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by A.C. Thompson, ProPublica, and Jonathan Jones, Special to ProPublica, Oct. 29, 2013. A version of this story was co-published by (PBS') Frontline.

Workers found 82-year-old Vincenzina Pontoni submerged in a deep whirlpool bathtub. She had drowned.

Pontoni, a resident of an assisted living facility near Cleveland, wasn’t supposed to be left alone; her care chart stated that facility workers were to stand by while she was bathing "for safety." But records show she had been unsupervised for at least an hour that day in 2010, with deadly consequences.

State law in Ohio does not require assisted living facilities to alert regulators at the Ohio Department of Health when a resident dies under questionable circumstances, so administrators at Pontoni’s facility never did. While law enforcement did an investigation — ruling the death an accident — the people actually charged with safeguarding seniors in assisted living never so much as visited the facility in response to Pontoni’s death. Indeed, the Department of Health was unaware of how Pontoni died until notified by a reporter investigating assisted living for ProPublica and Frontline.

When asked about Pontoni's death, and whether the Department of Health feared other care issues had been overlooked, Tessie Pollock, a department spokeswoman, said it did not appear that any regulation had been violated by the Cleveland facility. She encouraged the families of residents in the state’s assisted living facilities to be vigilant on behalf of their loved ones.

Ohio's hands-off approach to regulating assisted living is hardly an aberration.

Over the past two decades, assisted living has undergone a profound transformation. What began as a grassroots movement aimed at creating a humane and innovative alternative to nursing homes has become a multibillion-dollar industry that houses some 750,000 American seniors. Assisted living facilities, at least initially, were meant to provide housing, meals and help to elderly people who could no longer live on their own.

But studies show that increasing numbers of assisted living residents are seriously ill and that many suffer from dementia. The workers entrusted with their care must manage complex medication regimens, safeguard those for whom even walking to the bathroom can be dangerous, and handle people so incapacitated they can be a threat to themselves or others.

Yet an examination by ProPublica and Frontline found that, in many states, regulations for assisted living lag far behind this reality.

Despite the growing demands on care in assisted living, most states set the entry bar low for facility workers, requiring little in the way of education or qualifications. In Minnesota and 13 other states, administrators don't need high school diplomas. Caregivers can be as young as 16 in Illinois. Facilities in some states, Colorado among them, are not required to have even one licensed nurse on staff.

Under most state regulatory schemes, assisted living companies are also free to decide how much staff their facilities should have. Just 14 states set staffing ratios; in Mississippi, facilities must have at least one staffer on duty for every 15 residents during daytime hours and one per 25 at night. In California, by contrast, facilities housing as many as 200 seniors need no more than two workers on the overnight shift. Neither of them is required to have any medical training. And one of them is allowed to be asleep.

Compared with nursing homes, assisted living facilities in many states receive relatively little outside monitoring. Under federal guidelines, nursing homes are supposed to be inspected at least once every 15 months. For assisted living, the interval between inspections can be five years in some states. South Carolina and five other states require no regular inspections.

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