One fall Sunday last year, Connie Sewell embarked on what has become a routine 130-mile journey to visit her father at the Georgia War Veterans Home. When she arrived, she found him sitting unwashed in a soiled diaper outside a feces-smeared bathroom. It was, she said, a situation that had become depressingly routine for the 90-year-old Korea War veteran.
“This is so unsanitary, gross, neglectful and a great way of spreading diseases,” Haskell wrote in an email to the head of the facility in Milledgeville after the visit. “I don’t know what has happened to this facility, staff, and the management, but it really should be addressed.”
Two weeks later, Haskell Sewell was hospitalized after he fell, unattended, in his room. Emergency room doctors diagnosed him with sepsis, pneumonia and a urinary tract infection, none of which had been previously documented in his medical records.
Mr. Sewell, a former U.S. Navy machinist, moved into the Milledgeville facility in 2023 after he was diagnosed with early stage dementia. He, like many other elderly and infirm Georgia veterans, needed full-time care. The war veterans home, one of two state-owned facilities, provides such services for an affordable cost.
Her father’s travails last autumn illustrated what to Connie had been clear for some time: staffing levels at the veterans’ home in Milledgeville, which is managed by a Virginia-based company called STGi, were inadequate and failed to fulfill its promise did not fulfill its promise of providing veterans with dignity and respect.
Since taking over the facility in 2024, the company has struggled to retain staff and maintain standards outlined in its contract with the state of Georgia, according to seven staff members who currently work at the home or who have recently quit. These staffers, who worked directly in patient care, as well as records and documents reviewed by The Current GA, suggest systemic problems that impair the treatment and lives of many of the facility’s approximately 150 residents, including:
- An estimated 50% of people hired since the spring have left the Milledgeville home this year.
- On the memory care unit, where Mr. Sewell lived until early November, nurses were frequently reassigned from that floor to plug staffing holes on other floors, leaving the most vulnerable residents without proper levels of trained caregivers.
- Nurses without licenses to dispense medications have given agitated residents psychotropic drugs not authorized by the attending physician, as a way to lessen workloads for staff.
- While the contract with the state demands two fulltime licensed social workers, a key part of a care team who help the psychological well-being of residents, the facility has hired one without the required license.
Medical staff who have brought these and other issues to the attention of managers say they have been sidelined or pressured to quit. No current employees were willing to speak on the record for fear of reprisals and instead requested anonymity to speak about conditions at the Milledgeville facility.
STGi did not respond to multiple requests for comment. The company, which operates VA clinics in several states, did not have any experience with skilled nursing or memory care facilities before the state awarded it the Milledgeville contract in 2023, after negotiations broke down over costs with the previous company that managed the facility.
The Georgia Department of Veterans Services, the agency that oversees the home in Milledgeville, said that it was unable to provide comment about STGi’s performance, saying it was preparing a new request for proposals to manage the facility and citing state procurement protocols that prohibit the appearance of bias.
Monthly reports sent by STGi to GVDS showed staffing levels exceeded contractual requirements, said the agency’s head, Patricia Ross, who added that her department was not aware of any chronic patient neglect.
“Based on observations and inspections conducted by both State and Federal agencies annually, we do not believe unsanitary conditions are routine or prevalent, nor that there is a pattern of inadequate care. In a facility serving more than 170 veterans and employing over 200 staff members, isolated situations can occur. When they do, corrective actions are taken promptly, and steps are put in place to prevent future occurrences,” Ross said in a written statement.
Connie Sewell, meanwhile, has spent the last year advocating for better care standards for her father and other veterans at the Milledgeville facility and for state lawmakers to pay more attention. Although she is critical of STGi’s operations, she does not have a pick of facilities for her father. Other memory support facilities in the vicinity of her home in northwest Georgia are full, she said.
“No one is advocating for these veterans,” said Sewell, the chief financial officer of a building contractor who lives in Cumming. “I’ve been telling officials for months, telling lawmakers, telling the VA. You’d think that this would be a topic that politicians would want to take on, but you’d be wrong.”
Fraught reputation
Georgia has nearly 700,000 military veterans and, like other states, runs nursing homes for them. Overseen by GVDS, the two veterans’ homes have been in operation for more than half a century.
The installation in Augusta is overseen and staffed by the Augusta University’s Medical College of Georgia and routinely receives positive reviews by the U.S. Department of Veterans Affairs, which performs annual surveys on state veterans’ homes. The Milledgeville facility, however, has a more fraught reputation.
Up until 2023, the complex, which is designed to accommodate more than 250 residents, was managed by Georgia-based Pruitt Health, which operates dozens of nursing homes throughout the state that provide 24-hour care and rehabilitation services. Officials say that the company’s demand for more funding to offset rising staff costs at the aging, 1950s-era facility prompted the search for another management company.
STGi was the only qualified bidder to take over the contract, according to the state veterans’ agency. The privately held company cited its experience in “similar facility management” and its track records in constructing VA clinics.
STGi put in place a transition plan and outlined new procedures, determined to increase standards and address deficiencies that VA inspectors cited in their annual inspection of Milledgeville in July 2023 before it assumed control.
That report cited a failure to provide necessary services to maintain good grooming and hygiene for 148 residents who were then in residence. It also pointed to a failure to provide necessary services to promote healing of bed sores. The VA report, written after a three-day inspection of the home, noted that three residents appeared disheveled and unwashed.
Approached by an inspector for information about one resident, a certified nurse aide said “that they were not sure” when the person had last been offered help to shower or shave, according to the VA report.
Employees navigate tough transition
For some long-serving nurses at the Milledgeville veteran’s home, the transition to a new management company was rocky.
Some nurses with long experience with skilled nursing and emergency room care were wary of STGi’s lack of knowledge of the specialized care required for aging veterans. “Frankly, they didn’t know what they didn’t know,” said a registered nurse. “The environments they knew were nothing like” the level of care we give, the nurse said.
For others, the change in corporate administration meant an immediate dent in their wallets. Pruitt offered profit sharing to veteran staff. STGi promised raises, but nearly two years later, those have not materialized, multiple employees said.
STGi also promised to make the transition for residents as smooth as possible. But some daily routines and procedures diminished the lives of veterans instead of improving them, according to family members and staff.
Connie Sewell said the erosion of care included a drop of attention and services for her father, who for much of his life after the U.S. Navy operated a dental lab in Valdosta and was a longtime volunteer firefighter there.
In his initial exam records after moving to the facility in March 2023, medical staff described Mr. Sewell as “pleasant, elderly Veteran” who likes watching baseball, doing word searches and spending time outdoors. His care plan included keeping him in a “stimulating environment” to help the early stages of dementia.
When the veterans’ home was still operated by Pruitt, Connie said her father was content and busy. He participated in Tai Chi classes and other activities, according to his records. Those activities dropped off under STGi, she said.
Her father’s intake form also noted that Mr. Sewell suffered from chronic urinary tract infections. He was receiving regular lab tests to monitor that issue, Connie said. But that also changed when STGi took over, she said.
“We went from having blood work done on a monthly basis to nurses telling me it could only be done every three months” despite my father having insurance to pay for it, she said.
‘Yo-yo land’
For employees of the Milledgeville veterans’ home, the changeover was rough, too.
STGi’s contract with the state required the company to maintain staff levels in keeping with Georgia law and that ensured that residents would have access to nursing care for three hours each day — an increase over the federal standard for veterans’ homes at the time.
In 2024 federal law changed to require 3.48 hours of nursing care per day, a standard that most skilled nursing homes in Georgia struggle with.
By then, Connie recalled, she started noticing how reduced staffing levels on the floor where her father lived, a unit that specialized in dementia care, were affecting her father.
In April, Mr. Sewell fell in his room, according to his records. Nurses found him helpless on the floor and told Connie that he had slid off the bed as he was trying to stand up.
Later that month, staff started administering her father a psychotropic drug called Seroquil, which his chart said was supposed to aid his sleep. That decision was made despite his intake form noting that he had adverse reactions to such drugs.
During her next visit, Connie told a physician’s assistant that he felt like he was “in yo-yo land,” records show.
It was then she realized that she would need to more forcefully advocate for her father’s care. At least briefly, that seemed to work.
By mid-May, Mr. Sewell was taken off Seroquil. Nurses subsequently described him as pleasant, and showing no signs of distress.
Yet within a matter of weeks, his quality of life and level of care dropped precipitously, according to Connie.
On July 27 and again a week later, Connie and other relatives visiting over a weekend found Haskell Sewell in squalor.
His clothes were wet and sticking to him. His diaper was full and leaking, and he had dried feces caked to his body.
When she asked for towels to try and clean her father, the certified medication aide, the nurse responsible for bathing and cleaning patients, simply handed her the materials and did not offer to help, according to an email Connie sent to the head of the facility.
Mr. Sewell’s records show that during this period he was unable to bathe or groom himself without help. Through August, nursing assistants were giving him baths once every three or four days.
Alleged thefts, another fall
In September, Connie complained to the veterans’ home that her father’s clothes, prescription glasses and his dentures were missing from his room, according to internal records and emails reviewed by The Current. One of the staff members also appeared to take money from her father, she said.
Dennis Mize, STGi’s director at the veterans’ home, assured Connie that he would look into the theft allegations, according to an email reviewed by The Current. He did not follow up with Connie about the outcome of the investigation, she said. Later, she was told that STGi had instituted new procedures for staff who buy lunches and other items for residents.
On Sept. 29, Connie again complained that her father had been sitting in his own waste and that his bathroom had not been cleaned. In another email to Mize, she quoted his words back to him: “Veterans deserve to be always treated with dignity and respect,” she wrote.
Mr. Sewell’s records show that at the beginning of October, he was getting bathed once every two days, rather than every third or fourth day.
Yet it is unclear how closely nursing or other medical staff were monitoring Mr. Sewell’s health. There were no nurses and physicians notes from Sept. 10 until Oct. 13, according to the patient records supplied to Connie.
It was on that day — Oct. 13 — that Haskell Sewell was hospitalized for his fall and he was diagnosed with “severe sepsis.”
No focus
After he was discharged from the hospital and returned to the veterans’ home, Connie sent a complaint to the VA outlining her concerns about her father’s care. She said that a VA staff member told her that the correct place to lodge complaints was with Georgia’s Department of Veterans Affairs and its commissioner, Patricia Ross, a retired U.S. Air Force officer.
Connie started widening the email chain of recipients from her father’s nurses and their supervisors in what became a monthly litany of issues. She included officials from the Department of Veterans Affairs, corporate officials from STGi and state lawmakers.
The veterans agency requested more funding for the war veterans’ homes during the 2025 state legislative session, but their focus was for a separate project: a planned new sub-acute therapy program. Lawmakers did not address care or funding for the elderly residents already living at Milledgeville.
Staffing shell game
At the start of 2025, Milledgeville’s director told Connie that he had asked for registered nurse supervisors to increase their rounds on the memory support unit in the evenings and weekends and to check on her father more regularly to ensure “he is appropriately dressed and groomed.”
Later that month, Connie complained again in an email of finding her father in filthy bed sheets and unbathed. A bloody pillow she had told nurses about a month earlier had not been washed or replaced, she said.
The director continued to correspond with Connie, offering assurances. In one email, he said that a more robust schedule on the memory support floor now would include two or three certified nursing assistants and a nurse supervisor.
However, two people familiar with the staffing levels told The Current that for much of 2025, the increased rotation might be assigned on paper, but nurses from the memory floor were routinely reassigned to other, understaffed floors.
In March, STGi’s contract was renewed for one more year. It soon hired approximately 100 new employees with different levels of experience and medical specialities.
Yet by September, close to 50% of those new staff had quit or been let go, according to five STGi employees.
The state veterans agency said that its officials had discussed staffing turnover with STGi and the company outlined steps to address retention. In a written statement, the agency did not spell out those steps and noted that challenges to hiring and retaining skilled nursing care “are not unique to the current operator” due to tight labor markets.
Longtime nurses and other medical staff, they said, reported feeling burned out due to the increased patient workloads and what two employees said were shortcuts that appeared to be condoned by supervisors. That included overmedicating residents to keep them quiet and sleepy, they said.
A physician’s assistant who reported this behavior to the director of the home said that her concerns were ignored.
The annual VA survey of the home, which was completed on Aug. 1, cited the facility for incorrectly billing for certain medications, for serving residents cold food and for improper and unhygienic storage of food, among other issues. There was, however, no mention of staff levels, or allegations of what is known as “chemical restraints.”
‘I’m just exhausted’
In October, Connie said that conditions on her father’s floor were no better than they were when he was hospitalized a year earlier. Three employees familiar with the floor and who spoke to The Current that month agreed, although STGi had started contracting with an outside agency to help increase staffing.
Connie decided to move her father from the memory support unit to another floor, where she had been told there was better staffing and care.
“I am just exhausted with all the things that are going on [at the veterans’ home] and how so many things are just overlooked. My father is one of the nicest people and never gives you any problems,” she wrote in an Oct. 13, 2025, email addressed to Dennis Mize, Milledgeville’s director, and another top executive of STGi.
At the start of November, Mr. Sewell celebrated his 90th birthday in his new room. Two days later, the head of state’s Department of Veterans Sffairs wrote Connie saying that she appreciated Sewell’s advocacy and that the department was committed to “the health, safety, and well-being of every resident” of the home.
A week later, Connie said she had to make three phone calls to get someone at the facility to order a medical test after nurses reported that her father had become agitated. The subsequent lab report found he was suffering from another urinary tract infection.
“It still feels like if I wasn’t on them all the time, then nothing would get done,” she said.
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