Hobbs wants investigation of Arizona response to problems at Mesa assisted living center after Republic report

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Gov. Katie Hobbs will force state agencies tasked with protecting seniors to investigate where they "fell short" in their response to repeated failures at a Mesa assisted living facility.

She also announced on Tuesday priorities for the next legislative session to improve accountability for health care institutions, including assisted living facilities.

The move came one day after The Arizona Republic and azcentral.com revealed how Heritage Village continued to make mistakes that endangered residents after a woman with dementia killed her roommate there more than three years ago. An employee had skipped the woman's Lorazepam, which she took to control agitation.

"These health care facilities lack true accountability,” Hobbs said. “The stories from Heritage Village and others are horrific and unacceptable."

It's unclear what the investigation might find, as the agencies Hobbs tasked with the effort ― the Arizona Department of Health Services and Adult Protective Services — were responsible for the initial response that the governor is now criticizing.

The governor's spokesperson, Christian Slater, said the administration doesn't have an external investigation planned.

State Sen. Catherine Miranda, D-Phoenix, posted on social media about auditing the state Health Department so the Legislature also could take action in the coming months.

The family of the woman who was killed by her roommate is glad the governor is taking the problem seriously, their lawyer said.

"It's unfortunate that it took this much pain and suffering and distress to finally get it to this point. There have been a lot of people that have suffered at the hands of Heritage Village," Attorney Robert Glassman told The Republic.

"But thankfully because of our legal system, the court system and our journalists, like you, we're finally bringing it to a head and getting it the attention it deserves by our elected officials."

Heritage Village received 148 state citations over the past three years. That's 2.5 times more than any other assisted living center licensed to serve residents who need the most help and supervision. Heritage Village also has paid more fines than most; its penalties over three years added up to $18,500. Other facilities typically paid less than $2,000.

The Republic has published several investigations this year chronicling failures within the assisted living and nursing home system, starting with a series in May outlining resident-on-resident harm, particularly in memory care units.

Hobbs' announcement said the administration has worked for months to develop reforms that "crack down on bad actors, protect patient care and strengthens accountability." The Governor's Office previously had not responded to The Republic's repeated requests for interviews to talk about any possible changes that Hobbs supported.

"It has been a process of trying to develop some of these things and it happens over the course of a long period of time and sometimes just the timing doesn't add up. I apologize," Slater said.

Changes Hobbs wants for Arizona senior care centers

The governor's list includes:

• Hiking fees and fines based on the severity of an infraction. Right now, the state Health Department can only fine facilities $500 for each violation, for each day that it occurred.

• Empowering the state Health Department to revoke licenses for cause and crack down on other problematic practices.

• Closing inspection loopholes. Right now, assisted living facilities can skip an annual inspection if they have a clean inspection the year prior.

• Implementing "robust licensure requirements for assisted living facilities."

• Hiring more state Health Department employees and legal support.

• Increasing regulation and certification of facilities that advertise memory care. No additional licensure is required and no set rules associated with "memory care" exist today.

• Creating a transparent quality rating system for nursing homes, assisted living and long-term care facilities. The current system is hard for the average consumer to use.

"Over the coming weeks, we will be announcing a legislative package to ensure we are keeping Arizonans safe and bring accountability to a system that has lacked it for too long,” Hobbs said in her statement.

Families whose loved ones were injured, killed respond

Families whose relatives were hurt in assisted living facilities responded with tears and relief to the news.

Cathy McDavid, whose mother was killed by a fellow resident at Bethesda Gardens in north Phoenix, said the change was all she ever wanted. The death of her mother, Joann, prompted The Republic to launch a yearlong investigation into assisted living facilities. The state Health Department never told The Republic if it investigated what happened to Joann.

"Really, more than anything was something positive to come out of this. And now I'm feeling lately between the attorney general and this, it feels like something positive is coming out of this," McDavid said. "That's what mattered. Wow. I'm sitting here getting teary about it."

Arizona Attorney General Kris Mayes recently announced that she may sue or criminally prosecute facilities that jeopardize their residents.

'I want to send a message': Arizona attorney general says she may prosecute senior care facilities

Carlyn Bouchard, whose mother, Estalyn, lived at Heritage Village for a year, said she was emotional about the governor's announcement but also skeptical: You never know if you can trust politics.

"Even if nothing changes, but people see all of this, it can help them know what to do to protect their loved ones," Bouchard said. "Never having gone through it before, we were blind to the pitfalls and what to ask. ... I think that everyone needs to do much more due diligence when placing a loved one in a place."

Bouchard and her siblings pulled Estalyn out of Heritage Village after a long year of problems that ended with her mom breaking her wrist and coming home with night terrors about someone on top of her, hurting her.

Dellene Bouchard, Carlyn's sister, said she lives with the guilt that she decided she couldn't care for her mom anymore and moved her into Heritage Village.

"People that are supposed to be trained treated my mother worse than what I could have done untrained," Dellene Bouchard said.

Michele Bixby, whose mother wasn't given the medication she needed to keep calm and killed her roommate at Heritage Village, said she never thought her mom's story could prompt positive change.

Her mother, who suffered from dementia for a decade, went into "crisis mode" without her medication. People with dementia may lash out if they are confused and afraid of people and surroundings they don't understand.

"To me, there was no hope. These things happened to my mom, we sue the facility and we go home," she said. "But even though I can't get my mom back, and they can't get their mothers back, at least other loved ones are going to be under better care because people got together and did something about it," Bixby said.

Dangerous place to live: Senior facility where resident killed roommate has had nearly 150 citations

Reach Caitlin McGlade at caitlin.mcglade@arizonarepublic.com. Follow her on X, formerly Twitter, @caitmcglade.

This article originally appeared on Arizona Republic: Arizona Gov. Hobbs wants closer look at response to Mesa care center