresser.

“There was nothing. Bare walls and a bed. And his robe from the hospital,” he added.

There were other deficiencies about the facility’s care of Murray and her attacker, some of which were not connected with the violent incident.

The state found Emerald South had no documented evidence of an admission agreement for Murray’s attacker, which is a state requirement.

The department’s investigation led them to the nursing home’s business office, where a female employee told the investigator Murray’s attacker’s agreement “fell to the wayside,” and that she was “very busy because she was working for both buildings.”

“We know that this is pervasive throughout the facility because of their failure to staff the facility and their failure to follow the care plans, other residents are affected, and other residents in that building are at risk,” Scinta said.

“They want heads in beds, and they want to keep their facilities full, and that’s the way they operate their business,” he said. “But in doing that, in exchange of that, they have to have enough people there to properly care for these individuals.”

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State: Nursing home’s failure to ‘provide adequate care’ led to beating death

Nursing home fined $10,000 in beating death of woman

The Delaware Avenue nursing home where an 82-year-old woman suffered fatal injuries in a beating last year has been fined $10,000 by the New York State Health Department.

Ruth Murray was a resident of Emerald South Nursing and Rehabilitation Center, 1175 Delaware Ave. near West Ferry Street, in Buffalo. On the morning of Aug. 26, she mistakenly wandered into a man’s room in the dementia unit, where she also lived, and the attack occurred.

Inspectors said she wandered unsupervised into the room, and the man reacted violently believing a man was breaking into his house. Murray suffered a broken neck, several broken ribs, a broken nose, facial fractures and a collapsed lung in the attack. She died three days later in Erie County Medical Center.

An inspection based on a complaint cited Emerald South for not ensuring that each resident receives adequate supervision to prevent accidents. That was one of four deficiencies that led to the fine.

The state also said there was no documented evidence that an admission agreement was signed by the male resident or a responsible party, and the nursing home should have notified authorities within 24 hours of the incident and did not. The review also cited the facility for not notifying the family or legal representative of the male resident in a timely manner of his transfer out of the nursing home for evaluation at ECMC's Comprehensive Psychiatric Emergency Program.

Emerald South submitted a plan of correction acceptable to the state to address the shortcomings.

"The Department required the facility to submit a revised plan of correction for review and approval. Based the seriousness of this matter, the department fined Emerald South $10,000 and conducted a post-survey visit at Emerald South Nursing and Rehabilitation to make sure all of the corrections were made," according to a statement from the Health Department.

The fine is the maximum that can be assessed for a violation that directly results in serious patient harm.

Prosecutors decided not to charge the 84-year-old man. An official in the Erie County district attorney's office told The Buffalo News in October that it was determined that the assailant lacked the mental capacity both to participate in a trial and to form criminal intent in the incident.

Richard Sullivan, an attorney with the Harris Beach law firm who has represented Emerald South, did not return a phone message seeking comment Tuesday.

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Nursing home fined $10,000 in beating death of woman