They really are the heavy lifters. That's why the people who do the caregiving in America's nursing homes reportedly have the highest rates of workplace injuries and illnesses in the country.

Certified nursing assistants are eight times more likely than a roofer to suffer a back injury and twice as likely as a sheet metal worker to be bruised, according to the Public Health Institute.

For all this hard work, and the kindnesses they provide for families who can't or won't take care of an elderly relative, CNAs are paid about $10 an hour. Nationally, nearly 30 percent of direct-care workers (who include CNAs and the noncertified personal aides who do home care) live in households at or near the poverty level, and more than half have no health insurance.

"We pay them such paltry wages and expect them to take care of the people who should be our most revered," says Marilyn Luptak, assistant professor in the University of Utah School of Social Work.

No wonder, then, that there is a high turnover rate and a shortage. And it's only going to get worse, predicts Carrie Blakeway, senior manager with The Lewin Group, whose emphasis is long-term-care policy. "It's going to be a crisis pretty soon," she says. The increase in the "traditional" caregiving work force — generally women 24 to 45 — will lag far behind the number of elderly who will need them.

At Wasatch Valley Care Center, half of the residents don't have any outside contact at all, says former administrator Alec Stephenson, and another 25 percent have a visitor maybe once a month. CNAs become surrogate family.

At the funeral of one Wasatch Valley resident a few years ago, the woman's grandchild told CNA Pam Peterson that when his grandmother died "your name was the last one she called out."

"Verging on saints," is the way Salt Lake geriatrician Dr. Fred Gottlieb describes CNAs.

Occasionally a CNA abuses a resident. Even though the state Department of Health requires criminal background checks, if a CNA has previously assaulted someone the crime may still be wending its way through the court system, unbeknownst to the care center or home health agency that does the hiring. Or the abuse may have gone unnoticed or ignored. And sometimes the abuse goes the other way, because when people are old, sick and confused they might punch and slap and cuss the people trying to change their briefs or wake them for breakfast.

Juanita Albor has dodged the fist of the occasional confused or angry resident during her 28 years at Christus St. Joseph's Villa. Not long ago, she was helping a man in the bathroom when he took a swing at her.