Manse on Marsh death was ‘an accident waiting to happen,’ employees told investigators

The Manse on Marsh is located in downtown San Luis Obispo.
The Manse on Marsh is located in downtown San Luis Obispo.

Former employees of Manse on Marsh in San Luis Obispo told an investigator that the facility regularly accepted residents it wasn’t licensed to care for, and that a 65-year-old who died after wandering off in 2014 would be alive if the facility hadn’t bent the rules to take him, an investigator says.

A document unsealed by a judge last week says that Christopher Skiff, owner of the assisted living facility, and Gary Lee Potts, a former administrator, conspired to admit residents with dementia while also cutting down on staffing in order to increase profits, even though the facility had been cited by authorities for doing so in 2008.

“It was always about the money,” one former employee told the California Department of Justice.

The alleged practice came to light after the death of Mauricio Edgar Cardenas, 65, who died on Dec. 21, 2014, after he was struck by a car while walking in the dark about 10 miles from the facility.

The California Department of Justice launched an investigation into Cardenas’ death in 2015 following a complaint filed by a former employee. That employee, whose name is redacted in court records, said that Cardenas should not have been at the facility because it’s not licensed to care for dementia patients, and didn’t receive a waiver for housing.

Gary Potts
Gary Lee Potts Photo courtesy of Smith County Jail (Tyler, Texas)

Christopher Edward Skiff San Luis Obispo County Sheriff’s Office

Skiff, 54, and Potts, 63, were arrested and charged in July with felony involuntary manslaughter and elder abuse. If convicted of both charges, they could both face a maximum of eight years in prison, according to the Attorney General’s Office, which is prosecuting the case.

Last week, a San Luis Obispo Superior Court judge unsealed a sworn affidavit submitted in March 2015 by an agent assigned to the Department of Justice’s Bureau of Medi-Cal Fraud and Elder Abuse. In it, Special Agent Sherry Zamanigan described her interviews with five then-employees.

One staffer said that Potts persuaded Cardenas’ physician to alter his patient’s diagnosis so that Cardenas could be admitted to the unlocked assisted living community, according to the report.

Skiff’s attorney, Robert Sanger, said he received the affidavit Monday morning but had not yet had the chance to review it, and declined to comment on the case.

At a bail hearing in August, Sanger told the judge that state policy at the time of Cardenas’ death allowed facilities like Manse on Marsh to accept patients with mild or secondary diagnosis dementia.

Skiff and Potts are due in court Wednesday for a pre-trial hearing. Attorneys for Skiff and Potts have not yet had an opportunity to scrutinize evidence or cross-examine any alleged witnesses in the case.

In her affidavit, Zamanigan wrote that Manse on Marsh, under the direction of Skiff and Potts, regularly accepted elderly residents with medical and nursing needs they were not licensed to care for beyond dementia, exposing the residents to circumstances likely to cause great bodily injury or death.

A previous director of wellness whose name is redacted in the report told the investigator that Potts would order staff to ask residents’ doctors to alter their diagnoses so they could stay at Manse.

She said, if (Cardenas) was not a resident at Manse, he would still be alive.

California Department of Justice Special Agent Sherry Zamanigan

“To meet the licensing requirements, the staff asked (Cardenas’) physician to change the primary diagnosis from dementia to mild cognitive impairment, and his chart reflected the change,” the affidavit reads, adding that Skiff was also aware of the change.

The employee said she was aware of at least one other nurse who had been forced to call a doctor’s office to get a diagnosis changed.

“The nurse cried because she did not want to do it,” the report reads. “The nurse would call and say to the doctor’s office, ‘Are you sure? Are you SURE, it’s dementia?’ coaxing the doctor’s office.”

The doctors’ names are redacted in the report, and it is unclear from the affidavit how many doctors changed diagnoses.

It was located on a very busy street and was an accident waiting to happen.

A former Manse on Marsh employee, as told to a DOJ agent

Another Manse employee told Zamanigan that it’s a “census-driven operation,” meaning they “strive to fill as many beds with residents to maximize revenue.” The employee added that the facility had not turned down an applicant while she worked there.

Another employee said that staff turnover was “ridiculous,” and that Potts constantly made her work with a skeleton crew, sometimes with just two staffers for a facility with an average resident population of about 84.

The employee said that, prior to her leaving in late 2014, there were about 20 dementia-diagnosed residents at Manse on Marsh.

“She said, if (Cardenas) was not a resident at Manse, he would still be alive,” Zamanigan wrote.

Other employees said other residents with dementia would repeatedly fall at the facility or wander the grounds naked, and there wasn’t enough staff scheduled to assist them one-on-one.

“It was located on a very busy street and was an accident waiting to happen,” an ex-nurse told Zamanigan.

The facility, which has been licensed since 2000, was cited each year from 2007 to 2009 for keeping residents who were not appropriate for the facility, and was fined in 2008, according to the DOJ.

Related stories from San Luis Obispo Tribune