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The cell phone that seems to ring constantly in Sharo Shirshekan's shirt pocket plays the signature theme music from James Bond movies.

"I only handle crises," half jokes Shirshekan, who operates about 40 for-profit nursing homes in Illinois and Missouri, where he is frequently called on by state regulators to help rescue troubled homes.

On an early morning in mid-February, Shirshekan sat at the head of a long table in a University City nursing home surrounded by a dozen worried employees.

At the request of a court-appointed trustee, Shirshekan had just taken over the operation of University Forest Nursing Care Center. Missouri state regulators had accused the previous operator of diverting residents' money to the home's payroll and other business accounts.

After changing the name of the home to U-City Forest Manor Nursing Home, Shirshekan was to bring the home's bloated budget under control and to correct chronic care problems, including bedsores and weight loss, among the nearly 100 residents.

Shirshekan knew that morning that the key to improvement was staring him in the face.

Within six months, more than a third of the home's 75 employees, including several in the room, would quit or be fired.

Shirshekan began the staff meeting with a prayer. Dressed casually in brown corduroy pants, a brown-plaid shirt, dark argyle socks and tasseled loafers, he told the gathering the importance of the coming days. He reminded them that state inspectors would be in the building and closely watching to see that care improved. The employees nodded their heads in agreement, adding an occasional revival-like shout of "amen" and "that's right."

He told them not to call in sick. That very morning, he'd called the home's administrator in to work after she had called in sick.

"There's too much at stake," he told them.

Shirshekan (pronounced SURE-sha-can) was born in Armenia and trained and worked as a physician at Moscow State University in the former Soviet Union. He's not licensed to practice medicine in the United States.

Not long after taking over U-City Forest Manor, Shirshekan ran a criminal background check on the staff and found that nine employees, including six nurse's aides, had convictions that by state law barred them from working in the home. One was a murderer who had just been released from prison. He fired them.

Within the first two weeks, the state's elder-abuse hot line recorded 18 complaints against the home, most of them from angry employees and upset families, Shirshekan said.



A chance to survive



At one point, the state decided to put the home out of business by no longer reimbursing the costs associated with providing care to Medicaid or Medicare residents. Shirshekan said regulators told him the existing staff was incapable of making the improvements needed. Shirshekan persuaded state officials to keep the home open - to give him a chance.

Before taking over a home, Shirshekan said, he checks the employment ads in local newspapers to see what other homes in the area are paying. He then tries to lure employees by offering a little higher wage, plus benefits that are often unavailable to nursing home workers, such as a 401(k) plan and medical and dental insurance.

Even with the benefits, finding good staff members proved difficult. Of the 50 nurse and aide jobs, 10 were vacant when Shirshekan took over. Constant turnover would keep the positions mostly unfilled for months.

Absenteeism also was a chronic problem.

On some days, one of every three aides called in sick or simply didn't show.

To compensate, many aides routinely pulled double shifts or stayed past the end of their normal workday to ensure the residents at least received the most basic care.

Many of the jobs in the home, such as aides, housekeepers and kitchen staff, paid not much more than minimum wage, and many who sought them weren't literate. Even many nurses who applied failed a competency test he administers, Shirshekan said. The test checks things such as the ability to measure and administer proper doses of medicine, where mistakes can lead to injury and even death.

Because many of the aides he hires often "have trouble remembering more than three things at once," Shirshekan creates a color-coded card for each resident with detailed instructions on everything from diet to medications. Even then, some staff members can't get it right.



The long struggle to improve



One month after taking over, Shirshekan fired the dietary manager for, among other things, poor food preparation techniques and failing to give supplements to residents who were losing weight. Without the supplement, residents ran the risk of malnutrition and kidney failure.

By the end of his second month, Shirshekan had fired the administrator. He acknowledged that some employees continued to practice poor care, but he still thought, overall, the quality was improving.

In late May, about 30 family members crowded with staff members into the nursing home's dining room for an evening meeting. That night marked the first time Shirshekan had had a chance to speak with residents' families since taking over.

Some complained about the lack of staff.

"You can't find anybody when you need someone," one woman said.

Another family member told of residents calling out to her for help.

Another complained that there weren't enough workers in the Courtyard, the name given to the home's locked Alzheimer's unit. She told of incontinent people sitting in soiled clothing for hours.

"I felt comfortable with you," the woman told Shirshekan. "Now when I come in here, there's one staff member in the Courtyard and Mom is wearing the same clothes three days in a row. That concerns me."

The husband of a bedridden resident complained that his wife was being ignored.

"I washed my wife's hair myself last night," the man said. "There was so much dandruff, you could have planted a garden in it."

Shirshekan listened quietly to their complaints, sometimes nodding in agreement. He told them that help wanted ads were going mostly unanswered. Many of those who did apply failed the criminal background check, and the health insurance and other benefits he offered weren't luring any new quality employees.

"It's not like we don't hire," Shirshekan said. "People don't want to work. We've done everything we could. We don't want to run the facility short."

The answers seemed to placate most of the family members, and the meeting ended with cake and punch.



Staff stability, at last



On July 2, families and staff members again crowded into the dining room for a town hall meeting with several local politicians. Shiny silver stars and red, white and blue crepe paper hung from the ceiling.

As of that day, the home had regained government approval to accept Medicare patients, crucial to its financial success. The threat of being shut down by the state had passed, if only temporarily.

But the home still struggled with staff vacancies, especially on the evening and midnight shifts.

The problems hadn't gone unnoticed by family members, who again complained.

By mid-August, the staffing problem had stabilized. Rumors of the nursing home being closed had faded, and the quality of applicants improved to the point where the new administrator could pick and choose. Only three positions remained vacant.

"But that's today," Shirshekan said. "If you turn your back for a minute, everything could fall apart."


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