Officials with the Department of Social and Health Services said staff mistakes and ineffective security measures at Canterbury Gardens Alzheimer Care in Longview are to blame for Norma Sheldon's death Dec. 6, The Longview Daily News reported.
Sheldon's body was found in an enclosed, open-air courtyard after staff missed a required hourly bed check at midnight. The Alzheimer's patient was wearing only a nightgown in the 28-degree weather, the newspaper reported. She died of hypothermia.
"This was a very serious situation," said Irene Owens, interim director of the state's residential care services, part of the health services department.
According to the state's revocation letter, the violations found by investigators "resulted in the death to a resident and put 61 other residents at risk for accidents or injuries."
The facility can continue to care for its current 57 residents while an appeal takes place, but it can't accept new patients.
Olympia-based Koelsch Senior Communities, which owns Canterbury Gardens, said in a statement that it was aware of the state's concerns and was "already in the process of taking every measure necessary to satisfy each issue."
"We are fully prepared to do everything necessary to earn the department's trust in our ability to ensure the safety of our residents," the company said
The facility has 28 days to appeal, a process that could take months.
The state said it will monitor patient care and require staff to accompany patients when they are out in the center's courtyard.
Investigators looking into Sheldon's death found a worker failed to do a midnight bed check. They also found that not all the doors to the courtyard had operational locks or alarms, and some alarms that were on were too faint to be heard clearly.
Officials said some safety hazards remained uncorrected three days after Sheldon died.
The woman's husband, Don Sheldon, told the Daily News he had not seen the report but wants the problems corrected.
"I don't have anger about this," he said Monday. "I'm very disappointed, and I don't want it to happen again."
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