COLORADO SPRINGS, Colo. (KRDO) -- Margarita Sam settled down at Union Printer's Home in Colorado Springs over three years ago.
It was a place the Alzheimer patients' family trusted the 89-year-old would get the care she desperately needed.
But on the cold morning of February 3, 2020, Sam was found half-clothed, frozen to death on a bench outside of Union Printer's Home. Sam's cause of death was reported to be hypothermia.
It wasn't the first questionable death at the facility, according to lawsuits.
The nursing home never notified them about Margarita's death, according to her family. Instead, the family found out about her passing days later, when the coroner called them.
Margarita's death led the state to shut down Union Printers Home a week later, and three staff members were charged in connection to her death.
A 13 Investigates analysis of state data found 17 of the citations issued to Union Printers Home while it was in operation were for repeat violations.
It took an Alzheimer's patient freezing to death for significant action against the nursing home, despite the history of repeated violations and lawsuits highlighting other questionable deaths at the facility.
Randy Kuykendall, the Colorado Department of Public Health and Environment's (CDPHE) director of health facilities and emergency medical services, says shutting a facility down is a rare enforcement measure.
"That's the first time that's happened in Colorado in a little over a decade," Kuykendall explained.
13 Investigates dug through state nursing home citation records and found Colorado inspectors issued 14,284 citations during unannounced visits to 239 nursing homes from 2015 to October 2020. An average of more than 2,500 citations per year was issued to Colorado nursing homes from 2015 to 2019.
State regulators say they use a progressive discipline system for nursing home enforcement in the state.
When the state cites a nursing home, administrators have 10 days to submit a plan of correction of a date when the home will comply. Inspectors follow up unannounced at some point after that compliance date.
Penalties for serious violations can result in federal fines or outside consultants and management coming to the home to help get the facility on track. Regulators have used temporary management discipline for six facilities since 2019. According to regulators, over $7 million in fines have been issued to Colorado nursing homes in the last three years. That equates to over $7,000 in fines per day.
The current enforcement system doesn't appear to be stopping nursing homes from repeating the same violations multiple times.
"The repeat violations are problematic. That is not a new issue in terms of health facility oversight. You want to see folks get better and stay better as they move forward," Kuykendall said.
A total of 50 inspectors are responsible for regulating all nursing homes in Colorado on both the state and federal level. Those inspectors issued dozens of repeat citations over the years, including failure to protect residents from abuse, failure to investigate resident allegations, not providing a home free of accidents or hazards, unsanitary serving of food, incompetent staff, infection control issues, and more.
"We track those as well, and we know what the repeats are. Without having looked into those facilities right now, I would expect that they are all on some level of discipline measure probably even today," Kuykendall said.
State data shows Castle Rock Care Center as the top violating facility in the state with a total of 160 violations since 2015. 13 Investigates found that 81 of those were repeat violations -- which means over 50% of their citations were for violations they already committed. This year alone, the facility was cited four separate times for infection control-related issues. Castle Rock Care Center did not respond to our request for comment regarding their violation history.
Homes with the most violations in Colorado:
- Castle Rock Care Center (Castle Rock)
160 violations since 2015
81 repeat violations, 50.63%
- Lowry Hills Care Center (Aurora)
151 violations since 2015
47 repeat violations, 31.1%
- Spring Creek Healthcare Center (Fort Collins)
131 violations since 2016
47 repeat violations, 35.8%
- Belmont Lodge Health Care Center (Pueblo)
42 repeat violations, 32.3%
Lowry Hills Care Center in Aurora had the second most violations in the state and is currently on a federal focus program.
Aspen Living Center in Colorado Springs had the fifth-highest number of violations in the state from 2015. Data shows 18% of those violations were for repeat issues. The facility is currently on a Speciality Federal Focus program.
The facility sent 13 Investigates this statement in response to their history.
"Aspen Living Center (“Aspen”) continues to work diligently to remain compliant with its policies and procedures and the Federal and State regulatory requirements. While Aspen has received deficiencies over the past two years, most deficiencies were relatively minor and were easily corrected with education. At this point, one deficiency remains. Aspen has submitted their plan of correction for that deficiency and expects to be found to be in compliance with that requirement shortly.
The key to remaining compliant is to give staff the tools, resources, and education necessary so that they understand not only the “how to’s” regarding providing quality care but also the “whys.” Experience demonstrates that individuals retain knowledge better when they understand why what they are doing makes a difference. Aspen’s leadership team is focused on empowering staff while supporting them as well.
The other key to success is hiring the right team, a team that is motivated to provide quality care to the residents they have the privilege to serve. Aspen works tirelessly to identify such team members and make them part of the Aspen family.
Finally, the Colorado Department of Health and Environment offers valuable education and resources to the skilled nursing centers in the State. Aspen embraces those resources and works with the Department to strengthen and improve the services it provides to the community.
We want to thank the leadership and staff at the Center for all of their hard work, particularly through this pandemic. We also want to thank the Colorado Springs community for their support generally and throughout this difficult time."
MAP: Nursing homes in Southern Colorado by total violations, 2015-2020
(Expand sidebar in top left for list.)
Regulators say those facilities are closely watched, but health leaders admit it's not the main priority at this time.
"Our focus has changed since March. We've been directed to --really by [Centers for Medicare and Medicaid Services] and the Governor's Office-- to focus on COVID and infection control," Kuykendall said.
Denver-based Attorney John Holland has been suing nursing homes since the 1970s. One of Holland's most notable cases resulted in the US Secretary of Human and Health Services implementing the current-resident-focused nursing home inspection system across the country.
"You can see over and over that the same damn thing is happening over and over, and nothing is really being done," Holland said.
Holland believes the inspection process is detailed and working correctly -- but enforcement is lacking.
"The sad truth about it is the regulatory system does not do its part to
disincentivize poor care. It allows you to make up plans of correction that
are basically paper mache," Holland said.
He believes regulators need to use more aggressive enforcement tactics like taking licenses, putting nursing homes in receivership, and stopping patient admissions to prevent the suffering of our elderly and possibly their deaths.
"There's a lot of frail, vulnerable, multiple-diseased people, but they're
still in their spirits. They're still present. They still live there. They
still care. They still love. They still have needs. And they don't need to
be rudely treated, and they need people to have time for them," Holland said.
Any action will come too late for Margarita Sam's family, but they still hold onto hope for others.
If you or a loved one has a nursing home experience you'd like our team to investigate, please contact us at firstname.lastname@example.org