Assisted Living Facility Open Despite Recent Deaths

CALL7 Investigation Prompts State To Take Closer Look At Eaton Terrace II

State health officials allowed a Lakewood assisted living facility to operate despite citing the facility after two recent deaths, a CALL7 investigation found.

On Nov. 6, a resident at Eaton Terrace II hung himself in his room and the state cited the facility for failing to give the man his anti-psychotic medication, state records show.

Ten days later, Shirley Wolf, a 79-year-old woman with dementia, wandered out on the fire escape and froze to death after the door locked behind her and she couldn’t find her way back into the facility, records show. Police reports say facility staff knew Wolf was going out on the fire escape. The police also found that the door alarm was not working.

The state cited Eaton Terrace II for failing to prevent Wolf’s neglect, noting staff questioned Wolf's whereabouts on the night she disappeared but did not follow up until the next morning.

“We thought she was safe there,” said Wolf’s sister Betty Miller. “She went out after lunch about one in the afternoon, so she was out there almost 18 or 19 hours before they ever missed her.”

A staff member reported that the staff member saw Wolf at dinner and waiting to get her medication, but that wasn’t possible since she was freezing to death on the fire escape at that time, records show. A staff member was let go, records show.

The Colorado Department of Public Health and Environment is charged with inspecting and regulating assisted living facilities and Eaton Terrace II has a history of problems going back to 2005, state records show. The reports detail missing medication, failing to properly give medication to residents and failing to check on residents.

Despite the two deaths and the history of problems, state inspectors did not move to shut down the facility. State officials had the facility write up correction plans after each incident and tracked how facility staff did with the plans.

But in March, the facility had another incident -- one the state did not know about until 7News started asking questions.

Paul Gonzales, 86, had returned from a hospital stay, but the Eaton Terrace II staff did not note his return, according to Gonzales’ family. Gonzales fell during the night and remained on the floor until the next afternoon because no one checked on him, said Keri Clifton. Gonzales is Clifton's great uncle.

“He apparently got up in the middle of the night and went to the restroom and fell … and he laid on the floor til the next afternoon,” Clifton said. “They had a staff meeting apparently, where the nurses asked how he was doing and that's when the light bulb went off that they had forgotten that he was back.”

The state did not know about the Gonzales incident until CALL7 investigators asked the agency whether that situation was reported. Howard Roitman, director of the CDPHE division that oversees health facilities, said his inspectors are investigating the Gonzales incident to determine whether the facility had to report it.

Roitman, at first, defended that state’s oversight of Eaton Terrace II.

“They've been addressed to the satisfaction of our staff in each situation that we've dealt with in the past,” Roitman said.

But Roitman later conceded that the state needs to take a closer look at the facility.

“You're looking at it as an individual instance when there's a huge pattern here in this facility. Are you looking at that pattern?” asked CALL7 Investigator John Ferrugia.

“We are now,” Roitman said.

“But you weren't before?” Ferrugia asked.

“We’ve addressed each issue as it has come up,” Roitman said. “Now I'm going to be looking into whether there is a pattern that we feel would warrant some kind action on our part.”

Eaton Senior Programs Chief Executive Officer David Smart refused an on-camera interview and declined to talk when 7News caught up with him on his way into work.

“I’d like to know if you might talk with me just a little bit about supervision?” Ferrugia asked.

“No,” Smart said. “No comment.”

Smart did provide a written statement, saying the facility implemented training and security measures to prevent further problems. Smart wrote that the state did not connect the lack of medication to the suicide death. The publicly available state report cited a deficient practice in the incident, quoting the man's psychiatrist as saying it would be difficult for anyone to say how missed the medication would affect the patient.

Smart’s statement did not address the Gonzales case.

Family members of Gonzales and Wolf said the state should have done a better job supervising Eaton Terrace II.

“When I think about the night she spent outside that really bothers us,” Betty Miller said. “It really should not have happened.”

If you want to check out your assisted living facility or nursing home, go to Colorado Department of Public Health and Environment website.