BIG SPRING, Texas – The Veterans Land Board promotes its seven state-owned veterans homes with a glossy brochure titled "Where Honor Lives."

But there was nothing honorable about what allegedly happened to World War II Navy veteran John Harris in the final months of his life in 2007 at the Lamun-Lusk-Sanchez State Veterans Home in Big Spring.

A certified nurse aide said she saw a co-worker grab the 97-year-old from his wheelchair and slam him into his bed. Harris, suffering from Alzheimer's disease, was taken to the hospital that night when he complained of hip pain, according to a state inspection report.

That same year, another employee at the home was accused of punching and trying to choke Albert Teague, 84, a Marine who fought at Iwo Jima.

Regulators have repeatedly found problems and cited violations at that West Texas facility, which the General Land Office, parent agency of the veterans board, says were promptly fixed. But the criminal investigation into the two former Big Spring workers languished for more than two years because of confusion over who should investigate, cumbersome bureaucracy and conflicts among local police, state officials and home administrators,

Felony charges were filed against the ex-employees last month. Two weeks before that, in an interview with The Dallas Morning News, Howard County District Attorney Hardy Wilkerson described the lengthy review as a product of "investigations at cross purposes" – a state agency that inspects nursing homes conducting an inquiry that should have been coordinated with police.

It was an "I-got-it, you-take-it kind of a deal; you're going to do it, we're going to do it, you all do it," Wilkerson said.

Big Spring and the Ussery-Roan State Veterans Home, which opened three years ago in Amarillo, received the second-lowest rankings possible this year from the federal Centers for Medicare and Medicaid Services of the state's seven veterans homes. Among the main problems: The home in Amarillo failed to follow policies to prevent neglect, which placed residents in "immediate jeopardy."

Over the past three years, inspectors from the state's Department of Aging and Disability Services have documented several problems at the Amarillo veterans home.

The General Land Office said any such deficiencies are corrected quickly . Officials said they use daily data to evaluate their homes and rely on land office visits to render judgments.

Rating the homes based on inspection and other data over a three-year period when fixes have been made is unfair, like branding a reformed convict "with a felon tattoo on your forehead," said Land Commissioner Jerry Patterson, a Marine and Vietnam War veteran who, as a state senator, wrote the 1997 law creating the nursing home program to help fellow veterans.

"It's been corrected," said Patterson, a Republican running for re-election this year. "You have served your time. That was then, this is now. I'm concerned about the care that is occurring today and in the future."

Ron White, director of the state's veterans home program, said he doesn't believe Big Spring and Amarillo are the most in need of improvement among the seven.

"Every nursing home has problems. It depends on the day they're [inspected] and how they're looked at," he said. "But do they get back on track real quick? If they do, you really don't have a major issue."

The head of the Big Spring nursing home said residents there are in a "safe and secure environment" and employees were retrained on policies for reporting abuse and neglect.

Experts note that most nursing homes at some point must grapple with allegations of abuse and neglect.

The seven state-owned nursing homes are open to veterans who are Texas residents and did not receive a dishonorable discharge, and to their spouses.

The Veterans Land Board, the division of the land office that runs the homes, says the price is cheaper than most privately owned nursing homes because of extra funding from the Veterans Administration.

The homes are popular: Six of the veterans homes are certified for 160 beds, with Amarillo at 120, and capacity averages 98 percent. Each is run by a private contractor that the state hires.

Inspections by the state's Department of Aging and Disability Services, reviewed by The News, show a series of problems at the Amarillo home, which is run by San Antonio-based Touchstone Communities. Among them:

•A woman was hospitalized with gastrointestinal bleeding after a physician-ordered lab test, including blood work, was not done and a staff member misread her doctor's orders. As a result, she received too much of a blood-thinning drug, resulting in an "abnormal bruise" from her lower back to her right leg from a fall.

•An elderly woman with Alzheimer's was found on the floor with the neck of her nightgown caught in her bed's rails. The inspection found that she had redness around her neck. A previous assessment of the woman said a staff member needed to get her in and out of bed, but it didn't call for the use of restraints, which generally are used to prevent falls.

•From September 2008 to April 2009, four residents suffered first- and second-degree burns from spilled hot coffee.

After three residents were hurt, an employee put a sign on the coffee machine for her colleagues: "You will bring coffee down to 140 degrees by adding ice. No exceptions. You will go to the Administrator's office to explain why you burnt someone!!!"

But the employee later told a state inspector that she took the sign down after complaints that the coffee was not hot enough. Soon after, one of the residents spilled coffee on himself at breakfast, suffering a burn on his abdomen.

Home administrator Vicky Robertson acknowledges that when asked by a state inspector about the findings, she replied: "I was afraid you were going to find that. Is this going to be an IJ?" – a reference that residents are in "immediate jeopardy." That triggers an investigation in which the nursing home must develop an immediate plan to address the violations, with inspectors remaining on site until it's done.

In a recent interview, Robertson confirmed making a "stupid remark."

"I probably wasn't the best administrator, but I by far wasn't the worst," said Robertson, who said she resigned in August 2009 because she was "totally stressed out." She now works as a consultant for another nursing home company.

At the Amarillo home, Donna Conway, the widow of a retired Navy veteran, said she has noticed what appears to be a shortage of certified nurse aides recently. But she said she is grateful for the care she receives and has seen few problems.

It's meaningful, she said, to live amid so many veterans, especially those who served in World War II.

"These are the men who saved us," said Conway, 71.

The Big Spring home, which opened in 2001, is a sprawling complex set on a hill next to the state hospital and overlooking a highway. From the outside, it resembles a neatly maintained school. On one recent day, men in wheelchairs slept outside the front entrance under a warm spring sun.

Since 2004, state regulators cited the home for several violations, including:

•A resident leaving the veterans home unattended in his wheelchair. The resident was found in the cold darkness, lying on the cement about 80 feet from the front door, with swelling to his left eye and cheekbone. He spent two days in the hospital.

•A man choking to death on a radish, although his physician earlier had ordered a soft diet for him. The man had Alzheimer's disease, schizophrenia and dementia.

Jim Suydam, a spokesman for the General Land Office, said the choking death was "not neglect" but the result of "some good-intentioned kitchen staffer who just wanted to make the plate look nice."

An employee, though, said the physician's order for a soft diet was incorrectly entered in a computer. The entry said "regular" diet instead of "soft," according to an inspection report. Suydam said he couldn't account for the different explanations.

•A resident with Parkinson's disease who was not offered timely counseling or psychiatric help last year after he talked three times about death and suicide, and then wrapped his feeding tube around his neck twice in one day.

•Lack of a system for ensuring that beds were in locked positions after a man fell when his bed rolled. The home also did not properly supervise another resident who had been found on the floor at least four times in less than two months.

"I guess I missed that one," the employee replied, according to the inspection report.

Veterans interviewed in Big Spring said they enjoy living among those with common experiences, and they have not seen any problems.

Ken Liljestrand, a Vietnam War veteran who has lived at the Big Spring veterans home for a year and a half, referred to his experience as "wonderful."

He added with a smile: "The one thing I have complained about is that the doctor who visits us once a week was in Saigon when I was in Saigon, and he was 6 years old. I was 26 years old. I have 20 years of seniority on him."

The allegations that resulted in the recent criminal charges were first checked by Big Spring police in late 2007. But interviews and records obtained by The News through state open-records laws indicate that a criminal investigation was delayed partly because the police yielded to the state agency that inspects nursing homes.

Wilkerson, the local prosecutor, acknowledged that "this should have been brought up and reviewed by a grand jury quicker."

On March 25, a Howard County grand jury indicted the two former employees of the home, Bryson Vanderbilt, 25, and Connie Mae Johnson, 52, charged with "striking, pushing, grabbing and forcefully handling" two residents in separate incidents. If convicted, they could face a maximum 20 years in prison.

Vanderbilt and Johnson couldn't be reached for comment. They are scheduled to be arraigned soon, and the district attorney said he expects the court will appoint lawyers to represent them.

Vanderbilt is accused of injuring Harris, the WWII veteran whose destroyer escort was credited with helping to sink a Nazi U-boat in 1945. Harris died in May 2008 at age 98. Johnson is accused of hurting Teague, the Marine who died in October 2009.

Johnson was hired in August 2006 and her last evaluation was "good," according to the inspection report. Vanderbilt's employee file said he was hired about a year after Johnson, and it contained no evaluation form.

Conflicts over the investigation at the home occurred almost immediately after the incidents were reported.

Senior Dimensions, the Austin-based firm that manages the home under a state contract, said it contacted the police and began an internal investigation. The police report, dated Nov. 9, 2007, said Cpl. Adam Stovall spoke with a unit manager who said a certified nurse aide had seen a male co-worker abusing one of the residents.

But, Stovall wrote, the home's administrator, Bob Kerr, would not give police copies of the employee statements about the incidents.

Stovall said he saw one statement, from resident Wilson Sikes, who said he had slammed Vanderbilt's hand in his nightstand because the man was going through his belongings. Vanderbilt then "lifted his wheelchair and dumped Sikes in his bed, then sat on him and slapped him across the face with gloves," the police report said.

Sikes recounted the same abuse to Stovall, who said he saw no "obvious injuries" to Sikes.

Kerr, a Senior Dimensions employee, told The News that he couldn't recall whether he declined to turn over witness statements. But if so, he said, it was "because we were in the process of doing an internal investigation and we felt those were part of our internal investigation."

"I do my job and [police] do their job," he said.

Senior Dimensions said last week that it wouldn't release a copy of its internal investigation.

When police tried to go further, a detective said he didn't get cooperation from the state's Department of Aging and Disability Services.

Detective George Oliver said in his report that he contacted the agency and an official told him that he was unable to release any information. The agency would investigate and consult with the district attorney. Oliver said he would not interfere with the agency's inquiry and would "wait to [hear] from them before any action was taken."

In an interview, Oliver said he now has second thoughts about having deferred to the state agency, partly because it didn't record interviews with witnesses or share witness statements with him.

The agency's inspection reports "substantiated" allegations that seven residents in the Alzheimer's unit were abused over two months in 2007, with five employees as witnesses.

Cecilia Federov, an agency spokeswoman, said, "Substantiated means when we did the investigation, we found the claim was true."

In late 2007, the agency cited the Big Spring veterans home for violating federal and state regulations, including failing to ensure the "residents' right to be free from repeated verbal/physical abuse" by two staff members over a period of almost two months.

Under state law, the agency must send copies of investigation reports that confirm abuse, neglect or exploitation to local law enforcement, the county district attorney and the attorney general's Medicaid Fraud Unit. It did so in January 2008.

Wilkerson said the letter he received from the aging agency referred to the abuse allegations as "substantiated, but not cited" – a phrase that Wilkerson took to mean that the incidents might not have been that severe. The incidents were not "cited" because the company running the veterans home had appealed them to the state Health and Human Services Commission and succeeded in having them deleted from the final inspection report.

Wilkerson also received a copy of an attorney general's office investigation in April 2009. He said he could not disclose its contents, but confirmed it included handwritten statements from witnesses.

What the attorney general's office did – and when – is unknown because the office won't discuss it.

"What you are asking is beyond the pale," said Thomas Kelley, a spokesman for Attorney General Greg Abbott. He said the office's policy is not to acknowledge an ongoing investigation, let alone discuss it.

Oliver, the Big Spring police detective, said he was unaware until recent weeks that the attorney general's office had been involved.

"Sometimes we know about them, and sometimes we don't know," he said.

Before the aging agency sent its investigation to local authorities and the attorney general's office, Senior Dimensions used that internal review to overturn the agency's findings.

Senior Dimensions argued to the state that two of the incidents never happened and that the aging agency hadn't offered enough evidence that the others occurred, documents show.

Using a nationwide program called "informal dispute resolution," Senior Dimensions argued its side in a January 2008 hearing with the state Health and Human Services Commission, which ruled in the company's favor. The commission sided with all of Senior Dimensions' points. Aging agency officials had the option to attend the conference, but could not present information, according to state law.

The final version of the inspection report did not include any references to the alleged abuse. And the decision saved the Big Spring veterans home from possible fines and sanctions, which can include being cut off from Medicaid and Medicare patients.

Kerr said he doesn't believe the lack of a prompt criminal investigation – in which police would have taken statements from employees and alleged victims – helped Senior Dimensions prevail.

Senior Dimensions fired Vanderbilt and Johnson. A company official said they were dismissed for failing to disclose they had allegedly abused residents.

A month after Senior Dimensions succeeded in getting the violations stricken from the inspection report, the aging agency sent letters to Vanderbilt and Johnson stating they had abused residents. Both letters listed incidents in the original agency inspection report, and the pair have been barred from working as certified nurse aides in nursing homes.

Although the Veterans Land Board has an on-site representative at the Big Spring home and sent another official there when the abuse allegations surfaced in November 2007, agency officials say they're not responsible for ensuring that local authorities do a timely criminal investigation.

"Sometimes you have a policeman come out and take a report, and you will never see them again. They rely on us to police ourselves," said White, director of the veterans home program.

Patterson, the land commissioner, said police and prosecutors should have pressed harder.

"If I had evidence of elder abuse and I am an elected DA and I thought it was prosecutable, I would be on it like a duck on a June bug," he said.

Wilkerson said when he received the attorney general's report in April 2009, the case wasn't "time critical" because Vanderbilt and Johnson had been fired. He said one reason for delay was the need to subpoena Harris' medical records from the hospital.

As for Patterson, he said: "He's the land commissioner. I expect him to do his job as land commissioner, and I'll do my job that I'm elected to do. ... I don't think they have a complete record of the facts, quite honestly."

John Harris' son, Jerry, who lives in Lamesa and runs a cotton gin company, said he was glad to learn of the indictments. But he still has questions about the investigation.

He recalled that his father was older than the others on their destroyer escort ship during World War II and counseled those who feared death or not serving bravely.

"It sounds like the two of these employees went berserk," Jerry Harris said. "Sometimes with government agencies ... what probably happened is they had other agenda items. It's a bureaucracy thing."