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All 23 of the patient files randomly reviewed by state inspectors revealed negligence in the administering of drugs at Chancellor Gardens.
Thursday, Oct. 29, 2009 | 2 a.m.
Sun Coverage
All 139 elderly patients at an assisted-living and Alzheimer’s facility may have gone without their medications for weeks, according to a Nevada State Health Division report obtained by the Sun.
Health authorities reached this conclusion after randomly inspecting the case files of 23 residents at Chancellor Gardens of the Lakes. In every instance caregivers either did not have the drugs available, or did not have the time to administer them and threw away the medications, according to a report delivered to the facility Tuesday by inspectors from the state’s Bureau of Health Care Quality & Compliance.
The problems have persisted since Sept. 19, said Marla McDade Williams, the bureau’s chief. The state is considering a takeover of the facility, a ban on admissions or limiting its occupancy. The facility will also be fined by the state at the conclusion of its investigation, she said.
Representatives from Chancellor Gardens, at 2620 Lake Sahara Drive in Las Vegas, did not return phone calls seeking comment.
Acting on a complaint, officials from the Health Division, which licenses the facility, inspected the home between Sept. 19 and Sept. 24. The precise nature of the complaint was not disclosed. Inspectors reviewed the records of 23 of the patients and discovered the collapse of protocol in each.
Inspectors have since visited the facility multiple times a week and the ongoing problems are causing serious concern about the well-being of all 139 elderly residents, McDade Williams said.
“Their health issues could escalate to the point where they could be hospitalized,” McDade Williams said.
She said the investigation has not yet determined whether any patients have been harmed.
Health inspectors often find problems when they inspect assisted-living facilities. But rarely do they discover problems as severe and widespread as what’s been detected at Chancellor Gardens.
Carol Cable, chief operations officer for Senior Management Concepts, the company that owns Chancellor Gardens, did not return calls for comment. The Health Division reported Cable to her licensing agency, the Nevada Board of Examiners for Long Term Care Administrators, which is now investigating the case. The board fined Cable in May for neglect of patients and using unqualified staff.
Chancellor Gardens is the company’s only facility in Nevada. It owns one in Seattle and nine in Utah.
Many of the 23 residents whose case files were reviewed were supposed to be taking multiple medications. For example, Patient No. 1 in the report was not receiving aspirin, calcium and drugs for Alzheimer’s, diabetes, schizophrenia and high cholesterol.
According to the state’s report, the facility’s executive director admitted to inspectors that the facility was negligent in administering the medicine to that patient.
In an interview, McDade Williams said multiple factors contributed to the breakdown. Sometimes family members were responsible for providing the drugs, she said. In other cases management and staff were disorganized, or there were problems with physicians and pharmacies, she said.
The facility’s former wellness director, a registered nurse, told inspectors that she knew that caregivers were not dispensing the drugs and were “throwing the medications away because they did not have time” to administer them, the report said.
The patients’ families have not been notified, McDade Williams said.
Sylvia Healy, founder of the advocacy group Citizens for Patient Dignity, was not familiar with the current investigation at Chancellor Gardens, but said the findings are similar to problems she’s seen in other nursing homes.
“The patients are either are not given their medication or they’re overdosed,” Healy said. “It seems like there’s no happy medium.”
The primary problem in the homes is insufficient or unqualified staffing, Healy said.
The state’s September inspection revealed other violations:
• In late August a caregiver performed CPR on a resident who was still breathing and had a heart rate.
• The facility is licensed for 30 Alzheimer’s patients, but had 34 in the unit.
• Medical records were inconsistent or did not indicate when patients received medication or were discharged.
According to a separate Health Division report filed in July, a 72-year-old resident went missing from the facility on July 16 and was found five days later, dehydrated and in a diabetic coma. The man died.
When officials investigated the incident, the Chancellor Gardens executive director could not find records related to the incident or any evidence it was reported to the state.
Another resident left an outside porch at the facility on June 12, the July report said, and was found unharmed the same day.
The July report also noted two of nine sampled cases where residents did not receive medication.
All involved should be charged with elder abuse.
probably a profit making institution - just like the insurance companies who engage in systematic and deliberate abuse!
My mother was a resident at Chancellor Gardens for three and a half years on the assisted living side and her last year we moved her to the Alzheimers Unit. She passed away last February. During the time she was at Chancellor Gardens she received very good care. I visited her at least four days a week and found that most of the care givers I met were very kind, very professional and cared very much about the residents. She never had any problems with her medications being administered correctly and on time. Had I heard anything negative from residents and/or families, I would have brought it to the attention of the management immediately.
revtomperl,
EXACTLY. Everything is so tied up in Corporate Greed Mode. The people are just a means to the end of MAKING MONEY. Not human beings in need of proper care & treatment.
All 139 residents are on medication because they all have health problems. That is why they are in an assisted living facility. These people are not first brought into the facility and then put on medication. I know some people who work in that facility and I have been there. The overall care the residents get there is not as bad as this article would have you believe. Yes, there are problems there that have been caused by bad onsite management staff in the past. But, they are gone and highly qualified staff has just taken over. Very quickly that place will be turned around. With our aging population, more assisted living facilities will be needed. They provide a vital service to our communities.
My grandmother spent 4 years at that facility, having come from a rural area where she wasn't eating well and taking her meds. The Lakes provided excellent service and care and she was very happy during those years until her death last year at the age of 97. The staff were always kind and attentive and my grandmother loved it there.
Bottom line is, this is someone's parents, grandmother, husband, or wife.. Their life is in danger. I don't care what anyone have to say how good or bad the company was or is. They are grown people, doing grown things, and need to take responsibilities. Stop trying to cover something that already happened, the facts are written. New management? New Management should have come in when the problem first exist and not when it is esclating.. License and certification, point blank should have been revoke for all staff.
Beverlee, your mom was lucky to have been a resident at Chancellor Gardens before a new Ex. Dir. took over a couple months after your mom passed. Karveseth, be glad your grandmother lived at the facility when she did, also. As a former Bus. Office Mgr there, I can assure you, EVERYTHING in this article is 100% true. I ended up being fired for contacting the Operations Director regarding such concerns written in this article, by the Ex. Dir. who was running the facility, and who (thank god) eventually was forced to resign. As the newest Dept. Mgr on staff, I did what I thought was the right thing (and still do) by standing up to protect the elderly residents living there. Many were indeed neglected by untrained caregivers who were hired without background checks, Health cards, TB tests and other requlations that are required by the state to work as a caregiver of an Assisted Living/Memory Care facility. I believed that their health and safety was in jeapordy on a daily basis.
jrp_702, I can attest as a former employee that the events written in the article are indeed facts. You are absolutely right, the companies corporate managers are at fault for not responding to these very serious issues in a timely manner. It was revealed in our many staff meetings that the faciliy was constantly being fined by the state. They all need to be held accountable.
May I just say, I miss all those wonderful residents who I have enormous compasson and love for and going the extra mile to give then all hugs and put a smile on their faces in the 8 weeks I worked there - is the only thing that made it the best job I've ever held! The state needs to take over the facility and then I would like my job back.
Beverlee, Karveseth, I'm happy to hear that you had the same experience that I did at Chancellor Gardens. I can't say enought about the staff there, they have continued to go above and beyond! As for debell4kids, you should be ashamed of yourself, I had dealings with you and I felt that you were horribly unorganized, and unprofessional, who are you to comment when you couldn't even complete my bill correctly? I hope you dont get your job back, at that point I will remove my mother from Chancellor Gardens. As for the Operations Director and the Exe. Director they gave me hope when we my family had none. My mother has been in Chancellor Gardens since May 2009 and my mom has had no issues with her medications.
The extent to which none of the contributors to this blog understand what this story is really based upon, is amazing. For those who are in the industry, this is everyday fare. The "investigation" was a survey of the facility done in September, 2009. These surveys are done in every facility in the nation that accepts Medicare, Medicaid, and/or must be licensed to operate under State law. They are done frequently for quality control purposes. If anyone simply looks at Medicare.gov, clicks on Nevada, then on a facility, you can see the surveys/reports that Medicare generates from their surveys. The same information is on the Nevada State website.
"Deficiencies" can be anything from a record not kept from six years ago, to background checks, to the medication issues here, which were not found to be life-threatening. If you actually read the article, no one was harmed. In fact, only about 50% of the article even dealt with Chancellor to begin with. The rest was inflamatory and "space-filler."
Once a survey is given to the facility, the facility then has a limited amount of time to file a "plan of corrections" with the State. When the State accepts the plan, which is almost always, then it is up to the facility to implement the plan so that the same deficiencies do not show up on the next survey. Had the State found the deficiencies to be so bad as to justify a takeover, doesn't logic tell you that they would have in September? Or do you really think that they will wait for someone to be harmed before they do so? This is the result of a disgruntled employee who has found a media outlet for her sour grapes.
The woman in question here was not fired, not forced to resign, and did absolutely nothing wrong other than take responsibility for the very serious mistakes of the previous Executive Director. As someone who is very familiar with this person, this facility, as well as most others in the city, the staffing problems encountered at Chancellor Gardens are city-wide. The sense of entitlement, and complete lack of accountability simply fuels the problem. The blame game I see above is both self serving and indicative of what I am saying. Grow up.
For those of you writing positive things, I thank you for taking the time to negate the whining of former employees. Just so it is clear, I am not, nor have I ever been, an employee of Chancellor Gardens. I simply know how the system works and that you are unlikely to see anymore on this in the future. Once the plan of corrections is filed and implemented, that's the end of it until the next survey.
To those of you with family members in any facility, you will always have to be diligent and attentive. Humans are imperfect to begin with and, since we don't have any alternatives, we will continue to make mistakes. Try understanding before you bring out the nuclear weapons on something, and someone, you know very little about. If you're going to have an opinion, at least make it an informed one.
Vegaschance, the day the door to my new office was opened my jaw dropped when I saw the stacks and stacks of paperwork, unopened mail and complete disaray that I was faced with. I had never seen so much UNORGANIZATION, in addition to the 20 - 25 files sitting in "my" office for weeks before they were signed and lose important documents that had not even been set up the folders, yet. This Business Office Manager position had been vacant for a couple months from what I was told. During this time, very little had been kept up on. Little did I know that I was being handed the biggest financial mess I'd ever seen. I actually could relate to Pres. Obama on a lower level.
Customer Accounts (let's not even go into Vendor Accounts) were so inaccurate that it took me hours of working late at night to review each and every Residents financial folder trying to make sense between what the Customer Accounts said in the system compared to what the signed contracts said. The two did not always match. Due to this descrepency, without getting the many questions I needed answered, when payments were not posted correctly, community fees paid in cash not being applied to accounts and the many accounts that were invoiced twice, accuracy was very difficult. You obviously only "see what is on stage, and not what is behind the scenes." I felt as though I was in a no-win ituation from day I took this job, yet took a proactive approach which was to try and clean up a mess that I did not make. So,in response to your mom's bill not being correct, perhaps it not the person's fault who took over the disater that this dept. was in. FYI - your mom's bill may have been one that was not set up correctly to begin with or a miscommuniction or - I may have made a mistake. I do apologize. I will refrain from going into all the other numerous issues that plaqued the business dept. On a personal level, I treated each and every resident with the utmost dignity and respect.
Needless to say, I was not the only Dept. Mgr. that got blamed for EVERYTHING in the place that was not being run efficiently. Unfortunately, I believe that the problems got as out of hand as they did due to the untimely manner in which they were NOT handled. The state does not continually audit a facility unless complaints are continually being made.
I am so happy that your mother is receiving her medication and is being taken good care of by some of many contiencious, well trained caregivers at Chancellor Gardens.
My last comment to vegaschance: In response to your comment of "being ashamed of myself,"........I could not be more PROUD of myself for being the Dept. Mgr who "stood up to the plate" to contact the operations director about the concerns that other Dept. Mgrs. had besides myself, who said, "I was their HERO for doing so, when they were too chicken." After 7 1/2 weeks, I realized I had nothing to lose since I was unwilling to remain in a position that the longer I was there, the more reason the ED would have to blame me for "the mess."
My mother has been at Chancellor Gardens and in Sara's Garden since 2004. She is 92. She became very lonely after Dad passed and was having lots of problems with daily life, including wandering and rapidly deteriorating memory. After much research we found Chancellor Gardens.
We found it to be the neatest & cleanest of all the facilities of it's kind in Las Vegas so we moved her in. Mom liked it's large apartments very much and brought her own furniture. She received good daily meals and care, had her nails and hair done on-site often and made many friends.
Within a couple of years things changed drastically. All her jewelry disappeared, the towels and bed linens that she brought disappeared. Often the staff was replaced so no one was accountable for the missing items and nothing was done about them. Complaints went checked.
Within the years since, the staff has changed so many times that the only person I recognize anymore is the hairdresser and an occasional assistant. Of course, Mom doesn't recognize me anymore either, and so, I don't visit as often as I did. But after reading this article I will be visiting again. I don't think the best thing for mom is to move her to another facility at this time of her life. I know that there are not many choices and I am not able to manage my mother with stage 4 dementia. I'm just not sure what to do. I will check with the committee in my head and report back.
I too, am I Business Manager by profession. Although I never working for Chancellor Gardens, I can not believe the comments put out here in a public forum by a Business Manager who worked for the facility. I understand that there was a mess. I once walked into an office that had not had a Business Manager for 6 months. First of all, do not think you are the only one who this have ever happened to. I have NEVER met an Executive Director who keeps the files up to date and billing accurate while there is no Business Manager employed. In fact, with out being rude, most are lacking in the Business Management aspects of the industry.
The point I guess I wanted to make, is for you to come on here and take out your frustrations of getting let go publicly is something you should probably be careful about.
I am just judging off of your comments, but I sense you are probably the type of person who spent more time complaining and gossiping with the other department heads then fixing the problems.
Basically, move on. Quick stalking an article about your previous employer. Sounds to me like the original complaint to state... was probably you. So you have got your, "revenge" on the people who fired you.... Funniest part of all, in the end, you probably helped them. The employees that were being negligent- will probably be fired. New staff will be hired and the company will come out stronger and better.
Be more professional... and definitely do not argue over a stupid blog with a former customer. YOUR job is to not let the customer see the mess.. YOUR job is to fix one at a time... and that day.. you should have spent whatever time it took to fix that account and make that customer happy...
Well said, Amanabanana. I completely agree.
My father was a resident in Sara's Garden until Mid September, when he passed away.
I want to say the he received EXCELLENT care.
The staff in Sara's Garden was very caring and attentive.
I would love to thank each staff member by name - but for privacy reasons, I will not do that here in a public forum.
Unless you have a family member with END STAGE Alzheimers, you just do not understand. These patients require a huge amount of attention and care which was more than our family could provide in our home. Do not assume that these patients are "dumped" there by families ... they are placed there for their safety.
Our family was there every day. To comfort and take care of him. Of course, we live close and had the luxury that some do not.
I would recommend this facility to any family looking for Alzheimers care.
Daughter in Las Vegas
In Memory of an abused victim of Chancellor Estates Garden of the Lakes
Part 1.
I am ABSOLUTELY livid by some of these comments and also by the revelation of this story.
Four years ago my ex and I moved his very vibrant 90 year old mother from upstate NY to live here.
Although he and I are separated we both loved Helen very much- she was a part of my life for 2 decades.
I took this decision VERY seriously. I must have visited a dozen nursing homes in Vegas, staying all day at each one as I observed the activities, the dining, the personnel, etc.
Before anyone goes off on either he or me, I was working two jobs and he was out of the country often. She could NOT stay alone in NEW York nor at either of our homes.
Therefore we shelled out $4,000 a MONTH because the administrator convinced us that despite this steep price she would be well cared for.
The first two years I was so enraged at many incidents that my ex told me to just stay away- because I "upset" the staff when I visited.
I had asked for only TWO things for Helen:
- That she was accompanied to Mass every Saturday since she had only missed ONCE in her entire life.
and
- That she be provided a glass of red wine at her dinner.
Neither of those requests lasted longer than 2 weeks, despite their promise..
There were at LEAST 6 directors in the two years I visited. They'd sit at a table and discuss the issues I felt needed to be addressed, act shocked that those things HAD been occurring and promise they would never happen again.
These are some of those issues:
1. That facility should have been locked at dusk (with a password given to the relatives). That door was frequently unlocked throughout the whole night- just one block off Sahara Avenue. Once, I visited after I got off work at 2 AM (the very DAY I sat through one of those "We Promise, Never Again!" meetings) and some homeless bum was standing outside the front door. Come to find out he would often sneak food out of the kitchen or sleep in the library!
Most of those residents in the residential area were made to feel safe that they could keep their doors ajar after they retired for the evenings.
Did you know that rape of the elderly is one of the most common problems in this state?!
2. I was only able (due to work) to visit Helen once a week to take her out to dinner. Between one visit and the next, when I went to go pick her up her eyeglasses were hanging off the side of her face with only one ear piece holding them on. I alerted the care nurse and it was another 3 weeks before she had fitting glasses again.
3. Her purse with money was stolen. Her wedding rings were stolen. Who knows what monies in her accounts were stolen?
4. At one point she had woken up in the middle of the night and walked out the front door, up a very steep incline and was on Sahara Avenue before anyone noticed she was missing.
In Memory of an Abused Victim of Chancellor Estates
Part 2
5. If I would go check on her at night it took FOREVER to actually see any staff. One night, when I freely walked in and sat down on a lobby sofa without any indication of staff ANYWHERE for over 15 minutes I was tempted to roll the lobby grand piano out into the parking lot just to prove a point.
6. When we finally decided to transfer her over to the Alzheimer's unit, she was supposed to be provided with ONE pill a day (other than her mind she was healthy as could be). I imagine she is one of those many who were considered too inconvenient to properly medicate.
7. When she finally died this past summer I went through her things and found TONS of clothing, etc. labeled with someone else's name in her closet.
I went out and demanded her medical charts two weeks ago. To date they have not sent them to her legal guardian, my ex. I don't expect them to.
I can tell you this. I am about to sue the HELL out of Chancellor Gardens for the 1/4 of a million dollars we paid for Helen these past 4 years.
She was a registered nurse her entire life, an honest and good woman who cared for many and she deserved to die with dignity. Had we autopsied her, it wouldn't surprise me to find that she had starved to death.
This company is notorious for the abuse done to the residents and should have been shut down years ago. They went through major turnovers in the staff only to hire far worse. The company was very good at one time until the head nurse retired and the corporate office terminated the Executive Director and hired and incompetent person in her place.
They filled the Head nurse position with someone who was too lazy to do her job and fill out the proper paperwork. Yet alone could care less about the residents. She went on a firing spree and decided to terminate any employee that was on to her. Many of which were employees that were assets to the company and loved to take care of the residents. She would not let her staff call emergency on a resident because she didn't have the file on the resident ready for the E.M.T's, instead she would wait until the family took them to quick care. Once taken to quick care by a family member the residents would be admitted into ICU for suffering serious conditions such as staff infections and heart conditions.
A resident was vomiting in the lobby and when the Head nurse was notified, she didn't bother to do anything to help the resident and just left her there leaving someone else to care for her and clean up the mess. Family members had to take her to quick care and she was admitted in the hospital for suffering a staff infection.
A resident that couldn't move her head or left side of the body was forced by the head nurse to take and exercise class. When the head nurse was confronted with the issue she refused to call emergency saying "there is nothing wrong with her and she needs to exercise" Needless to say, when the family took the resident to quick care she was admitted in the hospital for suffering a heart attack. She died a few days later. Meanwhile the head nurse had the audacity to attend her funeral as if she really cared!
The majority of residents have dementia therefore, when a resident would complain about feeling ill the head nurse wouldn't take them seriously.
Because the head nurse terminated so many caregivers and med techs that the company remained under staffed. Many of the residents would be found sitting around all day with wet and soiled clothes. One resident would have to be spoon fed and was left sitting alone in the dinning room. After all residents finished eating, she would still be waiting for someone to feed her.
Another resid4ent was having difficulty trying to transfer from a wheel chair to a couch the Executive Director and Head Nurse laughed at him and kept on walking. Not bothering to help assist him into sitting in the couch.
Numerous times residents would be found roaming the streets with dementia and the police would be called to help locate them.
to be continued:
Continue Part 2
During a management meeting the Executive Director was upset because one of the residents that lived in the memory care section of the facility would urinate on the walls. She gave orders to have him sent to a psyche unit so he could receive "shock treatment".
When the Health department would show themselves on the property the caregivers and staff would be given orders by the Executive Director and Head Nurse to hide certain residents in other areas of the building so the Health Department wouldn't see them.
These are all facts. Chancellor Gardens should be shut down. These are human beings and should be treated with respect. After all, they are paying a large portion of money to be given the proper care. This is not an independent living it is assisted! The company needs to do the job right.
Corporate was too concerned about its cosmetic looks and interior decorating to get their census above 80% then they are on taking good care of the residents that are paying for it.
I am disappointed in the Health department too. They have been given numerous complaints for years and it took up until now to do something about it. Meanwhile, more residents had to suffer. I was never fired from the company in fact I quit and reported them to the state yet, I would only be quoted as a disgruntled employee. Amazing how the truth comes out in the end!
For all those caregivers and med techs that did a good job and really cared about the residents I praise you for your hard work. Working for the elderly is a mentally and physically draining job yet it is rewarding to see the smiles on the residents faces and the appr3eciation they give you back when they know you care.