Chronic offenses may close facility

By Marshall Allen

Friday, Dec. 4, 2009 | 2 a.m.

State health authorities are revoking the license of Chancellor Gardens of the Lakes after a third investigation in two months revealed that residents were still not receiving proper medications.

Chancellor Gardens was notified of the revocation Wednesday, but the facility will appeal, which means its 109 residents will not be forced to move right away. A decision about the revocation could come within three months, state officials said, although there’s still a chance it could be shuttered immediately.

Chancellor Gardens is an assisted living and Alzheimer’s facility where some residents pay more than $4,000 a month for care, but where the staff has failed to provide promised services and health care. The revocation notice was prompted by the latest state inspection that showed residents were not receiving their medication — even after the state had warned the facility’s management twice before of the same problem.

In mid-September an inspection revealed residents were in “immediate jeopardy” because they were missing medications. A month later another inspection revealed that residents were not receiving their drugs, resulting in three hospitalizations. State inspectors discovered technicians were throwing pills away rather than administering them to residents.

And the most recent inspection, between Nov. 18-19, found that 25 of 78 residents were not receiving medications as prescribed and nine of 80 did not have one or more medications available.

“The facility is neglecting the medical needs of the residents, and the residents are not safe” because of the failures to properly administer drugs, the revocation letter said.

Larry Blake, managing member of Chancellor Gardens, released a statement saying he takes the issues seriously, and the facility has made numerous staff changes to correct the problems.

“The public should be assured that we are moving quickly and effectively to answer any concerns regarding resident care,” the statement said.

Residents are safe and the facility will remain open, Blake said.

The state’s most recent survey turned up a litany of additional problems at Chancellor Gardens:

• Four of 13 caregivers who were administering medications were not properly trained to do so.

• Fifteen of 69 employees failed to meet background check requirements.

• The Alzheimer’s unit reeked of urine.

• Caregivers did not respond to an alarm when it was activated in a resident’s room.

• Ten residents had not had an annual physical — a repeat deficiency from a February inspection.

• Caregivers did not prevent a resident from smoking inside a room.

• Syringes and needles were not disposed of properly.

• An exit door to the Alzheimer’s facility did not have alarms that operated when the door was opened, and chairs positioned by the outside fence would enable residents to escape — a repeat deficiency from the October investigation.

• Six serrated knives were stored in an unsecured drawer in the kitchen of the Alzheimer’s facility.

Sylvia Healy, founder of the advocacy group Citizens for Patient Dignity, said she was shocked when she heard of the continuing problems at Chancellor Gardens.

“These people are just total idiots, aren’t they?” Healy said of the facility’s staff. “The state is not taking enough action. (Regulators) need to get in there and find someone to run that facility properly — $4,000 a month, and they can’t get anyone to offer proper care? It’s unbelievable.”

Healy said she has complained about problems in elder care facilities for years to legislators and state officials, but received little response. Senior citizens need to voice their concerns to their elected officials to get things changed, she said.

The state’s Health Care Quality and Compliance Bureau fined Chancellor Gardens $9,800 for various deficiencies, and more fines could be forthcoming. Its directed plan of correction requires the facility to hire enough qualified medical technicians to administer drugs, ensure the medications are available at all times and hire an additional registered nurse to oversee their administration.

Bureau Chief Marla McDade Williams said Chancellor Gardens has systemic problems that need to be rectified with additional staff and better internal practices. The facility has made progress in recent months, but not quickly enough, she said.

“I think they’re well-intentioned, but don’t have enough people in place to really make an impact,” she said.

The state always leans toward working with a facility to correct its problems, rather than shutting it down, but if things don’t improve the state could suspend its license, which would require the immediate removal of residents, she said.