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A Deep Dive into a Facility's Rat Problem
Did you catch Reveal from The Center for Investigative Reporting & Jennifer Gollan's latest article on assisted living? We certainly did. We've followed some leads in the article to uncover more about the facilities and how CCLD handled them. Here is a timeline we made to keep track of all the events.
Let's start with the facility.
The licensee Dimitri Zafiris and Court Yard Estates failed to properly care for resident Ms. Geslicki. From February 2016 to August 2017, Ms. Geslicki improved while under a hospice agency's care. Once she was eating better and no longer needed oxygen, she no longer needed hospice care. However, seven months after hospice was discontinued, she was hospitalized with 10 pressure wounds, which ranged in severity, sepsis, pneumonia, and toxic encephalopathy. These pressure wounds and other complications happened due to Court Yard Estates' lack of care as she had no skin issues or breakdown when she moved in or when she was taken off hospice care.
The sepsis, caused by the pressure wounds, coupled with pneumonia and toxic encephalopathy, made Ms. Geslicki's condition life-threatening. Despite this, Ms. Geslicki was discharged back to Court Yard Estates 2 days later. She went back on hospice. The severity of her pressure wounds required more care and supervision than assisted living facilities are allowed to provide, making her readmission a violation of the facility's license.
In early March, a staff member noticed Ms. Geslicki had wounds on her hand and foot that looked like rat bites, as well as rat droppings around her bedding. It is unknown what actions were done by Court Yard Estates at that point, if any, to protect her. She died four days later.
It would be a week before CCLD came out to investigate a rat problem and discover anything about Ms. Geslicki. Everything at Court Yard Estates fell through the cracks for CCLD. With early intervention, the State could have changed the outcome for Ms. Geslicki.
The State appeared to have no idea about what happened to Ms. Geslicki until after her death. From our public records review, CCLD only visited Court Yard Estates once during Ms. Geslicki's 2-year residency. Her neglect, hospitalization, and death were unknown to the department. As is the protocol for CCLD, they relied on Court Yard Estates to self-report any resident hospitalizations or deaths--which did not happen in this case.
CCLD staff also failed to recognize Court Yard Estates had been cited for the same citations multiple times and missed the deterioration of the house. Regulations allow for civil penalties for identical citations within 12 months. The 2nd citation related to the rats should have come with a civil penalty. Reoccurring issues like accessible sharp knives and missing carbon monoxide detectors show a facility-wide inability to remain compliant with the regulations.
And further, there is a lack of transparency for consumers. The reports available on the CA Department of Social Services website do not accurately portray what happened in Court Yard Estates. Not only did CCLD failed to report on what happened to Ms. Geslicki until 10 months after her death; but the report, attached to Jennifer Gollan's article, confirming Ms. Geslicki was bitten by rats is still not on the State's transparency website as of October 8, 2019. Well-informed consumers would have no idea about the horrors that occurred in Court Yard Estates without the investigative reporting of Jennifer Gollan and Reveal.
Lastly, Ms. Gesklicki was failed by 3 different mandated reports: Court Yard Estates' staff, the doctors, and nurses who saw her in the hospital, and the hospice agency staff after she returned from the hospital.
- Once Ms. Geslicki was no longer on hospice, there was no more outside oversight of her care. Staff had ample opportunity to report the issues at Court Yard Estates to CCLD or the Long-term Care Ombudsman. Instead, they elected to send an anonymous text message to Ms. Geslicki's son.
- Ms. Geslicki was seen by multiple health care practitioners when she was hospitalized with sepsis, 10 pressure wounds, and other conditions. Hospital staff are mandated reporters and should have also reported her pressure wounds. Pressure wounds are not a normal part of aging; they are what happens when people are neglected. In CARR’s view, Ms. Geslicki should never have been discharged back to Court Yard Estates. Her pressure wounds made her too "medically needy" for assisted living and ER staff had to have known that the care she was receiving from CYE was substandard. The hospital’s discharge to Court Yard Estates essentially handed Ms. Geslicki a death sentence.
- The hospice agency overseeing Ms. Geslicki's care should have seen the injuries caused by the rats. They must have recognized that the pressure wounds were signs of neglect. They should have contacted CCLD or the Ombudsman.
Families pay for the pleasure of entrusting their loved ones to licensed assisted living facilities with the expectation they will receive compassionate and competent care. Not only did Ms. Geslicki not receive compassionate and competent care, but she was also robbed of her dignity and her life.
Article by: R. Ruiz