KALAMAZOO, Mich. (WOOD) - Amerriel Cegers only has photographs to remember her mother's smile.
"I wear her ring," Amerriel told 24 Hour News 8.
Amerriel's mother Alicia Cegers died in August of 2010 after her tracheostomy tube got caught around a bed rail and became dislodged while she was living at Borgess Gardens nursing home near Kalamazoo.
Because of her size, Alicia was supposed to have two assistants help her to ensure her tracheostomy didn't dislodge. But in August 2010, only one aide was helping her. As the assistant moved her, Alicia warned that she was stuck. The aide adjusted her but Alicia said that she was still caught.
The aide the called a registered nurse for help, who later described Alicia as looking fearful and repeating that she couldn't breathe.
"That hurt, that she suffered like that," said Amerriel.
Alicia's breathing tube eventually came completely out and she was later pronounced dead at a local hospital.
The nursing assistant later claimed she cared for the resident by herself all the time.
The nurse called in to help with the tracheostomy told investigators that she'd only recently received her nursing license and hadn't worked on tracheostomies since nursing school.
"They promised us that they would take care of our mom," said Amerriel. "They didn't do it."
Target 8 pulled state inspection records on Borgess Gardens about three weeks ago because the nursing home is now on a federal watch list of nursing homes that need improvement called the Special Focus Facilities (SFF) list.
When the Centers for Medicare and Medicaid Services (CMS) recognizes what it considers a pattern of serious problems, it puts facilities on the SFF list. Those facilities are then at risk of losing federal funding if they fail to improve.
Borgess Gardens Administrator Beth Ann Brehm told Target 8 in November that the nursing home was working hard to improve their service after the serious incident.
Now that there's a pending lawsuit, Borgess Gardens won't comment specifically on what happened to Alicia Cegers, but reiterated that it has made several changes to ensure safety.
Brehm said earlier this month that Borgess Gardens now has a skills competency lab in which newly-hired employees have to demonstrate that they know how to do their job. Staff members also now have daily meetings, which they call 'huddles,' to go over safety concerns and improvements.
The nursing home has also hired more staff, including more registered nurses to ensure that more qualified people are working directly with patients.
Borgess sent Amerriel a check for $100, the amount of the fine the facility had to pay the state for what happened, but Amerriel won't cash it. She said it's a slap in the face.
Now, Ammeriel is on a mission. She's planning a wrongful death lawsuit to make sure this doesn't happen again.
"Fix it," she said.
Cegers' attorneys, with the Sam Bernstein Law Firm, sent Borgess Gardens a Notice of Intent citing a series of breakdowns they say ultimately lead to Alicia's death.
They're also questioning if Borgess Gardens is pouring most of its money into its state-of-the-art facility rather than better patient care.
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