Margarita Sam crouched on her knees and elbows in front of an elevator, her hands clasped as if praying.
A nursing home housekeeper asked the 89-year-old if she was OK, then turned away.
Moments later, Sam was found laying on the floor.
Two days later — nearly to the minute — Sam would be found dead on a bench on the facility's grounds, partially clothed. Her immediate cause of death, according to the El Paso County Coroner's Office: hypothermia, prolonged exposure to the cold.
The broader cause of her death, according to a recently issued report from a federal agency: the nursing home's failure to adequately supervise her — even after she suffered a "significant mental status change," a fall and a hospital visit, all just days before her death.
Colorado health officials pulled Union Printers Home's license to operate both a nursing home and an assisted living facility on Feb. 12, forcing about 115 residents to face relocation.
The suspension came after the Colorado Department of Health and Environment received a complaint about a female resident's death at the nursing home the week prior. The state wouldn’t identify the resident, nor does the federal report. But the Coroner’s Office confirmed that Sam was found dead Feb. 3 on facility grounds.
Union Printers failed to provide Sam "adequate supervision and monitoring to prevent her elopement from the facility ... which resulted in her death," according to a Feb. 10 report from the U.S. Department of Health and Human Services' Centers for Medicare & Medicaid Services.
Though the facility became aware the morning of Feb. 3 that Sam was missing, an official search was not initiated until hours later, the report concludes.
The search lasted only 11 minutes before she was found dead.
A troubling timeline
Sam suffered a "significant mental status change" on Jan. 29, five days before her death, according to the federal report. She fell on Feb. 1. On Feb. 2, the evening before her death, she was taken to the hospital, where she was placed on anti-psychotic medication.
But "she was not adequately monitored after her return," states the report, which paints a troubling timeline of events leading up to Sam's death, pieced together based on interviews, scanty nursing home documentation and video surveillance footage.
The Union Printers facility did not respond to The Gazette's request for comment.
The death is being investigated by the Colorado Springs Police Department’s Crimes Against At Risk Adults Unit under the Special Victims Section, Sgt. Jason Newton told The Gazette last month.
The McDivitt law firm has been hired by Sam's family to investigate her death and is looking into "about a half dozen" cases of death or abuse linked to the facility, said attorney David McDivitt.
"The broad themes are that health conditions aren't treated appropriately," he said.
McDivitt said he agreed with the federal report's conclusion, adding that the facility "dropped the ball — and I think it goes deeper than that."
The facility's owners, Kansas-based Heart Living Centers, used "willful decision-making" to "put profits over people, over patient care; revenue over residents," he said.
Sam had been admitted to the facility in April 2018. A care plan generated that month showed she was at risk for falls as a result of a medication she was on, and that she required monitoring for changes in anxiety, sleep, behavior or mood. A Jan. 10, 2020, assessment revealed moderate cognitive impairment but noted that she was independent in activities of daily living and at low risk for falls and wandering, according to the report.
A doctor's note 18 days later, however, included a concerning observation: Sam thought she was leaving Union Printers for an assisted living facility.
"Social worker unaware, will address," the doctor's note read, the report states.
An interview with Sam's neighbor and friend, also a resident, revealed that she had taken a turn for the worse the day after the doctor's note, on Jan. 29. Sam had told the woman that she couldn't live at Union Printers any longer and would be moving. Staff and a resident stated that in the week before her death, she began giving and throwing away personal items, and staying in her room. At one point she threw away her purse and phone and then reported them stolen, the report states.
When the housekeeper encountered Sam on her knees and elbows before the elevator, Sam responded that she was indeed OK. But about a minute later, she was found lying on the floor. Sam was allowed to return to her room before being assessed by a nurse. Though the facility completed some neurological checks after the fall, multiple checks were missed. Some assessments that were completed indicated "increased confusion and alteration in usual pattern" and "wandering" and labeled her as "risk-disoriented," as well as fearful and anxious, according to the report.
Slipping away, but undiscovered
Shortly after 6 p.m. on the day before her death, Sam was transported to the hospital via ambulance "due to increased confusion." Though she was "alert and oriented to herself," she was "disoriented to place, time and situation," the report states.
Sam had been behaving strangely. She drank olive oil out of a cup with a cookie in it and removed all of her clothing, wrapping it like a turban around her head. "She also stated witches were entering her room," according to the report.
With that behavior to go by, hospital staff concluded that Sam should again begin taking anti-psychotic medication. She was given her first dose at the hospital around 9 p.m. and returned to the nursing home at 11 p.m.
An associate director of nursing later told investigators that 72-hour charting and 15-minute checks should have been initiated after her mental-status change on Jan. 29, as well as after her fall and ER visit. But these things didn't happen — at least not consistently, the federal agency contends. A staffer later told investigators that Sam was not considered at-risk after she returned from the hospital because paperwork said the effectiveness of her new prescription — not Sam herself — should be monitored.
Upon her return, Sam was talking "crazy," saying the FBI was being sent to take nursing home residents away, her best friend told investigators. An overnight volunteer reported that she encountered Sam wandering on the fourth floor at 3 a.m. and saying she wanted to go home. She had a bundle of clothes under her arm, the volunteer told investigators.
Around 4 a.m. video surveillance captured Sam — clad in a thin, white blouse and white skirt-slip but without shoes on, her hair braided — in the facility near an elevator. The video last captures her traveling toward a door that leads outside, near where she was found, the report states.
A security guard on duty that night told investigators that he did not patrol the outdoor area where Sam was found because "it's too dark back there."
When she did not show up for breakfast, Sam's food was delivered to her room at 7:45 a.m. At 10 a.m., a housekeeper asked Sam's nurses where she was. A nurse rounding sheet seems to confirm Sam wasn't in her room as of 8 a.m., but documentation and interviews from earlier that morning make her whereabouts unclear, according to the report.
At 9:39 a.m., the person holding Sam's power of attorney contacted the facility and asked where she was, the report states.
A maintenance technician told investigators that he was notified around 11 a.m. that Sam was missing and went outside to search for her with another employee.
He found Sam laying on a bench, he told investigators. Her blouse was pulled up over her head.
An LPN called to check on her added that she wasn't wearing shoes. She didn't attempt CPR, as rigor mortis had set in, she told investigators.
Another attempt to flee facility
In subsequent days, as the facility reportedly worked to rectify issues that federal officials said put residents in "immediate jeopardy," investigators encountered a resident sitting in his wheelchair near a door. The man said he was getting ready to leave the facility in the snow and 25-degree weather to get food.
He'd been downstairs since 5:30 a.m. without being checked on. Food at the facility was terrible, he told investigators, so he often ordered take-out or left on his own to get food.
When asked where the man was, one nurse told investigators she thought he was at an appointment, then said she thought he was at a residents coffee gathering.
Another nurse said the man was not allowed to leave the floor and wasn't sure.
"She was the straw that broken the camel's back," McDivitt said of Sam. If not her, "it would have been somebody else, and it probably took a horrific death like this to get the state to wake up that this needed to stop."