They were told their mother's death was peaceful. It was all a lie. Questions persist about Colorado's oversight of assisted living industry

Jan. 19—Donna Golden had slipped into pajamas and was watching the news the night it all began. She was exhausted. The heat had been excruciating that day, topping 100 degrees in Grand Junction and prompting the National Weather Service to issue its first-ever excessive heat warning for the region.

A little past 10 p.m. on June 14, 2021, her cellphone chimed.

"Donna, I'm just so sorry to tell you your mother has died," said the nurse from HopeWest, a local hospice that helped the assisted living facility where her mom lived.

The nurse reassured her it was a peaceful death.

"What?" Golden sputtered, starting to reel. She had gone on a walk with her mother just a few days before and she seemed the same as always. How could she suddenly be dead?

Hazel Place was 86 and in surprisingly good physical health, spry even. The doctors had found nothing wrong with her heart or lungs during a recent checkup. It was her mind that had slid away, ravaged by Alzheimer's disease. "I'm starting to be stupid," Hazel once said in dismay when the confusion became impossible to explain away. "My brain is dying."

So three years before, Golden, who lives in Palisade, and her brothers Dave Place and Steve Place, both in Clifton, like hundreds of thousands of others in this country overwhelmed by a parent's needs too big to handle, reluctantly turned to assisted living for help.

They picked Cappella of Grand Junction in the fall of 2018. Its parent company, Englewood-based Christian Living Communities, a non-profit, faith-based organization that owns, runs or provides management to nine senior living communities across Colorado, had advertised care based on Christian principles. As a churchgoer, Golden liked that.

With its charming Craftsman-like exterior and long list of activities, the facility also offered private studios in a secured memory unit for those in cognitive decline. It would be pricey at $7,600 a month. They would have to sell their mother's 32-acre ranch near Collbran. But it felt worth it to keep her safe.

"Your mother had a very good day," Golden said the nurse told her. She said Hazel had participated in activities and eaten a big dinner — even asked for seconds. Then, around 8 p.m., before going to bed, she wanted to go outside to the facility's enclosed courtyard to watch the sunset. When the staff checked on her around 8:30 she was dead.

In her fog of shock and grief Golden had no reason to doubt what she was being told.

But it was a lie.

The truth was on the facility's time-stamped surveillance video of the courtyard.

Hazel Place had, in fact, died a gruesome death: frightened, immobile, and left unattended as she slowly, fatally baked in a brutal sun for six hours.

Her death and all that flowed after exposes a troubling glimpse of a system of caretaking and accountability meant to protect an elderly population at its most vulnerable.

The multi-billion-dollar assisted living industry with its promise of a safe, home-like atmosphere has boomed over the past two decades, often seen as a palatable alternative to the perceived bleakness of a nursing home.

There are now more assisted living beds in Colorado than nursing home beds, and nearly three times the number of facilities, although about half are small, according to state licensing data over the past five years.

But despite the explosive growth, assisted living facilities, unlike nursing homes, have no direct federal oversight. Regulation is left to individual states, leaving a patchwork of varying accountability. Colorado has plenty of rules on assisted living facilities — 70-some pages — but the regulations tend to be non-specific and open to interpretation. For instance, the level of staffing is only required to be "sufficient" to care for resident needs.

Colorado law does not require assisted living facilities to employ a registered nurse on staff nor for administrators of facilities to be licensed by the state.

And if something goes wrong, the state agency in charge of enforcement has limited muscle and criminal prosecution is spotty.

That, too, has become part of Hazel's story.

Despite irrefutable evidence of neglect leading to a terrible death, criminal charges began and ended with three low-level workers while supervisors and owners escaped prosecution and the facility was able to keep its license.

The surveillance tape, now in evidence, shows Hazel wandering into the unshaded, empty courtyard at 2:19 p.m. not 8 p.m. as her family said they were told. The Denver Gazette has not seen the tape, but the content has been described in detail in court documents.

Outdoor activities had been cancelled that day at Cappella because of the scorching heat, a former employee said. And although signs were posted throughout the facility warning residents to stay inside, the door to the courtyard in the memory unit was unlocked with no one monitoring it.

Just a week before, Ladona Luque, a Cappella employee in another unit, had found Hazel in the same courtyard at midday. She brought her inside, gave her water and cooled her overheated skin with a washcloth. Luque told the Denver Gazette she reported the incident and warned supervisors of the potential danger but was ignored. Luque quit Cappella after Hazel's death.

The tape captures Hazel sitting on a patio loveseat in the direct sun. At one point she tried to stand but could not, falling back onto the seat. Afterward she became agitated, fidgety. Still, she could not get up. Over the next two hours, in temperatures the National Weather Service clocked at 100 degrees — likely hotter on the concrete patio— her movements became slower and slower until just her hands were twitching. Then, just her fingers.

Finally, a little after 4 p.m., she was completely still. A few minutes later another resident, who also has dementia, tried to roust her but could not. He gave up and went back inside.

For four more hours she remained slumped on that loveseat. No one noticed despite a standing order that she was to be checked every hour because she was a fall risk. Around 8:20 p.m. — six hours after she first walked outside — the husband of a memory unit resident glanced out of one of several hallway windows that overlook the courtyard and grew worried when he saw Hazel's crumpled body.

He alerted a Cappella employee and asked if anyone knew Hazel was outside. No one did.

The three caregivers on duty that afternoon in the memory unit who were supposed to keep watch had already gone home. Information in the computerized system that logs medication distribution and safety checks of residents was later found by authorities to have been falsified by two of the workers, making it appear that Hazel was regularly monitored throughout the afternoon and early evening.

A forensic pathologist, later writing in the autopsy report, concluded: "It is my opinion that Hazel Place, an 86-year-old White female, died as a result of environmental hyperthermia." Hyperthermia at its most serious occurs when the body's temperature reaches 104 degrees or higher.

"The passing of Ms. Hazel Place is incredibly sad for her family, her friends and everyone in our community," Pam Sullivan, vice president of strategy and communications for Christian Living Communities, the parent company of Cappella, wrote in an emailed response to Denver Gazette questions.

"We continue to hold Ms. Place's family in our thoughts and prayers during this difficult time," the statement said, "especially as legal proceedings continue."

It is now known there was no dinner with seconds, no sunset watch. What has yet to be disclosed is who concocted the elaborate story. And when.

Christian Living Communities said in its emailed response to Denver Gazette questions that there was no deception. The company said it "immediately self-reported" to state regulators and cooperated with authorities in their investigation. The email also said it was transparent with the family as new information surfaced — something Golden and her brothers say is "absolutely not true."

The company referred questions about what happened after Hazel's body was found and the notification of her family to HopeWest, the local hospice. "We cannot speculate as to what may have been said to Ms. Golden by HopeWest," the statement said.

But Bailey Fraser, who worked for HopeWest at the time and made the call to Golden, told the Denver Gazette she merely repeated what she had been told that night by Cappella staff. She added she would have had no way of knowing the details about Hazel's last day and relied on Cappella's version of events.

Hazel became a HopeWest patient when her late husband, who also lived at Cappella, needed hospice at the end of his life. The organization did not provide daily care for Hazel nor was its staff there when she was found.

Through interviews with former employees, attorneys connected to the case, court documents and Colorado Department of Public Health and Environment enforcement records, a timeline of that night and the days, weeks and months that followed has emerged:

HopeWest was called by Cappella as required since Hazel was a hospice patient. Two HopeWest nurses arrived, including Fraser, pronounced Hazel dead and helped move the body inside. There, her soiled clothes were changed, and her body washed before she was laid on her bed.

HopeWest declined to answer questions from the Denver Gazette on the condition of the body, saying it "cannot comment on any care provided to any patient or release any protected health information."

Nearly two hours passed between the discovery of the body and the call to Golden around 10:15 p.m. When the family arrived at Cappella, they said they were instantly struck by how cold their mother's room was. Like a meat locker, Golden would later say.

It seemed odd but the family was too stricken to be suspicious. They now wonder if there was a deliberate attempt to cool the body.

In the meantime, Tracy Johnson, Cappella's director of nursing, called the three workers who had been on duty in the memory care unit and asked when they last checked on Hazel, according to court documents. She then called the head of maintenance and asked him to come to Cappella to retrieve the surveillance tape.

Johnson could not be reached for comment. The maintenance director, who has since left Cappella, declined an interview request.

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Joni Karp, executive director of Cappella at the time, was also called that night.

The maintenance director arrived around 11 p.m. He told an investigator for the attorney general's office he gave the tape to Karp the next morning.

Later Karp would admit to a state public health investigator that she knew she had a duty to report what she saw to police but did not. Christian Living Communities did not allow Karp to be interviewed, citing ongoing legal proceedings.

Before the maintenance director gave the tape to Karp, he watched it. A housekeeper, Cherie Whittington, told the Denver Gazette she walked into his office and saw only a few minutes but it was enough to sicken her. She called her friend, Megan Glenn.

"Oh Megan," Whittington said, "It was just awful to watch."

By then rumors were flying. Glenn said she got another call about what happened to Hazel and how the family had been told it was a peaceful death.

Suddenly Glenn faced a dilemma. She had left Cappella six months before and did not like the management. But she still worked in health care in Grand Junction and worried about reprisals if she made waves.

That's when her conscience kicked in. "I had a responsibility because I knew something," she said, "I was worried it was going to be swept under the rug."

So she first called Golden: "I just want you to know it didn't happen the way they said. You need to ask to see the surveillance video of the courtyard and request an autopsy."

Then she called the Grand Junction Police Department.

On Sept. 21, 2021, Colorado Attorney General Phil Weiser announced charges against the three Cappella caregivers on duty when Hazel died: Jamie Johnston, Jenny Logan and Letticia Martinez.

Initially the three faced charges of negligent death of an at-risk person, a class four felony, and criminally negligent homicide, a class five felony. Martinez and Johnston were also charged with second-degree misdemeanor forgery for allegedly falsifying the safety and medication checks.

But in the more than a year that followed, the most serious charge against Martinez and Johnston was dropped.

Last month, on Dec. 8, in an emotional sentencing hearing in Grand Junction, the families of Hazel sat on one side of the fourth-floor district courtroom and the family of Martinez on the other.

Martinez, who had pleaded guilty, offered an apology to Hazel's family in a rambling allocution and acknowledged that the death was entirely preventable. She begged the judge not to send her to prison and take her away from her children. She also talked of the toll the case had taken on her.

"They think I'm a monster," she said of people who saw her on the news.

Her public defender, Christine Tabora, argued that that the real villains were the administrators and owners of Cappella who failed to enact safety and staffing measures. It was just easier to prosecute low-wage workers, she later said.

Tabora pointed out that previously health care workers at Cappella were assigned specific residents to care for, creating more direct accountability. That policy had been discontinued.

Christian Living Communities acknowledged the change of policy in its email to the Denver Gazette, saying "most assisted living communities have moved away from an institutional hospital-like model of care to provide a more holistic and resident-focus model of care."

District Judge Valerie Robison was visibly disturbed. "I can only imagine what Hazel went through that day," she said from the bench, "When somebody dies in such a horrible way, somebody is to blame. And perhaps it's not just a somebody. Perhaps it's many."

More than a year before, during the attorney general's investigation, a nurse analyst within that office's Medicaid Fraud Unit also suggested the high-ups bore some responsibility. "Based on my education, training, and experience the facility's failure to initiate and implement a process of assigned residents to specific staff resulted in the failure of any staff to initiate and accept responsibility to conduct hourly safety checks for (Hazel) Place," according to court documents.

The attorney general's office declined to comment because the case is ongoing.

In the end Martinez received 30 days in county jail, 100 hours of community service, and a three-year deferred sentence for one count of misdemeanor caretaker neglect and one count of felony negligent homicide.

On Dec. 9, 2022, Johnston pleaded guilty to felony negligent homicide, the only remaining charge. She will be sentenced next month. Logan, the only of the three to plead not guilty, is scheduled for trial on Jan. 30.

Separately, the state Department of Public Health and Environment investigated Cappella in October 2021 and found 9 violations of Colorado assisted living regulations, plus one "informational" citation that is instructional rather than punitive.

The violations included failure to train staff on how to monitor the whereabouts of residents, failure to ensure staff did not falsify resident records, failure to make sure an outdoor area is directly supervised, and failure to notify law enforcement if there is suspected abuse or neglect.

While the agency has the power to strip a facility of its license, it did not. Instead, the facility was fined $2,000 — the current maximum fine under Colorado regulations. The facility was also required to submit a plan to correct deficiencies, which it did. The maximum fine for facilities is expected to rise under new regulations passed last year but the amount has not yet been determined.

"Our top priority is always to get a facility into compliance as quickly as possible so that they can safely serve Coloradans," the agency said in an email to the Denver Gazette.

A year prior to Hazel's death, Cappella was given a citation for failing to follow infection prevention procedures during the pandemic, including not adhering to sanitation guidelines and a staff member not wearing a mask properly. In interviews with investigators, employees at the time complained that the facility was understaffed, and family members had to help provide nighttime care.

The state required a correction plan for the COVID-19 deficiencies but did not address staffing. Cappella submitted a correction plan which the state approved.

In December 2022, a follow-up inspection was conducted in connection with Hazel's death. The state was satisfied that corrections had been made and closed the case.

"Sadly, this is not new," said Shannon Gimbel, ombudsman manager for the Denver region's Area Agency on Aging who reviewed the citations for the Denver Gazette. "For the level of care that many homes are now providing in Colorado, the existing regulations do not provide the protections that people would expect."

While she said it appeared CDPHE had cited Cappella appropriately under current guidelines, she added that in extreme neglect cases there needs to be more aggressive law enforcement and harsher prosecutions to move the needle:

"When someone dies, is a citation by the health department ever going to be enough?"

Nineteen months have passed since Hazel died. Her ashes are in an urn at her son's house.

The family has never seen the surveillance video. Golden said she asked for it just after her mother's death but was told by Karp it would have to be cleared "with corporate."

Christian Living Communities said in its email to the Denver Gazette that the day after Hazel's death, Karp called the family twice, once to offer condolences and a second time, after viewing the tape, to tell them about the footage.

The family says there was no second call.

Martinez and Johnston were fired by Capella. Logan was put on leave and has since left. Johnson also has left. Karp still works there but is no longer executive director.

The family is at every court proceeding, either in person or by internet, as a reminder that Hazel mattered. At Martinez's sentencing, Golden clutched a framed picture of her mother in her lap.

"She was the rock of our family," said Steve Place.

At 5-foot-2, Hazel Place was small but mighty. Born into the Great Depression in Rifle in 1935, she married at age 18 and then again at 81.

Her first husband, a man everyone called "Hoot," died in 1999. For years afterward she remained on the family ranch, whistling for the cows and horses who would come when she called. She loved the old-style country music. Her favorites were Jim Reeves and Don Williams. An accomplished seamstress, she would design and make fancy western shirts to be sold at a store in Aspen. One of those shirts was once worn by singer Donna Fargo.

Her second husband, Tom Hayes, had moved into Cappella before her and struggled with dementia as well. When Hazel's condition worsened, her children told her she needed to go take care of her husband. On the day she moved in, she happily grabbed his hand, waved good-bye to her daughter, and together they walked down the hall. He died three months before her.

The family has hired a lawyer, Chadwick McGrady. He calls Megan Glenn a hero.

"Sometimes I wish I didn't know," Golden said, "but I do."

Evan Wyloge contributed research for this article