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The Office of the Long-Term Care Ombudsman released a scathing report today demanding an independent audit of the Oregon Department of Human Services in the wake of the death of an 83-year-old resident of a Sandy nursing home late last year.
Ki Soon Hyun wandered away on Dec. 24 and was found dead in a nearby ditch a few days later. Police found a GPS device hanging from her neck. The nursing home, Mt. Hood Senior Living, was shut down by regulators a month later.
In the wake of Hyun’s death, the ombudsman launched an investigation culminating in the report released today. Not only did the nursing home “catastrophically” fail, the ombudsman found, but state regulators missed a series of “red flags” preceding Hyun’s death.
The ombudsman “finds that this resident’s death and the additional harm and trauma that occurred to residents at this facility in the weeks following could have been prevented,” the report says.
After state regulators shut down the nursing home a month after Hyun’s death, residents were abruptly transferred to hospitals and other homes “in the dark of night,” some reportedly without their lifesaving medications, according to the ombudsman’s report. Thirteen of the 18 residents were moved “to locations that ODHS should have considered to be unsafe,” the report says. (”No facility that received a Mount Hood Senior Living resident had restrictions on admissions due to a safety compliance issue,” ODHS says.)
One former resident, Charles Hess, was found dead in his recliner after a series of falls—“potentially related to the transfer trauma,” the report says.
Hess, who suffered from a terminal illness and was in severe pain, had been sent to another nursing home in Clackamas County without “his durable medical equipment (walker, bed) or personal belongings.” He suffered a fall the next day, prior to being given a “pendant alarm” that could be used to call for help.
“Trust is currently broken. This report and its recommendations are intended to move our state closer to that goal and improve the lives of residents in long-term care,” the report says.
ODHS has pushed back against the report’s findings. Its leaders say they did what they legally could given the information they had. “We respectfully do not agree with many of the report’s statements or its representation of the agency’s options in pursuing regulatory action at Mount Hood Senior Living,” agency directors Fariborz Pakseresht and Nakeshia Knight-Coyle wrote in a letter in response to the ombudsman’s report.
Mount Hood Senior Living was a new facility, opened in 2023 by Joy Zhou.
Zhou “had no experience delivering long-term care services” and was relying on a consultant to help get it off the ground. But that consultant hadn’t been in the facility for months, a fact unbeknownst to regulators, and had, in fact, quit three weeks before Hyun’s death. The consultant raised concerns on the way out about the facility’s adherence to safety plans and other regulations.
It wasn’t the only opportunity to step in that was missed by state regulators, the report contends.
In early November, inspectors entered the facility and found it to be “regularly understaffed,” the ombudsman’s report notes. Not only that, the facility hadn’t had an administrator since Nov. 2.
A few weeks later, the interim administrator emailed ODHS, saying she wasn’t qualified for the position. Regulators still didn’t intervene.
Hyun died two months later. The next day, the facility submitted a safety plan to regulators that they noted was “insufficient to protect residents from further harm.”
The plan was worrisome for other reasons, the ombudsman notes. It “included a plan to install an alarm system on certain exit doors, indicating that they may not have had the alarms in place” at the time of Hyun’s death.
But regulators were ultimately satisfied. In a Jan. 24 letter to the ombudsman, ODHS staffers said they declined to sanction the facility’s license because they were satisfied with the “short-term interventions.”
They changed their mind that day. Two days later, they shut the facility down, leading to a “rapid and chaotic closure,” the ombudsman found. This was despite the agency pushing through a law over a decade ago that gave it the authority to keep facilities open in such situations by obtaining an expedited court order to transfer ownership to a trustee. Such a move would have prevented the chaotic shutdown that preceded Hess’ death. (In their response, the agency’s leaders said they “weighed many regulatory options” and that keeping the facility open wasn’t feasible.)
The agency’s response also appeared to violate state law, the ombudsman found. In 2021, the state passed a new law requiring ODHS to issue sanctions on a nursing home’s license if a resident died as a result of a facility’s failure to follow state rules. “ODHS did not issue a condition for an ‘immediate jeopardy’ situation until 30 days following the resident’s death, in violation of statutory expectations,” the report notes.
In its response, ODHS leaders did acknowledge they have faced new challenges lately. “The difficulty of this regulatory response is indicative of how Oregon’s long-term care system has increased in size and complexity in recent years. Workforce shortages, which are commonplace among long-term care providers, have exacerbated the challenges,” the letter notes.
The Long-Term Care Ombudsman is calling for more inspections of new facilities, as well as an independent audit to ensure ODHS is fulfilling its mission to protect nursing home residents across the state. “It is unclear why ODHS is reluctant to use the full force and effect of the laws in existence,” it notes.