MESA, Ariz. — Arizona's Department of Health Services has issued Canyon Winds a notice of intent to revoke the memory care facility's license.
Now, the state says it had an informal settlement agreement with the facility and a final agreement is pending.
The state's action comes after 90-year-old Lawrence Bearse died outside the facility over the summer. The Marine veteran with advanced Alzheimer's was transported to an appointment but when he was driven back to Canyon Winds, he was left inside the transport van.
When his wife showed up on July 22 to visit him, he was nowhere to be found. His body was later found inside the vehicle. He had been unaccounted for more than 20 hours.
The day after Bearse's death, ADHS launched an investigation and conducted a site survey.
According to the survey, the state found eight citations.
Canyon Winds' citations
The state claims the driver did not have the minimum qualifications per the job description. In addition, he had no orientation prior to working at the facility.
Out of the six Canyon Winds employees sampled by ADHS, five of them did not have their qualifications, experience or skills verified when they were hired. In addition, several employees did not fill out reference check forms and didn't include all information that may have been relevant to their fitness to work in a residential care facility.
Canyon Winds had no master schedule for all staff including drivers. It also did not have a sign-in or sign-out log for facility transportation.
In Bearse's case, he wasn't accompanied by a caregiver or family member during transportation to his appointment despite his residency agreement requiring one.
One of the most egregious violations identified by ADHS states that an employee signed off claiming they provided Bearse his required medication on July 22 despite him being missing since the day before and having already passed away.
The state's survey also revealed that the transport van driver left Bearse inside the vehicle on July 21 then went home. The following morning, he returned for his shift and took that same van to the gas station with Bearse still inside.
The driver then brought the van back to Canyon Winds without noticing Bearse was there.
After locating Bearse's body, documents show another employee told investigators Bearse was "in plain view in the rearview mirror."
The severity of these violations prompted ADHS to issue the notice of intent to revoke Canyon Winds' license.
Now, as they proceed instead with an informal settlement conference, experts say Canyon Winds will have to follow a correction plan to address deficiencies.
Canyon Winds declined to comment for this story.
The medical examiner ruled Bearse's death an accident.
The Mesa Police Department is investigating Bearse's death. The case is still open and no charging decisions have been made.
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