Senior facility found deficient after death probe
Oct. 28—The state health department found deficiencies during its inspection of a Mesa memory care facility within Gilbert Police's jurisdiction where an elderly female resident wandered away and was later found dead.
Maricopa County Medical Examiner ruled 88-year-old Ina Jenkins' Aug. 8 death an accident and listed the cause as environmental heat exposure. Besides dementia, Jenkins also suffered from hypertensive cardiovascular disease, and hypothyroidism, according to the medical examiner.
Parent company Koelsche Senior Communities in Olympia, Washington, did not respond to a request for comment.
After Jenkins' death, Arizona Department of Health Services, which licenses these facilities, conducted an investigation in September and faulted Silver Creek Inn Memory Care Community near Baseline and Recker roads, for not adhering to state protocols.
According to the state, Silver Creek did not have policies and procedures in place that ensure the safety of a resident who may wander and that the facility's manager should not accept or retain a resident if the individual requires continuous behavioral health services.
The facility also failed to have in place controls or alerts notifying employees if a resident leaves the facility unsupervised.
Health Services spokesman Tom Herrmann, citing a state statute, said the department was unable to disclose how Jenkins left the facility undetected.
He said in an email that Silver Creek's inspection "has been referred to the enforcement team for review."
"Licensing does not request a written plan of correction until the enforcement action has been determined," he said. "However, licensing nevertheless urges the facility to immediately correct the deficiencies cited in the interim."
Jenkins was clad in a short-sleeve shirt and red plaid pajama pants and at the time it was believed she walked away at 2 p.m., according to Gilbert Police, which issued a Silver Alert.
The facility is near Baseline and Recker roads and has a Mesa address but is in Gilbert's jurisdiction.
Less than an hour after her reported disappearance, Jenkins was found dead in a dry canal in Mesa, police there said.
Jenkins had moved into the Mesa facility in August 2021.
This isn't the first time for violations at a Koelsch facility.
Reportedly, a memory care facility in Arlington, Texas was fined for nearly $2,000 for not keeping records of deaths, injuries and illnesses during the pandemic.
A company spokesman at the time explained it was a "clerical oversight" and that the delayed information to a federal agency led to the citations.
