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Ave Maria Jacques had lived at Courtyard Manor for three years when her youngest child, the son who visited nearly every day, got the telephone call. In the suburban Detroit assisted living facility, bedecked with fireplaces, wainscoting and gleaming chandeliers, his mother, 82, had suffocated in bed, her head and neck caught between her mattress and the siderails meant to keep her from falling out.

The police and Michigan state inspectors who arrived after her deathin 1998 discovered that the aluminum rails fastened to her twin bed hadn't fit, creating a six-inch gap. Despite its sales brochure promising "loving care, dignity and quality of life in a safe, homelike environment," despite its elegance and its $3,100-a-month price tag, Courtyard Manor had no system to make sure safety rails were properly installed, investigators concluded.

This month, the Michigan attorney general filed charges of involuntary manslaughter against the company after an inquiry into Jacques' death. It is the first time a state is known to havetaken criminal action against an assisted living facility and reflects an intensifying scrutiny of an industry that has enjoyed a pristine reputation.

Minnesota's attorney general just settled a consumer fraud case involving shabby care at a half-dozen facilities owned by Alterra Healthcare Corp., the largest assisted living chain in the country. California regulators are moving to shut down nine facilities run by Regent Assisted Living Inc. because they contend poor care caused at least one death. The Pennsylvania attorney general and a district attorney, meanwhile, are investigating whether workers at a Bucks County facility for people with dementia abused a man who died after his lung was pierced by a broken rib.
With an estimated 11,500 to 30,000 facilities housing up to 1 million people across the country, assisted living facilities represent the most popular innovation in long-term care since the advent of nursing homes more than a half-century ago. Yet unlike nursing homes, hospitals and most other forms of care in the United States, these facilities have grown up with scant government rules or oversight.

Assisted living operates entirely without federal standards. U.S. health officials inspect only those few assisted living facilities that accept Medicaid money. Even then, officials typically look in once every three to five years.
In such a climate, no one can document how often problems arise. Indeed, many assisted living facilities deliver what they advertise -- more personal service than an apartment complex and more amenities than a nursing home.
Yet public records and more than 150 interviews with residents and their families, state regulators, researchers, consumer advocates, lawyers and those who run or work in facilities across the country reveal that facilities cannot always be depended on to provide sound care. Some occasionally imperil their residents through neglect, medication mistakes, ill-trained workers or a sheer eagerness for profits.

Questions also havearisen about how long residents should stay and whether the industry's very philosophy -- which emphasizes lifestyle over health services -- offers as much help as some residents need. Some people remain in assisted living even though they need more care than a facility can provide.
Assisted living officials say they have greatly improved the lives of older Americans who no longer can remain safely at home. Karen A. Wayne, president of the Assisted Living Federation of America, the largest trade group, says the industry has reduced elderly people's dread of long-term care by creating a form that is more respectful and tailored to each resident's needs.

The vast majority of those who have moved into assisted living communities, industry officials say, live there safely. And most residents, internal industry surveys suggest, are content.

"Nursing homes are human warehouses. Here you are a person," says Roger Wallace, whose wife, Alice, 84, has advanced Parkinson's disease and moved last April into one of Alterra's "memory care" communities near Kalamazoo, Mich.

Nonetheless, it is evident that Ave Maria Jacques is not the only resident of an assisted living facility who has been harmed:
• Early one morning last August, Lucille Giroux, 79, bled to death in her rocking chair at Regent at Sunnyside Court Assisted Living Facility in Fremont, Calif. She had begun to hemorrhage from a shunt that had been implanted into her arm to allow dialysis treatments, according to state and police officials. Twice, she pressed a call button to summon help, but nobody came. By the time an aide stopped by 90 minutes later, she was dead. At first, the facility's marketing manager told Giroux's daughter her mother had committed suicide.
• Mary Bell, 80, didn't receive her blood pressure medicine for more than two months last spring at Morningside Assisted Living in Lexington, S.C. Her medication record didn't contain the proper instructions, even though she moved there because she had had two strokes, according to her daughter and state regulators. Her daughter discovered the oversight when she noticed her mother's vision failing and took her to an eye doctor, who believed Bell might have suffered another mild stroke as her blood pressure soared out of control.
• A suburban Minneapolis police department received more than four dozen "911" calls last year from residents of Alterra Clare Bridge in Eagan, Minn., who needed help the staff could not provide. When one person arrived by ambulance at a hospital, an emergency room worker called Alterra to find out about her medical history, but no one answered the telephone. The hospital was unsure how to treat her; police went to the facility and were met by a cook who barely spoke English and had not been taught how to use the phone.

In the absence of federal oversight, such incidents are beginning to draw the attention of states, which oversee the industry through a quilt of separate rules. Many states investigate specific complaints, and most issue some sort of license. But their regulations tend to be vague and to provide consumers with fewer rights than federal law ensures every nursing home patient.
States seldom dictate how many workers facilities must have or their training. Only half the states require yearly inspections, and many do not give advocates, including the nation's network of long-term care ombudsmen, an automatic right to go inside facilities. In certain parts of the country, licensed and unlicensed facilities are allowed to coexist.

Research into assisted living is starting to hint that such loose oversight may jeopardize adequate care. The U.S. General Accounting Office, in a 1999 study of assisted living in four states, found that more than one quarter of the facilities it examined had at least five quality or consumer-protection problems, ranging from poor care to inadequate staff to faulty admission and discharge practices. Similarly, the first major national survey of assisted living, commissioned by the U.S. Department of Health and Human Services, found that one of every four people who moved out said they had been dissatisfied with the care or the cost.

Owners of assisted living communities say that federal regulation would drive up costs and squeeze out the innovation that they say is the industry's hallmark. Besides, they are quick to point out, strict government rules have not guaranteed that every nursing home offers good care.
The children of Ave Maria Jacques, however, believe they were misled. "We think of these facilities as being capable of doing what they purport they can do," says her eldest son, Gary, 53, a retired real estate broker. "If they hadn't been capable of taking care of her, the family deserved to know about it."
'Mr. Carver Is Gone'

As a professor and college administrator specializing in environmental health, Franklin Carver had taught students to inspect long-term care homes. So when it was time for his own father back in North Carolina to find an assisted living facility, he thought he knew what to watch for.
When he arrived at Greystone Manor in Red Springs, N.C., he recalls, "It was just gorgeous. The wallpaper. The flowers. It looked like one of those five-star hotels."

Opened just four months earlier, Greystone Manor had plenty of staff because it was only half filled. Every door was rigged with an alarm and security lock, reassuring features because William James Carver Sr. had Alzheimer's disease and a tendency to wander.

He had been at Greystone Manor only a few months when he wandered out of the building and down a busy highway. An employee was fired, and the administrator promised it wouldn't happen again.
A month later, on the Sunday night of his 80th birthday, Carver was killed. A door alarm had been disengaged while members of a church choir arrived. As residents listened to them sing, the supervisor summoned the staff for a meeting.

"My father put his coat on, his hat, and walked out the door," his son says. By the time a fellow resident announced, "Mr. Carver is gone," he had walked a half-mile west along the dark highway and been struck by a car.
The aftermath of Carver's 1997 death was, in a sense, unusual. North Carolina fined Greystone Manor $5,000, and Carver's son and daughters won the largest