MARY ROACH sat on the side of her bed mending a torn slip and wondering who would have been foolish enough to wash such a delicate garment in a machine. Mary wouldn't have done it that way. Then again, there's a lot in Mary Roach's life these days that she would do differently, if only she could. "I never wanted to go into a nursing home," she says, with all the vehemence that this gentle woman can muster.
For Mary, the irony is overwhelming. As the second youngest of 12 children-the only daughter to live to adulthood-she spent much of her life caring for her brothers and her parents. "I never expected to live this long," she says. "And I never thought of being the one left alone." At 86, her heart is weak, her blood pressure is high and her stride is unsteady. She doesn't talk about it, but she knows that she will probably never return to the North Philadelphia apartment she left eight months ago. She will probably die in a nursing home called the New Ralston House. "I have to make the best of it," she says. "What else can I do? What else can I do?"
Inside the three-story, red-brick building at the corner of 36th and Chestnut streets in Philadelphia, Mary Roach is but one of 70 residents who have had to ask that question--or have it asked for them. And for almost all, the answer was not pleasant. Quite simply, a nursing home is a last resort for people who no longer can care for themselves, who can't afford to hire people to tend them in their own homes and whose families can't carry the burden.
The New Ralston House, opened last August, is probably better run than most American nursing homes. It has 120 beds-about average size-and skilled nurses work every shift. It is owned by Presbyterian-University of Pennsylvania Medical Center, and operated as part of a nonprofit foundation. The average age of its residents is 80; with medication and other charges, their monthly bills average $2,300. The mix between private, paying patients and those on government assistance is about 50-50. Nearly 75 percent of its residents are women, and about 30 percent of the patients suffer from Alzheimer's disease.

The story of Ralston House-like that of all nursing homes-is not about statistics. It is about people: Those who live there, those who work there and those who visit. And Ralston House is also about emotions, so raw at times they are as visible as the ID bracelet wrapped around a wrinkled wrist.
As at any nursing home, life at Ralston House is a routine in which yesterday was a long time ago and tomorrow is uncertain. It is also chronic aches and new pains, a patient's longing for youth and a nurse's fear of sickness and old age. It's a son watching his mother die and the enduring bond between aged sisters. It's bingo and bowling and the cheer brought by a college group singing show tunes. It's small victories-a step taken, a hand raised, a seed planted-and bigger defeats: Incontinence, confusion, loneliness and death. More than anything, it's people growing old, in many cases, very old. Neither Ralston House nor any other nursing home can cure old age. It simply provides a place for it to live.
At 5:30 on most mornings, the thousands of University of Pennsylvania students across Chestnut Street are fast asleep, and the commuter traffic that will later flood toward Philadelphia's booming Center City is still a trickle. The lobby of the New Ralston House is dark, and-except for a night attendant-deserted. But upstairs, another day, not much different from the one before or the one to follow, has already begun. There is a lot of work to be done before the night shift can turn over the charts to the day staff. Breakfast is still more than 2 hours away, but getting 70 elderly people up, cleaned and dressed requires an early start.
It also requires a great deal of patience. Most of the residents have come directly from a hospital. Because of changes in government reimbursement, which have shortened hospital stays in the last decade, they often arrive sicker -and thus in greater need of acute medical care. The list of Ralston House maladies is not much different from that of other homes. One out of 4 residents suffered some form of a cerebrovascular accident or stroke. High blood pressure afflicts two thirds of the patients, and a third have heart conditions. About 30 residents need a wheelchair to get around, a few are essentially bedridden and 40 or more patients need assistance to go to the bathroom.
A dozen residents need to be fed every meal, and everyone requires daily medication-ranging from Tylenol for chronic pain to Digoxin for a heart condition. About 12 residents are diabetics, half of whom must have an insulin shot every morning. From bedtime to breakfast, some incontinent patients need their linens changed as many as six times. At Ralston House, the sicker patients are mostly on the first floor for skilled nursing-and those requiring less care are on the second floor, for intermediate care. On both floors, the patients can be uncooperative, cantankerous and angry. The nurse or the aide bears the brunt of their frustration with growing old.
Rose Chandler, 50, is one of the first to arrive each morning. Rose is the assistant director of nursing, and she knows the frustration is not just one-sided. "Our work is more than just medicine, but there isn't always time for the rest, for the TLC," she says. "There isn't always time to stop and listen to a patient reminisce when you have eight more patients to tend to."
For Rose, who spent 20 years working in obstetrics before coming to Ralston House last fall, the old people remind her of babies. She's not the only one. Mary Beth Mooney, a pharmacy consultant who reviews the drug regimens at Ralston House and two other nursing homes, is struck by the circle that life sometimes makes. "You go out the same way you came in-unable to control your bodily functions, unable to eat by yourself, unable to know not to go out in traffic," she says sadly.
Less frightening, but equally pervasive, is the timelessness of life in a nursing home. What day is it? What month and date? How's the weather? At Ralston House, John Abbate supplies the answers. Each morning before he joins other second-floor residents for breakfast, John does his part to give everyone else a sense of the world outside. "I have October, I have Tuesday, I have Independence Day," John says proudly as he rustles through a shoe box full of reality. When he is done, he has filled_in the "reality boards" across from the nurses' stations on each floor: "Today is Thursday, June 18. The weather is sunny and warm. The next holiday is Father's Day." Officially, that's the way each day at Ralston House begins.
Near the top of every nursing-home' administrator's wish list, there is a space for a Pollyanna, a resident whose enthusiasm is so infectious and whose kindness so abundant that a day without such a person seems inconceivable. Many administrators never get their wish. But Peter Laudenslager at Ralston House saw his come true last December when a robust '85-year-old diabetic moved into Room 269.
Born in Ohio, John Abbate has been deaf since childhood and a loner most of his life. His thin, muscular body reflects his fondness for long-distance running as a younger man. He lived for a time above a stationery store in Philadelphia, trading odd jobs and errands for a free room. His last address was a seedy residential hotel in the city's historic district. It was while living there that John was mugged twice and developed pneumonia. He was in a partial coma when a neighbor found him.
For John, the reality board is only the first part of days spent trying to make Ralston House life a little easier, a little more fun. He helps his roommate, Gilbert Holloway, get dressed, clears trays after meals, encourages a reluctant newcomer to join the shuffleboard game. "I work for Sharon," he says loudly and proudly. Indeed, Sharon Yesner, the activities director, was worried about hurting John's feelings when she hired a full-time assistant recently. But John adjusted. "I'm the second assistant now," he says happily.

A Very Gentle Touch

For Mamie Green and the other seven aides who work the day shift, there are few idle moments. Clean sheets must go on the beds, fresh ice water on the night stands, stray clothes in the closets. But as she gives baths, combs hair, changes soiled clothing and spoon feeds meals, Mamie is guided by one thought. "I try to take care of them just the way I would take care of myself," she explains. Even after 25 years of nursing-home work, Mamie, 48-a big woman with a gentle touch and an ever present grin-hasn't lost her enthusiasm. And if an ornery old person slaps her hand, spits in her face or calls her "nigger," Mamie doesn't skip a beat. "I like to take care of people," she says simply.
Gloria Boring, the director of nursing at Ralston House, wishes she could find a whole staff of people like Mamie. The nurses' aides are the backbone of the staff, the most important people for the patients on a daily basis, far more important than the two doctors who check on each patient once a month. But they are also the lowest-paid members of the nursing staff, earning an average of $4.50 an hour. And although finding aides is fairly easy for nursing homes because comparable positions do not exist in hospitals, turn over and absenteeism are problems.
It's not much easier to attract licensed practical nurses and registered nurses who, even though they are fewer in number at a nursing home, are crucial to the quality of the medical care. The nationwide nursing shortage is partly to blame. Perhaps more important, nursing-home pay is considerably lower than hospital wages-in many cases $4 or $5 an hour lower. And there is still a stigma attached to working in a nursing home a notion that it is a second-class job for those who can't make it in a hospital. In fact, for many of the LPN's and RN's who work at Ralston House, a prime motivation is the opportunity to have much more direct responsibility for a patient's care since the layers of personnel in a hospital-interns, residents, doctors and other nurses-do not exist in a nursing home. For Ralston House nurses and aides, the biggest problem is the potential for emotional burnout. "The everyday chores are not the hard part," says Boring. "The hard part is wondering if your mother is going to be like the woman down the hall or worrying about ending up in a nursing home yourself."
For the younger staff especially, the adjustment can be difficult. It goes beyond patience, says Rose Changler. “They have to understand that these people were once young, that they weren't always slow or fussy or mean," Rose says. And they have to understand how these patients feel when so many choices have been taken from them. These people may not be mean. They just want some choices."
At Ralston House, one person who tries to provide such choices is Sharon Yesner, the 23-year-old activities director. Every morning, after breakfast and before lunch in the second-floor dining room, she begins the search for those moments that give her and her patients the incentive to try again tomorrow. Sharon is the person who looks at a bingo game and sees more than a bingo game, the one who knows what a group. Sharon is the person who looks at a bingo game and sees more than a bingo game, the one who knows what a group of preschoolers can mean to a roomful of old people. She has to walk a thin line between encouraging people to join in and seeming to force them to do something. But given a choice, she'd rather be accused of coercion than apathy. "I don't want them to just be put in a room and sit there," she says.
Given the age and health of the patients, Sharon's task of providing physical and mental stimulation is not an easy one. At least half of the residents, most of them on the first floor, are unable to participate at all. Another dozen or so choose not to. That leaves Sharon and her assistant, Frank Timmons, about 25 prospects for a range of activities from exercises and gardening in the morning, bingo, bowling and shuftleboard in the afternoon to, once a month, making ice-cream sundaes. It is often painstaking work in which the process is far more important than the product and the resemblance to a preschool class is sometimes striking.
The small victories gained during such activities help to make life at Ralston House a little richer. Elizabeth Lorentz wriggles her fingers and raises her hands a little faster and a little higher than before in a morning exercise class. Pauline Fox comes up from the first floor to the gardening class and shows her prized violets to Viola Buchannan and the others. Tiny Sara Noll gamely plays shuffleboard, and Pauline Madden, her body ravaged by Parkinson's disease, knocks down six pins with a toss of the plastic bowling ball. Eldred Dunn, 56 years as church organist on his resume, plays "My Wild Irish Rose" on the old lounge piano. Dr. Mametta Voght, 93, beams as the red plastic chips on her card, spell BINGO. "Dr. Voght playing bingo is important," says Sharon. "Not too long-ago, she wouldn't even consider playing."
Sometimes there are bigger moments, special events that provide a lift: The recent night when Nancy Morgan brought three fellow Penn graduates and performed barbershop-quartet music for almost two dozen residents and a few family members. Nobody danced, but many sang-and everyone smiled at the old favorites, including "Sentimental Journey."

Relentless Monotony

If there is one event that outranks all others in the course of a day at Ralston House, lunch is probably it. It's the big meal of the day, and along with breakfast and dinner, helps break the relentless monotony and allows residents to make some choices of their own. Lunch is early - beginning around 11:30 and, like the other meals, it's served family style in each dining room, with kitchen staff and nurses' aides working together to set the tables, serve the food and feed patients where necessary. Mary Wilson, the dietary manager, knows how important food is to the residents. "They are far more likely to complain about the food than about the nursing," she says. "Their day revolves around the meals."
Mary's kitchen staff has to prepare food to satisfy eight separate medical diets, including low fat, low sugar, high fiber-and one in which all the food is pureed. Approximately 45 of the 70 residents at Ralston House are on some kind of special diet. Beyond the restrictions ordered by doctors, Mary attempts to accommodate the likes and dislikes of each patient based on an interview shortly after admission. As a result, Mary and her staff become intimately familiar with the eating habits of the residents. She knows, for example, that Robert Hall doesn't like carrots, so she prepares a dish of peas instead. She knows that Mary Roach won't eat veal, so on the day when veal is being served, Mary gets fish. Despite all the effort in the kitchen, the scene in the dining rooms at mealtimes is far from festive. Just opening a milk carton can be a major undertaking for some, and for others, keeping their head up long enough to finish the meal is a problem. The family-style seating does foster some socializing, yet there is relatively little conversation. People often linger long after the trays have been cleared, but mostly that's because they have no particular place to go.
That doesn't stop several of the patients suffering from Alzheimer's disease, however. For them, the crannies and corridors of Ralston House are their constant companions. Aileen Cottingham spends about 2 hours of each day in one of the chairs in Gloria Boring's first-floor office, often while Gloria is working across the desk. She talks about how she's expecting her father and brother to visit, and Gloria listens, knowing both have been dead for many years. Gloria has been listening to the elderly in different nursing homes for 13 years. "It's easy to hug a child who is sick in the hospital," she says, explaining her affection for her job. "But an older person is not so easy to hug. They're not as cute as little kids, but I think they are."
Thelma Lewis walks alone, always on the tips of her toes and always wearing pretty, brightly colored dresses. At least 30 times each day she will stop at the nurses' station and ask the same question. "How do I get out of here?" Fannie Thomas and Marie Fanelli, one black, one white-strangers to each other and to the world, but united by Alzheimer's-pace the corridors together from before breakfast until it's time to go to bed.
Frank Fanelli and James Thomas are two of the earliest and most regular Ralston House visitors. It somehow seems appropriate that their wives have become companions. Frank is 79, James 75. Both have heart conditions that forced them to give up caring for their wives at home. The Fanellis have been married 56 years and the Thomases 49. Neither couple has children. Every day, James takes a bus and two subway lines to arrive at Ralston House around 1 p.m. He spends the next 3 or 4 hours keeping Fannie company. "There's nothing more important to me than this woman-nothing," he says flatly. He scoffs at any suggestion that visiting every day is a hardship. "It's what you have to do," he says.
That's the way Frank Fanelli sees it, too. Each day after lunch he leaves the tiny bedroom house he has shared with Marie since 1939 and takes a bus up Walnut Street to the nursing home. He is often carrying something for Marie-new underwear or a Danish pastry. When the weather is nice, he likes to take Marie out for a walk in the garden next door or up Chestnut Street past the Roman Catholic church where they were married. Frank knows that his efforts are not always appreciated by Marie because of her illness. And his life, which was always quite simple, is much lonelier now. "It's no fun," he says. "But I still think my being here does Marie some good."
The major difference between the Fanellis and the Thomases is money. Fannie Thomas has already qualified for medicaid. But Marie Fanelli hasn't. So each month, Frank writes another big check to pay for her care. By the end of November, Marie will have spent two years in nursing homes and Frank will have spent $50,000 of their savings to pay for it. On the advice of a lawyer, Frank has separated his assets from his wife's so when the two year medicaid eligibility period expires, he will be protected. "I don't mind paying my share," says Frank, a retired advertising salesman. "But I don't think I should have to spend every last nickel before we qualify. I have to live, too."
Leonard Cope is another one of Ralston House's frequent afternoon visitors, arriving like clockwork every Tuesday and Thursday to see his mother, Rose Copelman, 91, who lives on the first floor. His sister, Evelyn, comes two or three other days each week. In a way, Leonard is also trying to pay back his mother for her sacrifices. Leonard's father left early on for another woman, and Rose Copelman worked as a seamstress to pay the bills. "When you're 10 years old, you don't understand,"
. Leonard says. "It's not until you're 62 that you fully appreciate what your mother did for you. Somewhere along the line I realized she devoted her entire life to her children."
Leonard is trying to prepare himself for his mother's death, wondering how much pain he will feel. He knows that no matter what he does now, he won't be ready. But he knows he can make his mother smile. So he comes to Ralston House and wheels his mother down to the lounge for a private hug. He cleans her nails and occasionally rubs cold cream into her face and covers it with a hot towel. "She likes the idea that her son does such things for her," Leonard says. Without visitors, the afternoons can be long and lonely. Indeed, inside each of the 35 or so occupied rooms at Ralston House there is always a measure of sadness, a sense of loss. In room 273, where Sara and Alice Noll live, those feelings run very high. At 89, Sara is almost 10 years older than Alice. They have lived together their entire lives, beginning in Pottstown, Pa. "I was 14 when our mother died," Sara recalls. "Alice was only 4. I remember Alice saying to me after the funeral, 'You'll have to be my mommy now.' " Later, it was Alice who ran the household and cared for her older sister. But Alice's stroke last year changed all that. Alice has lost her speech almost entirely and spends much of the day slumped over in her wheelchair. Sara, a diminutive woman with a ponytail, wheels Alice to meals and is always by her side.
"It's the worst time of our lives," Sara says. She is quick to add that she means no criticism of Ralston House. "It's just the way life has fallen. If Alice had never had the stroke, we'd be getting along well, running our own home." Instead, they live in a sparse room bare of personal effects. They spend much of their time in the dining room, often arriving 90 minutes before breakfast and staying on after dinner is over. Sara's mind wanders a lot. She talks about a man she once dated named Leonard Beezer and about how she never did get to be a teacher.
But mostly she talks about being old and tired. "Nobody likes to get old," she tells a visitor. "I'm tired." Despite Alice's stroke, the sisters have no problem communicating. Alice can hear Sara and can respond by nodding her head or mumbling. And even if nothing is being said, Alice knows her big sister is still taking care of her.

A Chair on the Stoop

The second shift of the nursing staff, which begins work at 3 o'clock, brings fresh faces and rested feet to the task. Cynthia Hall is a 22-year-old aide who dreams of becoming a full-fledged nurse. Like so many members of the nursing staff, Cynthia's choice of profession stemmed from a personal experience. For her, it was Izetta Brown, an elderly woman who lived alone across the street. Cynthia was barely a teenager, but she knew the woman was lonely and she knew she could make her feel better. They watched television together, and sometimes Cynthia would fix her hair. They sat out on the stoop so much that a neighbor bought Cynthia a small rocking chair that she placed next to Miss Brown's. "I used to get teased a lot by my friends," Cynthia recalls. "Everyone thought she was a real mean person, but I didn't see her that way. I knew she just wanted someone to talk to."
Cynthia sees a lot of people like Izetta Brown every day at work, but she is an adult now, and sees old age a little differently. "I know they must feel bad when they look out the window and see young people walking down the street," she says. Cynthia admits she kind of hates the thought of growing old. "It scares me because I know it's going to happen to me-getting old. Or maybe," she pauses, "maybe I'd rather die before I get like this."
For Mary Beth Mooney, 33, Ralston House's pharmacy consultant, the prospect is more immediate. Her parents are in their mid-70s and she is their only child. It is a sensitive subject in her parents' house, so sensitive that Mary Beth tries to avoid talking about her work in front of them. As the only child and a single parent, Mary Beth can't help but look around Ralston House and wonder: "I look at patients and think of my parents and I say, 'I could handle it if they were like that, but I couldn't bear it if they were like that.' " Given a choice, Mary Beth says she would rather have her parents live a few years less if they could do so on their own. "The loss of individuality scares me," she says. "And I'm totally overwhelmed by the loneliness."
Many family members of residents come away from visits determined to avoid a nursing home for themselves. "This place is very good for my aunt," says Rosalee Ricci, niece of second floor resident Winifred Herron. "But I want to go out playing tennis. If I knew this was in store for me, I would go out in the garage and turn on the engine."
For some residents, the nursing home is a genuine haven. Helen Teasdale, who shares a room with Mary Roach on the second floor at Ralston House, is proof of that. For 91 years, Helen lived in the same home across from Gesu Roman Catholic Church in North Philadelphia. But eight months ago, she was forced out. She had been attacked three times in recent years. The first thug wielded a butcher knife, and the last sexually assaulted her, leaving her nearly dead. Father William Perkins, the pastor of Gesu, brought Helen into his rectory to live. She later returned to her house, but lived as a hermit until she was finally persuaded to move to Ralston House.
But Helen is also proof that being safe doesn't translate into being happy. She spends most of her days sitting on her bed or in a chair, tapping her feet, listening to Perry Como and Bing Crosby on the radio and lamenting her fate. She has been a widow for more than 30 years and has only an elderly cousin left alive. "All my people are gone," she says, over and over again. She is at least half deaf, is legally blind from glaucoma and has suffered from a curvature of the spine since childhood. She rarely leaves her room, taking all her meals there. And when she does go out, it's usually just to walk a few paces with her walker in the hallway. She sits for hours on end, in silence, her hand held up against her cheek, her rosary beads dangling from her neck like a string of pearls.
One person who helps to ease the loneliness for Helen Teasdale and Mary Roach is Betsy Neidel, 21, a recent graduate of Penn who comes to visit two or three times each week. For Betsy, what began as a desire for volunteer work has turned into an emotional attachment to two old women. She brings homemade pumpkin bread, runs errands and even takes their laundry home with her. The time Betsy has spent in Room 278 has reinforced her dislike for life in a nursing home. But it has also strengthened her feelings about the elderly. "No one should write them off," she says. '
By around 5 p.m., as the residents are gathered together for their supper, whatever sense of anticipation was evident in the morning has mostly disappeared. The nonnursing staff is getting ready to go home. Most of the afternoon visitors have already left and after dinner is over, about the only activity in the dining room will be the sound from the TV. Within a few hours, most of the residents in Ralston House will be in bed, while much of the outside world is just beginning its evening.
Vivian Blank has been a part of both worlds for the past few months, ever since she placed her husband Ben in Ralston House. For Vivian, 66, the "final straw" in the always agonizing decision was more dramatic than most.

Ben, 75, has been suffering from Alzheimer's for many years. But by juggling her work schedule and with help from Ben's brother and sister and "anyone else I could find," Vivian was able to keep Ben at home in their apartment near Rittenhouse Square. But on April 1, Ben disappeared. When the police found him three days later, his face had been bashed. Now, almost every evening after closing her children's clothing store, Vivian goes to Ralston House to spend time with "Benjie." They can't converse much any more, but Ben's face lights up when he sees his wife. In a relatively short time, Vivian has become a part of the evening scene-and it has become a part of her. "You can't help but get involved with the other patients, especially when they're upset” she says. Vivian hopes she will never have to go into a nursing home. "They're not great places to live," she says. But she concedes that her perception of nursing homes as "dreadful places” has changed. "If it's something you need," she says, "it can be a wonderful place."
Marie Ellis understands. Eighty-three years old and less than 5 feet tall, she has the enthusiasm and the strength of a person half her age and twice her size. Every Monday and Thursday morning, Marie arrives at Pauline Fox's first-floor room with a smile on her face and a shopping bag full of goodies. She brings the latest paperback books because she knows that Pauline's reading helps her pass the time. She brings news of the neighborhood where they began their friendship 48 years ago.

Doing God's Work

Most important, Marie brings affection and companionship because she knows that Pauline, 87, needs both now more than ever. "I feel like I'm in jail," Pauline is fond of saying, as she thinks of the stroke that forced her to sell everything and move to Ralston House. But, she concedes, "Nobody has a friend like Marie." And all afternoon, Marie is with Pauline, laughing, telling stories, playing Scrabble, watching the afternoon soaps or just listening to her friend complain or reminisce. And after dinner, before she heads downstairs to catch the first of three buses for the 2 hour trip home, Marie makes sure that Pauline is properly tucked in for the night. "Good night, Sweetheart," Marie will say as she gives Pauline a kiss on the forehead. "Take it easy."
It is often after 9 o'clock by the time Marie arrives home, but she doesn't ever seem to tire of it all. "I look forward to coming," she says. "I'm not all that religious, but I feel if I can help her pass the time and make her happier, then I'm doing something. In a way, I'm doing God's work"
But even doing God's work isn't enough to change the fundamental reality of life in a nursing home. Mary Roach knows that. And she knows that no matter how many times the staff at Ralston House repeats its slogan, "What a great place to live," it will never replace home.
Peter Laudenslager, Ralston House's chief optimist, concedes that even good nursing homes can only do so much. "We're never going to be able to turn back the clock for these people," he says. "But we can care for them, and we can bring in kids to make them smile." He admits, reluctantly, that Ralston House will be the last stop for most. "There's no way around that," he says. "But you have to do the best you can." Mary Roach knows that too.