It was only during the later years of her life that Anna Jo Mann stopped pleading with her parents and brother to take her away from Clover Bottom Developmental Center, the state's oldest institution for people with intellectual disabilities.

Born with a missing chromosome that left her severely disabled, blinded in one eye by another resident at a young age, Mann died unexpectedly in August at the age of 73 of cardiac arrest. She had lived at Clover Bottom for more than 60 years. Her death came just a few months shy of the state's long-delayed promise to move her into a suburban home on a tree-lined street, where she would have had her own room for the first time in her life.

Her brother and guardian, Patrick Mann, wept as he remembered.

"It's still very troubling to me," Mann said. "We would go visit her, but the visits became much less because it was so traumatic, not only for my parents but for her. She would cry, 'I want to come home' and 'Don't you love me?' We would wait in the lobby and take her out for ice cream and you would hear noises from the others inside, screams."

Four years after pledging to shut it down, state officials with the Department of Intellectual and Developmental Disabilities have yet to shutter Clover Bottom, the 90-year-old institution created in an earlier era when people with autism and other disabilities were sent to large state institutions at young ages to live out their days.

Forty longtime residents still live on the aging Donelson campus that once housed more than 1,500. Some have lived at the facility for decades, waiting for the state to deliver on its long-delayed promise to move them into homes in residential neighborhoods. Thousands of people with disabilities across the country have left state facilities as part of a national deinstitutionalization movement intended to improve quality of life and reduce costs.

Most residents were found as far back as 1997 to belong someplace else -- residential homes or small-scale intermediate-care facilities that could care for their complex medical needs while integrating them into the community. In 2009, then-Gov. Phil Bredesen said they would move by 2010. Officials now say the last resident won't leave until May 2015.

The delay in closing Clover Bottom comes not only with continued uncertainty for residents and their families but also with an enormous price tag to Tennessee taxpayers, who will help foot the bill next year for what could be the nation's most expensive institutionalized care, according to data compiled by the American Association on Intellectual and Developmental Disabilities.

Tennessee's annual cost for each remaining Clover Bottom resident is expected to surpass half a million dollars next year -- double the state's cost of care from 10 years ago. Tennessee already spends 50 percent more than the national average.

The high cost of care in Tennessee so alarmed federal officials that last year they investigated the state for possible billing fraud. They found none. Instead the costs continue to escalate, a result of a small number of residents living on an aging campus built for more than 1,500, with old buildings, expensive upkeep and a requirement for around-the-clock professional staff. Clover Bottom has budgeted for 101 staff members this year, even as the population at the facility is expected to dwindle to 24.

DIDD officials note the ratio of caregivers to residents has always been high, given the complex health and physical needs of its residents. But developmental centers were built for and operate most efficiently serving much larger numbers of people, according to Lance Iverson, deputy commissioner of fiscal and administrative services for DIDD.

"The economies of scale are not working in our favor," Iverson said.

Next year, the cost of care for each remaining Clover Bottom resident is estimated at $1,400 per day, or $511,200 per resident each year. Providing care to the same individuals outside Clover Bottom is expected to save the state $100,000 per person each year.

The spending on institutional care for these residents comes at a time when the state is turning away other residents with disabilities because of a lack of funding. More than 7,100 people with intellectual disabilities are on the waiting list for services from the agency, many for years.

Life at Clover Bottom is vastly improved from the early 1990s, when a Department of Justice investigation uncovered widespread abuses, including failure to provide education, inadequate medical care, abusive treatment and insufficient staffing. But ongoing inspections of Clover Bottom by monitors appointed by a federal court show serious problems still linger.

Inspectors found a shortage of physical therapy staff, which "presents a risk to the health and safety of most of the individuals." They noted multiple bruises, abrasions and lacerations sustained by residents while staff was moving them from wheelchairs to beds to showers. They found delays in obtaining proper medical care, and a large number of pneumonia cases -- a result, they noted, of residents inadvertently inhaling food into their lungs while eating.

Between September 2012 and August 2013, DIDD recorded five serious injuries, 17 allegations of abuse and neglect and 775 other injuries -- an average of 19 injuries per person living at Clover Bottom over an 11-month period. A DIDD spokeswoman stressed that the 775 injuries were minor -- "superficial scratches or abrasions, pinpoint bruises or red spots" that most other health care settings are not required to report. Only seven of the allegations of neglect were substantiated, she said.

Reasons for delay

Agency officials cite a number of reasons behind the delay in closing Clover Bottom.

The plan that Bredesen announced in 2009 did not foresee the need to build homes for residents leaving Clover Bottom. The initial plan was to move residents into facilities already open and operated by private agencies. Nearly 100 residents did move into those privately run residences and facilities between 2009 and 2012.

That left 53 residents at Clover Bottom in 2012.

Among those who remained were the most medically fragile, people who needed ongoing medical care and close supervision. Some family members resisted moving them, citing a series of problems with privately run homes in West Tennessee, where the state had closed Arlington Developmental Center in 2010 after the U.S. Department of Justice filed suit over deplorable conditions there.

Residents who moved from Arlington into private facilities experienced abuse, neglect and higher rates of mortality after they left the facility, according to monitors appointed by a federal judge to oversee their care. Families expressed concern about the quality of care in some of those agencies. DIDD decided to build homes for medically fragile individuals that would be operated by the state, rather than private agencies, spokeswoman Cara Kumari said.

"There were so many experiences with community residences not being prepared for, or fully prepared for, these individuals," said Lynn Burkett, guardian to her 67-year-old sister, Theresa, who has lived at Clover Bottom since 1991 but is scheduled to move within weeks.

Burkett, like other family members, also worries about the trauma of a move on her sister.

"Familiarity is security for this group of people," she said. "You can't have a conversation with my sister Theresa and say, 'You're going to be moving to a really nice house.' The change itself is going to be traumatic to her. Right now she and her roommates have a routine where they throw stuffed animals off the bed and laugh together before they go to sleep. When she moves, she will have her own room, which the state thinks is wonderful. But my sister has never been in a room by herself."

Other delays were purely logistical. Once the state decided to build and operate its own facilities, four-person homes that provided ongoing medical care to former Clover Bottom residents, that process ran into its own delays.

State purchasing rules, since changed, slowed the state's ability to bid on properties in a timely manner. The state scratched original blueprints for the homes, deciding to start over with a new design, even after the state had paid an architect to design 37 homes across the state that would have cost $825,000 each to build. The blueprints were used to build some of those homes before they were scratched.

Then there were construction delays, Kumari said.

Thus far, four of these homes in Middle Tennessee have been built. Sixteen residents are expected to move into them by this spring, leaving 24 residents at Clover Bottom. Seven more homes are to be completed by May 2015 to house the remaining Clover Bottom residents.

"Progress has been slow and unacceptable," noted one recent court-ordered review of Clover Bottom's progress in relocating residents.

Health problems

Those left at Clover Bottom live in small cottages built in the 1970s on the grounds of the sprawling campus. Under oversight of a federal court since 1997, the facility has been forced to make improvements to comply with standards set by the court.

Residents are taken on outings to day programs, and many have memberships to community organizations, such as the Nashville Zoo, churches and the library.

Court monitors noted that staff were engaged with residents and "everyone living at the facility was treated with dignity and respect."

But they also noted serious problems affecting the health and well-being of the remaining residents.

E. coli, a type of bacteria found in human and animal feces that can cause infection or even death, was a widespread problem, with investigators noting it was related to inadequate hand washing by staff and bathroom care provided to the residents.

Many residents had pressure ulcers and "red areas" associated with feeding tubes and wheelchairs, but the sores went unidentified by nursing staff.

Five residents had aspiration pneumonia -- related to ingesting food into their lungs, typically while eating. Investigators noted that staff probably had not propped them in the right position during meals.

Seven residents had multiple bruises, abrasions and lacerations related to staff improperly moving them from bed to wheelchairs to bathrooms.

Only one physical therapist was serving the group, but "the needs are so intense that the current staffing for physical and occupational therapy is insufficient and presents a risk to the health and safety" of the residents, the report said.

And there were continued problems in providing adequate medical care. One woman, identified as "Heath W," for example, experienced a steady rise in blood glucose between April and August 2013 but had no follow-up care to determine whether she suffered from diabetes. Another woman was on three types of seizure medication, although she had not had a seizure in two years. Another woman, named Doris H., had been injuring herself repeatedly for an unknown period of time, but the behavior went unnoticed by staff, who sought no treatment for her.

Former Clover Bottom resident Bill Gage says he doesn't understand why residents must still live in the facility. Gage and his twin brother, Sam, were admitted to Clover Bottom at age 6 and spent decades in state institutions before the brothers, with the help of advocates, asserted their right to live in their own home in West Tennessee.

"It's about our civil rights and our freedom," said Gage, now 59. "We just want to be treated like everyone else and live a normal life, not sent away where no one has to see us.

"It's been a long process -- too long, really."