Last December, staff at a Millcreek nursing facility took a resident outside to smoke. Because he had been medically determined to be at risk of injury, he was supposed to be watched.

But a staffer at Paramount Health and Rehabilitation left him alone to help another patient, according to a new Disability Law Center report. Then the resident caught fire.

With no staff nearby, other residents tried to save him, the report says. They patted at the fire with their hands, poured liquids on him — including hot coffee — and called out for help. Staff eventually extinguished the fire by wrapping him in a fire blanket.

The man later died from his burns.

That man, the Disability Law Center report says, “had lived at Paramount for several years, had friends who cared about him, and was a Vietnam Veteran.”

After his death, Utah licensors investigated and state records show they determined that Paramount failed to provide adequate supervision. Its punishment was an $11,500 fine.

A new Disability Law Center report connects the resident’s death to broader gaps in state oversight, asserting that the Utah Department of Health and Human Services is not doing enough to protect vulnerable Utahns. As evidence, it also cites the deaths of three men with developmental disabilities who were left in a running vehicle inside a closed garage while in Safe and Sound Services’ care, along with documented harm at Provo Canyon School.

The Disability Law Center has previously and repeatedly documented that Utah doesn’t provide the oversight necessary to protect those who need long-term services, said Nate Crippes, its public affairs supervising attorney, in a statement.

“Too often, Utah has prioritized facilities and profits over the well-being of Utahns with disabilities,” Crippes said, “and we, once again, urge state officials to review our recommendations and make the necessary reforms to protect those in long-term care settings.”

Utah should require care providers to show they can safely care for people before receiving a license, the law center says, and should ensure any state funds used support more staffing and resident care. It also wants the licensing division to have more staff, training and better tools.

DHHS officials said in a statement Monday that they share the Disability Law Center’s goal of ensuring Utahn’s health and safety.

“This is at the core of our purpose,” they said, “and the stories outlined in the Disability Law Center’s report weigh heavily on us. When safety is compromised and lives are lost, we feel it deeply.”

The state officials said they have previously identified the same concerns raised in the report, and that work is underway consistent with the nonprofit’s recommendations.

That includes hiring a contractor who led a symposium with community partners to better understand weaknesses and how oversight could improve. And they’ve hired four new workers in their disability services division to improve oversight.

DHHS officials said they are continuing to explore ways to keep problematic providers from receiving their contracts, and they want to enhance the qualifications required for providers who serve those with disabilities.

Here’s what the Disability Law Center described in its report.

Paramount Health and Rehabilitation: Residents dressed ‘only in briefs’

Paramount Health and Rehabilitation is part of a network of nursing homes in Utah that’s owned by Beaver County, and operated by the Ensign Group, the nonprofit law center noted in its report.

Beaver County takes part in a federal program that allows rural county-owned facilities to draw higher Medicaid payments. These payments were intended to support higher staffing levels and improved care in rural areas — but the law center questions whether that’s happening.

Since Utah implemented its version of this program a decade ago, three city and county hospitals — including Beaver Valley Hospital — have acquired ownership of the majority of nursing homes that operate throughout Utah, far beyond rural communities, the law center noted.

The Disability Law Center is Utah’s protection and advocacy agency, a federal designation that allows it to visit facilities like Paramount. The center’s observers have seen unsanitary conditions at the Millcreek facility, with residents wearing soiled clothing, it said in its report.

“On one visit, multiple residents were dressed only in briefs without any other covering,” the report reads.

The building recently had some cosmetic upgrades in the hallway, according to the nonprofit’s report, but it said overall the facility is outdated and unclean. It also noted that some residents’ mattresses were on the floor.

Ensign Group did not respond to a request for comment about the report.

Safe and Sound Services: A ‘filthy’ basement room

In February, three men died after authorities say a Safe and Sound Services employee left them in a running van in a garage for more than four hours as he ate and watched television in his apartment.

The Disability Law Center report said that after the deaths, state licensors visited six residential sites operated by Safe and Sound to assess safety — and found that only one appeared to have no significant problems.

At one location, a resident reported being yelled at and denied access to their money, and sleeping on the floor because they only had an air mattress. Another resident, the report said, was living “in a filthy basement room with no door and only a mattress on the floor.”

“The door to the upstairs was missing and staff admitted to locking them in the basement at night,” the report reads.

Safe and Sound Services had a contract with DHHS to provide support for Utahns with disabilities. The Disability Law Center said these conditions showed that the group was not using that money to provide “even basic utilities of a clean environment.”

State licensors shut down Safe and Sound Services shortly after the three men died; the program is appealing the action, according to state records. Safe and Sound Services has not responded to past requests for comment sent by The Salt Lake Tribune, including after the state announced its closure.

Provo Canyon School: Police called to ‘riot’

In June, the Disability Law Center released a letter it sent to licensors describing the “shocking” conditions it found during visits to Provo Canyon School’s Springville and Provo campuses.

The group highlighted those findings again in its most recent report, which included photographs of the thin mattresses young people slept on, and graffiti scribbled on several walls.

The report says residents told center workers that Provo Canyon was so understaffed, they pulled in administrative, clinical or office personnel to fill shortages.

In one instance, the center said it learned that an IT support staffer was required to watch teenagers. “During his shift, children became frustrated and escalated, culminating in a riot which required police intervention,” the report reads.

State officials have also revoked licenses for both Provo Canyon School campuses, and the school is appealing. Its leaders “disagree with the state’s decision,” but they have declined to comment about the appeal in detail.