Ombudsman Sounds Alarm Over Sandy Nursing Home

Red flags piled up in the months prior to the death of Ki Soon Hyun.

SANDY: The Sandy River viewed from Jonsrud Viewpoint, in the town of Sandy. (James St. John)

A state watchdog has launched an investigation into oversight of a Sandy nursing home that was suddenly shuttered last month following the death of a resident.

A presentation by the State Long-Term Care Ombudsman, obtained by WW, outlines a series of red flags at the recently opened facility in the months prior to the death of Ki Soon Hyun, an 83-year-old resident with Alzheimer’s disease who was found dead of hypothermia in a nearby woods. Fred Steele, the ombudsman, says he was told Hyun wandered out of a propped-open door at the locked facility.

The home, owned by a real estate agent, opened in 2023 despite a report by the Oregon Health Authority the prior September identifying 94 deficiencies, “including multiple for concerns with the door locking system and lack of secure area/fencing around memory care.” It’s not clear how or when the issues were resolved.

Steele now says, “What was shocking was the fact that licensing [investigators] had never been in. I don’t know what they were waiting for.”

By the time they did enter the facility late last year, inspectors found it hadn’t been doing background checks of staff. And in November, the facility’s “interim administrator” emailed the Oregon Department of Human Services to say she was woefully under-qualified for the position, having “no college education or formal medical training or work experience.”

Then, despite Hyun’s death in December, the DHS took no action until late January, when it found the nursing home posed an “immediate jeopardy” to residents and shut it down, giving residents only hours to find new housing. As a result, Steele found, “13 of 18 residents moved to unsafe locations,” including other homes DHS knew to be problematic.

Steele says he plans to complete the investigation by next month.

DHS spokeswoman Elisa Williams said the agency moved to close the facility “as soon as it became evident to the licensing team on site that there were widespread compliance issues that posed a serious threat to resident health and safety” and that agency employees “continue to work with residents and families who need additional help.”

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