The Christmas Day death of an Oregon assisted living community resident led to an audit by the state’s ombudsman, whose scathing report called for an investigation into the state agency tasked with overseeing long-term care facilities.
Two days after moving into Mt Hood Senior Living, a residential care and memory care community in Sandy, OR, Ki Soon Hyun was found in a wooded area outside the community. Police reports indicated that the resident of the memory care unit succumbed to the cold weather overnight after wandering outside undetected.
The Oregon Long-Term Care Ombudsman’s office launched an investigation into the community following Hyun’s death. The resulting report alleged numerous problems and chided the Oregon Department of Human Services for not intervening to protect residents both before and after Hyun’s death.
Gaps in state law lead to tragedy
Mt Hood Senior Living received its license on Feb. 7, 2023, to operate a 50-bed care facility, with 33 beds dedicated to memory care. The ombudsman’s report stated that gaps in Oregon law allowed Joy Zhou, an owner with no background or knowledge of long-term care, to open a state-licensed memory care community. The ombudsman also noted that gaps in the state’s regulatory framework don’t require the state licensing agency to closely monitor a newly opened facility to ensure that residents are safe and receiving required care.
“The lack of regulatory requirements for an inexperienced owner opening a facility for services to individuals with extraordinary care needs associated with dementia is particularly concerning,” the report read.
Within months of opening, the state received complaints about the community, but the ODHS failed to conduct an inspection until November, according to the ombudsman’s report. ODHS identified unlocked and unsecured doors, untrained staff members and inadequate staffing levels at the community. But the agency did not take formal action until three days after Hyun’s death.
Also in November, the building’s business manager, who was serving as interim administrator for the community, notified ODHS that the administrator had left and that she felt unqualified to fill in as an interim because she did not have credentials, training or education to manage a memory care community. The state responded that the facility should hire a qualified administrator but did not provide subsequent followup, according to the ombudsman’s report. That business director still as functioning as the interim administrator when Hyun wandered away from the community.
The long-term care ombudsman’s office began its investigation into Hyun’s death on Dec. 28. Jan. 22, ODHS conducted a licensing investigation of the community that led to the issuance of a condition of “Immediate Jeopardy.” That led to a late night removal of residents to “potentially unsafe settings” in a “rapid and chaotic closure,” according to the ombudsman’s report.
‘Broken’ system creates mistrust
The ombudsman’s report noted that the “actions and inactions” leading to Hyun’s death and further harm to residents after her death were “unacceptable.”
“Trust is currently broken,” the report concluded. “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 Oregon Health Care Association called the events of Mt Hood Senior Living “tragic.”
“Oregon has strong laws that prioritize resident safety and person-centered care,” OHCA Senior Vice President of Strategy Rosie Ward told McKnight’s Senior Living. “OHCA supports the enforcement of those laws and certain recommendations from the ombudsman’s report, such as more oversight for first-time operators and timeliness of licensing and complaint investigation.”
Based on its investigation, the ombudsman’s office recommended several improvements to consumer protection regulatory functions of Oregon’s long-term care system, including implementing processes to more urgently respond to red flags at state-licensed long-term care facilities.
The report also recommended an independent audit of ODHS’s licensing and regulatory functions to ensure that the regulatory system operates effectively within state laws, with a primary focus on consumer protections. In addition, the ombudsman’s office called for more timely licensing investigations and an evaluation of gaps in current state laws regulating long-term care facilities.
ODHS disputed the report in a response letter, noting delays in regulatory actions have been exacerbated by workforce shortages.
“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 Mt Hood Senior Living,” ODHS Director Fariborz Pakseresht and ODHS Office of Aging and People with Disabilities Director Nakeshia Knight-Coyle wrote in response to the report.
