State faults Longview facility for elderly woman's freezing death

2013-12-23T20:20:00Z 2015-08-20T15:56:30Z State faults Longview facility for elderly woman's freezing death Longview Daily News

State officials are revoking Canterbury Gardens Alzheimer Care center’s operating license, saying staff mistakes and ineffective security measures are to blame for an 88-year-old patient freezing to death earlier this month.

Some safety hazards were uncorrected even three days after the woman’s death on Dec. 6, according to state officials.

The Longview facility, located at 1457 Third Ave., can continue caring for its 57 current residents while an appeal takes place, but it’s immediately barred from accepting new patients.

The state Department of Social and Health Services said it will monitor patient care and will require staff to accompany patients when they are out in the center’s courtyard.

Norma Sheldon’s body was found in an enclosed, open-air courtyard in frigid conditions after staff missed a required, hourly bed check. The Alzheimer’s patient was wearing only a nightgown in the 28-degree weather and died from hypothermia. Her family has hired a lawyer and says it will work to prevent further incidents.

The state’s revocation action is one step down from an immediate, emergency closure and means state officials fear for the safety of patients in the facility, according to the revocation letter.

“We don’t do revocations lightly,” Irene Owens, interim director of the state’s Residential Care Services, a division of DSHS, said Monday. “This was a very serious situation.”

Canterbury officials said they’re confident they can work through the appeal process and fix all of the state’s concerns. They have 28 days to serve notice of the appeal.

“We are completely aware of the Department of Social and Health Service’s concerns, and we are already in the process of taking every measure necessary to satisfy each issue,” according to a prepared statement from Olympia-based Koelsch Senior Communities, which owns Canterbury Gardens and three other retirement homes in Cowlitz County. “We are fully prepared to do everything necessary to earn the department’s trust in our ability to ensure the safety of our residents.”

If the appeal is unsuccessful, the center would eventually have to close. Appeals can take several months and even up to a year, Owens said Monday.

A investigation of Sheldon’s death included daytime and nighttime visits and interviews with staff and reviews of some patients. The violations investigators found “resulted in the death to a resident and put 61 other residents at risk for accidents or injuries,” the revocation letter states.

Investigators found that:

• A worker failed to do the midnight bed check, losing track of time while sterilizing wheelchairs and walkers and not checking the time until 12:50 a.m. Sheldon was found a few minutes after 1 a.m.

• Not all doors to the courtyard had operational locks or alarms. Some doors also had no keys available.

• Of the alarms that were on, some were too faint to be heard clearly.

• Another patient was known to try and leave the facility and had removed an alarm from one of the courtyard doors.

• There was a policy to lock courtyard doors in case of snow or ice, but not one for cold temperatures.

• Following Sheldon’s death “there was inadequate response by the administrator to ensure all doors exiting to the courtyard were lockable and alarmed.” A door without an alarm was pointed out during the Dec. 8 inspection visit and staff placed a barrier in front of it. On Dec. 9 — when inspectors returned three days after Sheldon’s death — the door still did not have an alarm and the barrier had been removed.

• There’s confusion about how often Sheldon should have been checked after she injured her hand in the courtyard on Nov. 22. Some records said every 15 minutes, others had that crossed out. There’s no record such checks were being done at the time of her death. Her husband, Don Sheldon, remembers two other times she fell in the courtyard, but he said he doesn’t remember being told of the Nov. 22 incident cited in the state report. Just going by the two previous times, though, Sheldon said it’s “ridiculous” that his wife was allowed to wander out into the courtyard at night.

Don Sheldon hasn’t seen the state report Monday, but he said he’s glad the problems are getting attention.

As for Canterbury Gardens, Sheldon said he would be sad to see it closed because of all the workers and patients there. If the state certifies that all the problems are fixed, he said he’d be okay with it remaining open.

“I don’t have anger about this,” he said. “I’m very disappointed and I don’t want it to happen again. … I want someone to show me it’s going to be corrected.”

He buried his wife Saturday and said the service was standing room only.

Barbara LaBoe covers courts and law enforcement for The Daily News. Reach her at 360-577-2539 or

Copyright 2015 Longview Daily News. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

(13) Comments

  1. Wisdom
    Report Abuse
    Wisdom - December 23, 2013 1:00 pm
    Egad, what a mess, and so very sad for the Sheldon family. I do hope all of this gets repaired and resolved in an effective manner--it's going to be interesting to see what develops...
  2. forpetitionalso
    Report Abuse
    forpetitionalso - December 23, 2013 3:58 pm
    Very good state it seems your heading in the right direction. Lets just not have time pass that another loved was is harmed or dies
  3. Hawaiin_surf
    Report Abuse
    Hawaiin_surf - December 23, 2013 6:00 pm
    um, no they shouldn't get to work it out with the state, they should get a fine, get shut down and thats that!
  4. Sharky
    Report Abuse
    Sharky - December 23, 2013 7:04 pm
    Canterbury Gardens is a nice facility and Alzheimer patients are certainly a challenge. It is mind boggling the administrative missteps since the tragic event. Such simple items to implement immediately. An alarming black mark for all of management from the tip top on down.
  5. Cheney119er
    Report Abuse
    Cheney119er - December 24, 2013 2:15 am
    My biggest transition from military to civilian life, the utter lack of standards in civilian society in general. Why weren't the bed checks being done? For this population this is just basic, the first thing you'd what to be doing. No standards with any accountability; as usual. Just look at all the accounting irregularities locally (YMCA..) where basic accounting isn't being used. That wouldn't fly (or submerge) on a submarine. The only standard with civilians seems to be their absence
  6. Transplant
    Report Abuse
    Transplant - December 24, 2013 9:17 am
    I've tried to sort this all out as just a very unfortunate accident, however I cannot reconcile how an elderly woman freezes to death in an assisted living community. Fall? Sure. Choke? I get it. But freeze? How could the State have come to any other conclusion? What a terrible situation for all involved. I would like to hope that one outcome of this is that some agency (DSHS?) become more involved in the inspection process. Perhaps TDN could report on what inspections already exist if any?
  7. my3centsworth
    Report Abuse
    my3centsworth - December 24, 2013 2:57 pm
    It looks like I don't know how to prioritize. I never knew that sanitizing a wheelchair was more important than checking on the welfare of an elderly patient! Are employees just plain stupid, lacking basic critical thinking skills, and have ZERO compassion for patients? What kind of people are being hired? Who's doing the hiring and where is the accountability for murdering an elderly woman?
  8. missymae1963
    Report Abuse
    missymae1963 - December 24, 2013 7:10 pm
    I myself work at an Alzhemiers and dementia unit and it's tough work and we try the best we can to keep track of all our residents you have to keep a constant eye on everyone we do though have alarms to keep us alert on their whereabouts but you still need to be aware on where everyone is and we have a great teamwork too and that helps a lot prayers to the family
  9. WhatHappened
    Report Abuse
    WhatHappened - December 24, 2013 10:50 pm
    Pure neglect and poor discipline
  10. eyes wide shut
    Report Abuse
    eyes wide shut - December 25, 2013 7:06 pm
    What scares me the most about this whole mess is that the Canterbury is one of the nicest facilities in our area. It makes me wonder how safe our elderly loved ones are at some of the poorly maintained facilities. My heart goes out to this family. They thought they were doing the best thing for their wife/mother, and to lose her like this must be heartbreaking.
  11. Wisdom
    Report Abuse
    Wisdom - December 26, 2013 7:08 pm
    "eyes wide shut": You have raised a very good point here. Several years ago, my stepfather suffered a stroke and had to remain at a local rehabilitation facility (for the sake of fairness, I shall not say which) until he could return home. Had it not been for my mother's constant vigilance, there is no telling how much basic care could/would have been ignored or overlooked. She maintained daily records (time stamps included), and I still have all of them in a safe deposit box. Quite the read...
  12. Faith93
    Report Abuse
    Faith93 - January 01, 2014 8:42 pm
    Who thought it was a good idea to wheel her outside in just a nightgown in the first place? I don't even go into my garage in just a nightgown, BRRRR!
    Poor heartbreaking for her family. What a sad shame...
  13. Bone
    Report Abuse
    Bone - January 05, 2014 12:24 pm
    I think that the management needs to be looked at very carefully here, it is their rules that the shift workers were following.
Add Comment
You must Login to comment.

Click here to get an account it's free and quick