State agencies tasked with regulating long-term care facilities that are supposed to provide for some of Utah’s most vulnerable patients are failing, a new report from the Disability Law Center argues.
The scathing 11-page report was released days after the Utah attorney general’s office filed charges of neglect, abuse and exploitation against the owners of a former unlicensed care facility in Midvale, which was shut down last year because of unsafe and unsanitary conditions.
The Midvale facility, called Evergreen Place, had been overflowing with raw sewage, had a severe bedbug infestation and had no smoke alarms or appropriate fire extinguishers at the time it was shut down, charging documents filed in 3rd District Court last week state.
“However, closing Evergreen in the wake of deplorable conditions was not the end of the story for its residents,” according to the Disability Law Center report, which was released Monday.
The report focused on 48-year-old Chien Nguyen, who lived at the Midvale facility for a year before it was shut down and later died by suicide at Hidden Hollow Care Center, the Orem facility he subsequently was moved to.
The Orem facility served as a private care center for people with intellectual disabilities — not people with severe and persistent mental health conditions, like Nguyen suffered from, the report states.
“Chien’s life mattered, and he is survived by his family who loves him deeply,” the report states. “His story is an egregious example of how the state of Utah’s licensing agency fails people with disabilities.”
Regulators ‘ineffectively protect’ residents, report says
In the report, the Disability Law Center states it has “repeatedly” seen state licensing and other agencies “ineffectively protect” people with disabilities who live in Utah’s long-term care facilities, including at private care centers, intermediate care facilities, nursing homes, assisted living facilities and youth residential treatment facilities.
The report notes 14 deaths at intermediate care centers from 2018 to present, including people who died because of malnutrition, aspiration and sepsis.
The Utah Department of Health and Human Services houses the state’s Division of Licensing and Background Checks, the state agency that inspects and surveys long-term care facilities. The department released a statement Monday afternoon that said while DHHS officials were still reviewing the report, “our hearts go out to those mentioned ... who lost a loved on in one of Utah’s long-term care facilities.”
“Helping Utahns live safe and healthy lives is our priority,” the statement continued, “and we are always open to working with partners and advocates to identify ways we can better accomplish that goal.”
A spokesperson told The Salt Lake Tribune on Monday afternoon that the department was working to answer the news organization’s “more specific questions.”
In an August 2022 statement following the death of a child at a resident treatment facility, the state licensing office said its goal is to work with providers to “make sure the health and safety of vulnerable populations are protected.” That work includes helping centers comply with state rules and assisting them on “paths for correction,” the statement continued.
“If the [Department of Health and Human Services’] Office of Licensing determines that the provider is walking in the right direction, our job is not to close them but to support their efforts to become better providers,” the statement read, “as long as the health and safety of their clients are not compromised.”
The Disability Law Center, which is federally mandated to monitor conditions at these facilities, argued in its Monday report that such an objective is “dangerous” for those who live at these facilities — and a threat to the government funding such facilities receive to provide said care.
Chien Nguyen’s death
(Disability Law Center) Chien Nguyen, a 48-year-old who died by suicide while staying at a long-term care facility in Utah, according to a new Disability Law Center report.
Nguyen, an immigrant who primarily spoke Vietnamese, had a “long history of mental health disabilities,” according to the report. He had previously been institutionalized at the Utah State Hospital and was diagnosed with schizophrenia and schizoaffective disorder. He also experienced consistent suicidal ideation.
Because of his diagnoses, Nguyen received Medicaid services through Valley Behavioral Health, a nonprofit contracted with Salt Lake County to provide mental health services, and had a dedicated “Assertive Community Treatment” team — people tasked with providing him “intensive psychiatric and other support services” who “would have frequently observed conditions at Evergreen,” the report said.
Nguyen’s brother, Nick, said when he visited Nguyen he “did not seem well taken care of” and didn’t always receive his medications or food, according to the report. Nick Nguyen also wasn’t notified of his brother’s suicide attempt at Evergreen Place just before the facility was closed.
When Chien Nguyen and the others were transferred to Hidden Hollow, staff with the Utah Department of Health and Human Services as well as the facility’s own staff became concerned that Nguyen did not have the correct diagnosis to receive care there — but determined he “needed to stay because there were no other facilities available to him,” the report states.
While the three others were “quickly discharged” because they didn’t have a qualifying disability, Chien Nguyen remained at Hidden Hollow and was later given a psychological evaluation that “curiously” diagnosed him with an intellectual disability, the report states.
The determination was odd because “the records available for review demonstrate that Chien successfully attended high school and had no record of disability prior to age 18,” the report states.
Before he received the diagnosis, Nguyen went a week or two without his medications, including one that can alleviate suicidality, and soon began having “more serious psychiatric symptoms,” the report states.
These psychiatric symptoms culminated in two suicide attempts, the report states. On April 10, 2022, he ran out of the care center and laid on a busy road. An employee at the facility pulled him back inside, but no one notified management or incoming night shift staff about the attempt. Thus, there were no additional precautions put into place to monitor Nguyen, the report states. Nyguyen’s brother visited that night and was also not informed of the suicide attempt.
Early the next morning, Chien Nyguyen ran in front of a staff member’s car, was hit and died.
The report states Hidden Hollow was fined $8,000 in connection with Nguyen’s death, as well as another confrontation where a staffer allegedly assaulted a resident and broke the resident’s tooth. The facility was also barred from admitting more residents for one month.
The Disability Law Center has seen no evidence that Hidden Hollow ever created a care plan for Nguyen, and records suggest this alleged “lack of care planning” wasn’t an isolated issue, the report states.
In March 2021, for instance, a resident who required “line of sight supervision” was left alone with a roommate and “inflicted serious bodily harm on the roommate,” which resulted in the roommate becoming blind in both eyes, the report states. That resident had injured his roommate the week before, breaking his arm. He had also injured other residents, the report states.
Hidden Hollow was fined $1,000 for the reported March 2021 assault and the facility’s licensing was put in “immediate jeopardy” and placed on conditional status, according to the report. It was removed from immediate jeopardy a month later.
The facility continues to admit and care for residents with intellectual and developmental disabilities, the Disability Law Center’s report states.
Nick Nguyen told the Disability Law Center that it doesn’t seem like anything happened after his brother died.
“I am still angry with people [who] don’t care my brother died,” he said, according to a statement in the report. “I wish that he had lived with me.”
Regulators ‘reluctant’ to shut down facilities, report says
The Disability Law Center concluded in its report that state regulators “seem to operate in a culture of protecting businesses rather than protecting people.”
It notes that another unlicensed care facility remains in operation despite similar reports that it had no hot water and a bedbug infestation “so bad that individuals have needed to seek care in a hospital.”
Government workers and others say there are not enough facilities to care for residents with severe and persistent mental health conditions, which is why officials are “reluctant” to shut down the places offering “inadequate care,” according to the report.
In seeking information on the 14 people who died since 2018 at intermediate care facilities, the Disability Law Center was told that neither the Department of Health and Human Services nor the state Medicaid office reviews deaths, the report states.
Problems also persist at youth residential treatment facilities, despite Utah lawmakers passing a law in 2021 to increase oversight.
In January 2022, a girl died at Maple Lake Academy after her parents say she did not receive proper medical care, according to a recently filed lawsuit. Months later, treatment center staff didn’t immediately seek medical attention for a resident who hit their head on pavement and lost consciousness, the law center alleges in its report.
While state regulators moved to revoke Maple Lake Academy’s license, the facility remained open.
About a year later, a child at Diamond Ranch Academy died from sepsis after suffering from an infection that is usually “easily treated,” her family’s attorney said in April. She was the third child to die at the facility since 1999, according to the Disability Law Center. The facility continues to operate under a conditional license.
The Monday report states that Utah officials should increase regulations to ensure “quality oversight.”
“Across service systems, Utah licensing and state agencies have failed to protect people with disabilities,” the report states. “Time and time again, facilities that mistreat vulnerable residents and fail to provide them with appropriate treatment or even humane living conditions continue to operate.”
