Man says care of his mother at facility left her hospitalized

Chancellor Gardens of the Lakes slapped with admissions suspension

Leila Navidi

State officials on Tuesday placed a temporary ban on admissions at Chancellor Gardens until officials there can ensure that residents receive their drugs.

By Marshall Allen (contact)

Thursday, Nov. 12, 2009 | 2 a.m.

Yvette Bornstein

More Sun health coverage

State faults facility for care of seniors (10-29-2009)

When David Bornstein checked his elderly mother into Chancellor Gardens of the Lakes, she was able to carry on a conversation, walk with assistance and go on day trips.

Two months later Yvette Bornstein, 79, was admitted to a hospital. Her buttocks were covered in bed sores, David Bornstein said, and hospital nurses said it appeared she had been lying in urine-soaked garments for days. Her dementia had been controlled by medications before her stay, but now she was combative and disoriented. Her blood pressure was irregular and a wound on her back that had been managed with regular care had become severely infected. She was dehydrated, and her weight had dropped by about 20 percent to 102 pounds.

Two months at Chancellor Gardens had taken his mother to the brink of death, Bornstein said.

“She wasn’t getting her medications there,” he said. “They weren’t making an attempt to see that she received them.”

David Bornstein’s mother left Chancellor Gardens about two weeks ago and is recovering at a different facility. She was apparently one of many patients who were not receiving their medication at Chancellor Gardens. State officials on Tuesday placed a temporary ban on admissions at the 150-bed facility until officials there can ensure that residents receive their drugs. Patient record reviews by state authorities found that of 32 patients whose folders were checked at random, not one had received his or her medicines for the month, suggesting that perhaps no patients received the medications they needed for months.

The 72-hour admissions ban could be extended, according to Nevada Bureau of Health Care Quality and Compliance authorities.

The bureau reported that three residents were hospitalized because they did not receive their medications, though officials could not say whether Bornstein’s mother was one of them. Marla McDade Williams, the bureau’s chief, said the actual number could be higher.

State officials started their in-depth probe of Chancellor Gardens after receiving complaints in September. During the investigation, the facility’s wellness director told investigators that she knew caregivers were not administering drugs to residents and that some were throwing the medications away because they did not have time to administer them, officials said. Other staff members told state officials this was common practice.

Staff reported to the state that almost every resident was missing one or more medications. The state sampled 23 residents in September and found none receiving prescribed medications. In response, the facility’s executive director said arrangements would be made with a pharmacy to correct the problem.

In October additional complaints were received by the state, and a subsequent investigation revealed that all 28 residents sampled were not receiving their medications as prescribed, state officials said. Chancellor Gardens has since hired two registered nurses and a consultant to correct the problems. The executive director has resigned and been reported to her licensing board, officials said.

Williams, from the state, said Chancellor Gardens appears to be correcting the problems. If the situation is not rectified, the state could appoint a temporary manager of the facility, or suspend or revoke its license, she said.

Lon Records, whose stepmother was a resident at Chancellor Gardens, criticized the state’s slow response. He complained in December 2008 that Jean Records was not receiving her medication and was living in squalid conditions.

Jean Records was from Las Vegas and wanted to live in her hometown. Her children lived elsewhere and liked Chancellor Gardens when she was admitted in December 2005, said Lon Records, president of a wholesale distribution company in Riverside, Calif. The problems were not immediately apparent because the children could only make phone calls and occasional visits.

When Jean Records was admitted, her physician assessment said she was forgetful and unable to administer her own medications. The family’s $4,000 in monthly fees to the facility included about $300 to administer her medication, Lon Records said.

Records had a cat, and on Sept. 9, 2008, her visiting daughter found the room stinking and filled with garbage, including stacks of newspapers soaked with cat urine in the closet. A plastic bag containing several months of her medications was in a dresser drawer.

Records’ daughter asked the staff about the medication and was told, incorrectly, that she was a “self medicator,” according to the complaint filed with the state. The staff members told her that Records would not allow them to clean her room.

Jean Records died of pneumonia four days after the visit, Lon Records said. The facility failed to provide her with medication, proper care and a clean environment, and the filth and toxic odors contributed to her illness, he said.

The state investigated the complaint but could not substantiate it because of a lack of evidence. Williams, the state bureau chief, said there are many factors that determine whether a complaint can be substantiated, but sometimes the problems are hard to verify.

Lon Records blames Chancellor Gardens and the state for his stepmother’s death. He requested a $9,900 refund for the 33 months of medication fees, but received nothing. Records said a lawsuit should be filed against Chancellor Gardens.

“They need to pay for their neglect of these people,” Records said. “You’re giving your loved ones to them for care and maintenance and paying a steep price. When they (neglect residents) it’s just criminal.”

Two former staff members who worked briefly at Chancellor Gardens this fall told the Sun the executive director was inexperienced and prevented other managers from doing their jobs. The former wellness director, who worked at the facility in July and August, said the facility was short-staffed, employing only a single technician to administer medications for 110 residents. She said she often received calls from doctors, wondering why the lab results of their patients were not reflecting medications. Sometimes technicians initialed records as if medication had been administered when it had not, she said.

The former wellness director said when it became clear that her boss would not help rectify the problems, she quit and filed a complaint with the state.

“I knew I had to make that complaint because of the condition of the residents there,” she said. “They entrusted their well-being to the (facility).”

Discussion: 23 comments so far…

By rejco100

11/12/09 at 8:17 a.m.

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Of course all the strung-out junkies that work there, and help themselves to all the OXY TABS they want, are DENYING EVERYTHING!
By rumrunner

11/12/09 at 8:20 a.m.

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It didnt even take me to half the articale before i was wondering why is this place still open?And if you care to know,just to sit and listen to an elderly person is sometimes mind blowing to the fact what they have seen in their lifetime.And im still amazed at my age.
By Kaliscanner

11/12/09 at 9:04 a.m.

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I prefer the "knee-jerk" approach to this issue. Transfer all the patients to loving, caring facilities and close Chancellor Gardens until new staff can be properly trained. Drug test all current employees and terminate those in violation of their substance abuse agreement. This has to stop and needs to stop now. What does this say about our society when we can not or will not take care of our Senior Citizens. To all of those involved with this facility, thank God that they don't put me in charge for one day because you..well..an eye for an eye is all I can think of right now.
By MG

11/12/09 at 9:48 a.m.

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So the "state" investigated and were unable to find proof, what a bunch of BS. Based of the facts of this story there was plenty of evidence unless of course they don't want to find any evidence. The state receives payment to license and oversee these types of hell holes in order to prevent this type of abuse from occuring to human beings that are unable to protect themselves such as seniors and children. A full investigation should include not just the Chancellor Gardens but more importantly the state agency that licenses and inspects them. This probably continues to happen today in many other "care centers."
By tailspin

11/12/09 at 9:56 a.m.

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This facility has had alot of problems. The former Executive Director created a hostile work place for employees. She trusted another employee to hire and that person hired untrained bodies. Thank God the 2 of them are no longer there. Thats a plus into improving the property. I'm certain if the State investigated further they would find alot more issues. The former Exe. Dir.would not make the necessary changes recommended to improve the medication system. She was the problem. The residents there deserve the best. Like any AL facitity, it's all about MONEY. SHAME ON YOU!
By halfacre

11/12/09 at 11:41 a.m.

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This is a common problem in "rehab" care hospitals in Las Vegas. My mother spent almost a year in four different "rehab" hospitals recently because of a broken hip. Rancho rehab tied to UMC was the worst. She fell there and and shattered her other hip because of the incompetence and laziness of the nurses there the day before she was supposed to come home. They are all understaffed and the staff they do have are surly and uncaring.
By Babyboomer

11/12/09 at 1:02 p.m.

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There are so many reasons why this son should have done his homework.Perhaps it was as simple as he couldn't deal with it any longer. But, if in fact he truly cared for his mother then clearly he failed in checking this place out.No question this place needs to be closed or taken over my the state.He is very lucky she is still alive. I've seen it all too often and it's very sad.My friends mother was placed in a home but in her case at least 2 family members had constant contact with the staff and administrators.The fact this home was above board on so many levels is a credit to the staff. The $9,000 monthly fee for most people is impossible even with coverage. It's a total disgrace in this country it has come to it.
By BSsniffer

11/12/09 at 1:22 p.m.

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There are no strung-out junkies working there. And it is obvious from this article that the snitch is the former wellness director. The only thing she has done right is report the problems to the state. She is a big reason why there are problems there. It was her job to make sure the residents were cared for properly and she did not do her job. Her poor job at supervising her staff led to the problems. Now she is trying to blame the problems she caused on other people. As the wellness director, she had the power to rectify the problems and was too incompetent to do it. The Sun should be looking at her instead of just listening to her complaints. Thank god the place has competent people in place now. Give them some time and they will turn it around.
By MG

11/12/09 at 2:29 p.m.

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Typical response, let's blame the person that brought this to our attention. It's no wonder people are apprehensive to be a whistle blower and report problems such as this. The former wellness director only worked there a short time prior and tried to get her boss to support her to no avail. She then did the right thing by having the courage to quit her job and report them versus sticking around like the rest of them just for a weekly pay check. This problem is far from over especially considering the problem "her boss" still works there!!!
By NativeNevadian

11/12/09 at 3:07 p.m.

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This place should be shut down.

Mr. Records should sue for wrongful death and elder abuse.

Mr. Bornstein should also sue for elder abuse.

I know I would, faster than a New York Second!
By LKNaked

11/12/09 at 4:26 p.m.

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Considering that they let go the three highest ranked employees, because of lying to the state, etc, and replaced them with trained people, before the disgruntled employees started reporting them, I think they ARE doing all they can.
Most of the people that work there care deeply about the residents, and do all they can to keep them safe and happy.
Why did the Wellness Director wait so long after leaving to report to the state? Maybe because she found out she couldn't sue and get money? The fact that these people want their jobs back, after saying how awful it is there speaks volumes about them. If I thought a senior was in danger I would report it THEN, not three months later!
I know my parents have been cared for there, and wouldn't leave for anything, yes there are problems, there are everywhere, but they CARE for the residents, and it shows!
By wayout

11/12/09 at 8:32 p.m.

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I agree with LKNaked the people that work there care deeply about the residents. The truth is not always told in the newspaper only stories that disgruntled employees want printed. Why did the wellness director wait so long? Why was nothing done while the wellness director worked there? and why does she want her job back if the place was such a mess? It sounds like the problems are out of the building. Name one assisted living community that has not had problems. I guess the newspaper is not out after them. Keep up the good work Chancellor Gardens and all the staff that care and give great service. The changes you have made are great.
By nurse411

11/12/09 at 8:53 p.m.

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Ok I read this article and as a nurse who has worked in Assisted Living and skilled nursing, the first thing wrong is why didn't the nurse that reported Chancellor Gardens do something about the caregivers not giving meds?! It is her duty to protect the residents and she was responsible as part of her license to respond to what her caregivers were doing...not just ok I'm calling the state...it was her duty to take action. Also if the resident was debilitated and had a pressure ulcer she would have to have been treated by home health since it is an Assisted Living. That means resident can still remain in their residence and home health nurse treats the wound. They obviously must of dropped the ball, which is why Chancellor sent the patient to the hospital in the first place, yet they get blamed. And why is this story so one-sided and accusatory? They need to get to tell their side. I believe the nurse who reported them in the first place was negligent in her practice or she would have assessed her patient and taken action.
By Marshall Allen (Staff)

11/12/09 at 10:03 p.m.

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Hi nurse411 - thanks for your comment on my story. You're right, this story, and my story on Oct. 29, are "one sided," as you say. That's because this facility is not calling me back to tell me their side of the story. I have urged them to call me back, because they really do owe the community an explanation. Hopefully they will do so soon.
By rumrunner

11/12/09 at 11:58 p.m.

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Thank You Marshall Allen.And look foward to hearing a responce from them as well.I would like to hear there side before I make any more statments.
By tailspin

11/13/09 at 5:08 a.m.

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It's unfortunate for everyone involved especially the residents. A couple of employees with authority ruined this facility, I guess the power got the best of them and clouded their judgement. Where are these employees now? Still working with seniors or children. That concerns me. Attention Administrators, think twice before hanging your license in a facility if you are not the active Executive Director.
By nurse411

11/13/09 at 9:29 a.m.

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Marshall thank you for writing back to my comment. I think that a facility this large would have contacted you back. I think they do want their side of the story told and have tried to get in touch with no response. I know at the facility I have worked at for the last two years, we would promptly respond to any media requests, especially one that was painting us in such a negative light. Are you sure you can't get in contact? Maybe calling the wrong person?
By vegaschance

11/13/09 at 9:39 a.m.

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Has anyone every heard of accountablity? It has been my exprience that if employees are not able to perfom there jobs and are held accountable then they point the finger! As for this "Wellness Director" where you part of the soultion or part of the problem? It seems to me that you were part of the problem!
By mojaveman

11/13/09 at 10:01 a.m.

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Our parent has lived in Chancellor Gardens for more than 5 years. We visit at least 3 X's a week and have found this facility to be a comfortable place for our parent to live. For the most part, CG does a good job operating this assisted living center. We HAVE noticed over the past several months that the employee turnover has been extraordinarily high - lots of turnover in caregivers, wellness directors, executive directors, ect. Not wanting to traumatize our elderly parent by suggesting a move at this time, we have visited even more frequently during the last several months. That is probably why we have not experienced the problems reported by the LV SUN.

Comments on comments:

To Tailspin: For the last several months the problem has not just been with the inexperienced exec. dir., but also with the wellness director (she would call an ambulance at the drop of a hat, and apparently did not adequately supervise the administration of meds). I also question why she did not go to the state much earlier. However, the reported issues began even before the recent wellness director worked here. Too much employee turnover...

To Nurse 411: I agree with your comments about the previous wellness director. She should have done a much better job of supervising the caregivers and those that administered meds. It find it odd that she waited so long to report to the state if it was beyond her ability to remedy some of these problems herself. I too thought the 10/29 LV SUN story was too one-sided. In his comment, the reporter, Marshall Allen states that:

"this facility is not calling me back to tell me their side of the story. I have urged them to call me back, because they really do owe the community an explanation. Hopefully they will do so soon."

Mr. Allen, if and when they do respond, will you feature a front-page story with "their side"? I attended a special meeting at Chancellor Gardens after your last story. The CEO said that the COO of Chancellor Gardens returned the reporters calls, but they played "phone tag".

From my perspective, I feel the issues were possible because of lack of attention from the top. Why was the COO not on top of this facility when these problems were occurring over several months?

Finally, I must say that we have been impressed with the changes made since the October 29th story. I believe that the owners and management of CG are committed to excellent care and that they have hired supremely qualified management to oversee this facility to bring it to the standards of years past. We hope it continues.
By Marshall Allen (Staff)

11/13/09 at 12:31 p.m.

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Just to clarify - I have talked to two different people with the company, but they passed me on to others for comment. I got one call back from a third person for my Oct. 29 story, a voice mail. I called back immediately and never heard back. There has been plenty of time since Oct. 28 to call me so the community could be informed about what's going on. At the next special meeting, please have the CEO give me a call so the broader community can understand how so many residents apparently went without their medication, including some who needed to be hospitalized.
By MG

11/13/09 at 2:45 p.m.

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Surprise, Surprise! No response from them. It must be because they REALLY CARE SO MUCH!!!
By 1baja

11/14/09 at 2:20 a.m.

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I have wrote to the Sun before asking for investigations. These nursing homes and care facilities in this city are a joke. The state bureau of health care is a joke. I have contacted Ms. McDade Williams a couple of times, only to be transfered to someone here locally, who give you nothing but fancy BS talk, that they investigate and issue corrective actions. I've been in 2 of these hell holes in the last 16 months, complained to state, and there findings, which are on the state website, list nothing more than the floor in the bathroom needs cleaned. No where is it mentioned the complaints of several patients. No where is it mentioned the resident doctors and staff, charging insurance companies for medications not needed. I'm continually being charged for high blood pressure medicine, which I have never been on because my personal doctor says my blood pressure is as close to perfect as it can be. These places care about nothing but money. The CNA's are the only ones that try to do a caring job, but are continuously held back or stopped, by higher up staff. CNA's are told daily " these are not your friends or family, do not talk to them, do your job and get out. Anyone caught talking with patients will be fired on the spot." No one cares about the patients. The social workers at St. Rose Siena, deny patients their right to speak to their doctor, then more than likely get a kick back pay, for sending patients to hell hole nursing homes, regardless of orders from patients doctor. Management in these so called care facilities, are only working for there year end bonuses. They send nurses home, to cut cost, with no regards to lowering patient care because no nurses available. It is not uncommon to wait an hour to an hour and a half for a call light to be answered, because there is not enough nurses on duty. Nurses and patients have to beg for supplies, nurses sometimes have to bring toilet paper from home for employees bathroom. This is only a small example of what we go through dailly so management can show corporate they're saving money to get that almighty dollar at year end. The state bureau is typical government workers, care only about their paycheck. When you complain to them, the abuse at the facility only gets worse. They probably get kick back pay from facilities, for telling them whose saying what. After issuing there inspection reports, the facilities plan of correction says nothing more than "will talk to staff" and state accepts that. It's a joke. I have asked state several times for Federal agency that is over state agency, and they refuse to give that information.
A federal investigation needs done to these nursing homes and health care facilities. Not only are people not being taken care of, people are getting sicker, people are dying due to lack of proper care, and insurance companies are being scammed big time.
SOMEBODY PLEASE HELP US !!!!!
By harveyclan

11/18/09 at 9:18 a.m.

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I have sat here and read all your comments and find most of them to make me laugh. As children is it not our responsibility to make sure that our parents are doing well, whether you live out of state or not. My dad is in CG right now and I go and see him at least 4-5 times a week at different times so the staff doesn't get use to seeing me at the same time. Since he has been there he has gained over 10 pounds that he couldn't afford to loose he is happier more now than he has been in years. I don't know why people put so much into what the media reports on, the media only puts out there what is going to get the most responses. And I belive that Marshall Allen was called back and did not respond, because if he had he would not be able to print this story, it would have taken on a whole different story line. I and my dad are very happy with the care he is getting. If you all are so unhappy with the care then I suggest that get more involved with your loved ones care...