Editor’s note: The following story was written and reported by The Utah Investigative Journalism Project in partnership with the Standard Examiner, The Salt Lake Tribune and the Daily Herald.

In spring 2019, Elisia Eby’s 83-year-old grandmother was discharged from the hospital to recover from a simple knee replacement surgery. When family showed up at Rocky Mountain Care in Clearfield, they discovered that she had been left sitting in a chair after surgery for hours, with no one having gotten her into a room and a bed.

The red flags continued to pile up as the family watched nurses make repeated mistakes with her medication. Once, they forgot to administer her pain medication; another time, they accidentally tripled the dose of one of her medications, causing her to fade in and out of consciousness. Staff were always evasive with answers.

“We’d ask three different staff why she was left alone for hours and got three different responses,” Eby says.

The food served was as neglected as the residents. Once for breakfast, they left her a banana, for dinner a slice of baloney and a piece of toast.

“We got to a point where we were so worried we had a family member stay with her 24 hours a day,” Eby says. They even put up large poster board signs in her room explaining her medications so nurses would not make any more errors.

The family worked hard with her providers and insurance to get her moved out as soon as possible. But residents at such facilities don’t always have family there 24 hours a day. Often, it’s only a few staffers to care for dozens of residents.

Isolated nursing homes often come up in the news for poor health inspections and understaffed facilities. But that was before a pandemic settled in, endangering at-risk adults across the globe — and especially those in nursing homes.

When it comes to nursing homes in Utah, health reports show that issues of sanitation and patient care are not limited to one facility. The Utah Investigative Journalism Project reviewed dozens of inspection reports dating back years for nursing homes owned by Beaver Valley Hospital, such as Rocky Mountain Care – Clearfield, that comprise just under half of the state’s Medicaid-certified nursing homes. In 2019, inspection reports warned that nine of the nursing homes needed to implement infection control programs because of unhygienic practices. Many other reports documented shocking incidences of lack of care brought on by facilities, including:

  • In 2019, at Rocky Mountain Care in Logan, nine patients got urinary tract infections — five from E. coli — despite the facility being warned in 2018 about hygiene issues that could lead to infection.
  • In 2019, an inspector at St. George Rehabilitation observed a screaming and delusional wheelchair-bound woman asking for help, only to have a nurse wheel her in front of a television and then walk away.
  • In 2019, an inspector reviewing records at Millcreek Rehabilitation and Nursing found nurses had mistakenly coded a resident as “Do Not Resuscitate” when, in fact, the resident’s file requested resuscitation in case of medical emergency. “Oops, that’s bad,” said one of the nurses.
  • In 2019, a hospice resident at Provo Rehabilitation & Nursing was voluntarily taken off a breathing apparatus. Because staff did not have a care plan in place, the individual was not fully sedated during the procedure and died gasping for air.
  • At Parkdale Health & Rehab in Price in 2019, an inspection states a resident lost 28 pounds in 33 days despite having specific guidelines for feeding.

When it comes to the Beaver Valley Hospital, the largest owner of nursing homes in the state of Utah, a history of poor health inspections and concerns of a lack of oversight have been present for years, all while tens of millions of dollars of government funds are spent on care and improvements. Still, five facilities have been the subject of medical malpractice lawsuits since being acquired by Beaver Valley Hospital.

The Eby family has had more than their fair share of exposure to these facilities — Elisia’s mother, Kathy Eby worked as a director of nursing at two different homes owned by Beaver Valley Hospital between 2017 and 2019, including Crestwood Rehabilitation and Nursing in Ogden. She’s worried about the threat of COVID-19 in these homes, since in both the facilities at which she worked there was inadequate sanitation supplies well before the pandemic and overworked staff did not have time to clean up between visiting residents.

“Nobody was washing their hands,” she says.

Beaver Valley Hospital dominates Utah nursing homes

In 2014, Beaver Valley Hospital, owned and located in the southern Utah city of Beaver, began buying long-term nursing facilities throughout the state. In the span of five years, the Hospital bought 43 nursing homes from Logan to St. George. The residents and patients of these facilities outnumber the population of Beaver Valley Hospital’s hometown: around 3,100.

As with many health care organizations across the country, Beaver Valley Hospital gets federal funding through Medicaid to take care of its residents. But hospital administrators say Medicaid funding alone isn’t enough to keep facility doors open. Through a program created by the Utah Department of Health called the Nursing Facility Non-State Government-Owned Upper Payment Limit Program (UPL Program), the hospital is given additional federal funding each year to help keep Beaver’s nursing facilities open and improve them.

The UPL program works by increasing the amount of federal money nursing facilities receive to a standard Medicare rate. In the case of Beaver Valley Hospital’s facilities, it is much higher than the original Medicaid funding. The hospital just has to provide the state with seed money and comply with program rules, and the Department of Health obtains the additional funding from the feds.

When compared to other organizations in the UPL program, Beaver Valley Hospital is far and away the biggest player. Last fiscal year, it received funding for 44 facilities, compared to Gunnison Valley Hospital, the next biggest participant, which received money for only five. A 2019 report of financial statements says Beaver Valley Hospital and its network took in about $57 million in UPL funds.

Craig Davidson, executive director of Beaver Valley Hospital’s nursing facilities, says the hospital decided to buy nursing homes throughout Utah to help keep nursing homes from closing their doors, and to keep the local hospital profitable.

“We took over the ownership of these operations and the licenses for these facilities in order to bring the added revenue down to the nursing homes to get them so that they had a black bottom line instead of a red bottom line when they were dealing with the Medicaid patients,” Davidson said. “We (Beaver Valley Hospital) were facing significant financial challenges from the lack of reimbursement, declining inpatient admissions and having a market share that wasn’t really growing.”

Since the hospital is a UPL Program participant, it’s possible that federal regulators could require over $20 million in UPL payments to be refunded if program regulations have not been met. If Beaver Valley Hospital can’t foot that bill, Utah taxpayers may have to.

Same problems, different year

Despite tens of millions of additional funding flowing into Beaver Valley Hospital, the same violations arise year after year during inspections conducted by the Utah Department of Health. The Utah Investigative Journalism Project reviewed hundreds of pages of inspections, found serious problems to be recurring and that 23 of the facilities — just over half — had a number of health citations above the national average. Last year, 10 of them logged more than double the national average, and some had many more.

From 2017 to 2019, five facilities (Millcreek Rehabilitation and Nursing, Rocky Mountain Care – Hunter Hollow, South Ogden Post-Acute, St. George Rehabilitation and Provo Rehabilitation & Nursing) had three times more health deficiencies than the national average.

Riya Roberts says a lack of care and oversight at Provo Rehabilitation & Nursing caused her grandmother’s untimely and preventable death. Roberts’ grandmother was admitted into the nursing home after suffering a stroke and lived there for several years. She passed away in April 2019 after choking on food while eating in the facility’s dining room. Roberts says if a staff member had been present while she was eating, her grandmother would probably still be alive today.

“We thought at least she was generally safe,” Roberts says. “As it turns out, they weren’t even taking the basic measures to protect her safety and it ended up killing her.”

Roberts says she didn’t know why no staff members were in the lunchroom on the day her grandmother died. But at Provo Rehabilitation & Nursing, staffing issues appeared on an inspection two months after Roberts’ grandmother died. In an inspection report dated June 20, 2019, a CNA told the inspector, “there were not enough staff, and that it was difficult to get to all of the residents to provide cares that were needed because of it.”

In 2017, Rocky Mountain Care – Hunter Hollow in West Valley City received a total of 35 violations during a health inspection, 4.2 times higher than the national average. During this inspection, the reviewer noticed “a resident with broken dentures did not receive dental services to fix/replace her dentures” and as a result lost a significant amount of weight, going from 103 pounds to 85 pounds in just four months.

Despite denture issues being directly responsible for a dangerous amount of weight loss in a resident, during Hunter Hollow’s most recent inspection, a similar violation was documented. The inspection report for the incident stated, “a resident’s dentures were reported lost without adequate follow up documentation or a dental appointment over one month after the dentures were reported missing.”

When asked about issues coming up again and again in inspection reports, Davidson says Beaver Valley Hospital works with those who manage their nursing facilities to come up with solutions when violations arise.

“A lot of times when those mistakes have been made, we’ve already made corrections or in the process we’re making corrections,” Davidson says. “We address the issues up-front, which we do the very best that we can, and when a survey comes in and finds a deficiency, we correct that deficiency.”

Davidson did not respond to a request for comment on specific allegations made by clients in this story. Messages left with individual facilities named in this report also went unanswered.

Training day

Kathy Eby’s first indication something was wrong with her new job was the training — or lack thereof. In 2017, she was hired as a director of nursing at Rocky Mountain Care’s nursing facility in Heber, receiving only about a day’s worth of training.

From there, it was a crash course in running a facility that maximizes profits through understaffing. Oftentimes, she found the facility had one registered nurse and two certified nursing assistants to care for 30 residents, some with complicated needs. At that ratio, she says the nurse is lucky to get everyone their medication, let alone actually care for anyone’s needs.

Only a handful of states regulate minimum ratios of staff to residents in nursing facilities. Utah is not one of them. If Eby had worked at a facility in Delaware with 30 residents, for example, the law there would require at least two RNs and three CNAs on duty for that many residents during the day and evening shifts.

A review of inspection reports for 2019 found 14 reports registering complaints of understaffed facilities at Beaver Valley’s nursing homes.

Eby says the lack of staff meant patients would be left unattended for hours, unable to feed or clothe themselves or use the restroom. The overwhelmed staff ended up cutting corners wherever they could — and that included hygiene and hand sanitization.

As director of nursing, Eby was supposed to be able to turn residents away if they had health needs that the facility couldn’t handle, but says she was repeatedly overruled by administrators accepting high-needs residents to ensure beds were filled to qualify for the maximum federal reimbursement.

Eby eventually left the facility in disgust in 2018 and landed another director of nursing position at Crestwood Rehabilitation and Nursing in Ogden, a job she had until last summer. Eby didn’t realize it at the time, but she actually left the Heber facility only to land at another facility owned by Beaver Valley Hospital, though managed by a different company.

Here, she came across the same problems — overworked nurses in understaffed facilities accepting any resident they could bill the most for.

Drug use was a major problem with troubled residents at the facility, Eby claimed — traded prescriptions, marijuana and other substances.

At Crestwood, the facility had one resident with mental health issues who was suspected of using and selling drugs at the facility and who was violent with staff. He used to ram into staff and other residents in his electric wheelchair and run over people’s feet intentionally.

Every time she tried to get him out, she got the same pushback from administration — “How are we going to replace him?” As a long-term resident, he was also a steady source of Medicare reimbursement.

Care for profits over resident care also was alleged in a lawsuit filed against another Ogden facility, Lomond Peak Nursing and Rehabilitation, by a former resident. Lomond Peak also is owned by Beaver Valley Hospital.

“We deny the allegation and other than that we are not going to try the case in the media,” said Nan Bassett, an attorney for Lomond Peak.

In a lawsuit filed in February, a complaint alleges improper care led to a woman being dropped by staff, resulting in a fractured arm.

The complaint also alleges the facility had received inspection report with complaints about the quality of care and “ignored these complaints, concerns and problems and focused on maximizing its profits.”

“As a result of Lomond Peak’s persistent and systemic poor quality of care the government has identified this as a ‘Special Focus Facility,’” said the plaintiff’s attorney, Mark Carlson. That means the facility is under closer scrutiny and could potentially lose the ability to receive Medicare and Medicaid reimbursements.

Besides accepting any resident no matter how unfit for the facility, Eby observed something else common to both the facilities.

“I can tell you that protocols are not followed until it’s time for the state inspection, then it’s a mad dash for everyone to mind their Ps and Qs,” Eby said.

Ethical responsibility ‘left behind’

In 2017, Beaver Valley Hospital came under scrutiny in a legislative audit that focused on a perceived lack of oversight of facilities, finances and possible liability of the state for more than $20 million in federal funding.

Beaver Valley Hospital and its contracts with nursing homes “do not establish measurements to assure that a reasonable level of quality is being met,” auditors found.

In response, Beaver Valley said it worked with management companies who run the nursing facilities to “ensure compliance’’ with the UPL program and quality of care.

The Utah Department of Health, in partnership with Beaver Valley Hospital and other UPL participants, created a quality improvement program, which requires a certain amount of UPL funds to be used to improve nursing facilities, staffing and residents’ quality of life.

Beaver Valley facilities in early 2019 received average compliance scores 11.3 points below other nursing homes owned by similar government organizations, according to a Quality Improvement (QI) Program presentation conducted by the Department of Health.

One of the concerns raised in the legislative audit was that Beaver Valley Hospital was keeping 51% of the money, rather than sending it on to nursing homes. Davidson acknowledged the hospital does take back a “confidential” amount of money from nursing homes, most of it to cover “a tremendous amount of expenses” related to participating in the UPL program.

After those administrative expenses, between 9% and 11% go toward providing health care to Beaver residents, including allowing the hospital to purchase expensive new equipment, Davidson said. Based on Beaver Valley’s financial reports, that would mean the hospital would have retained between $5.1 million and $6.2 million of UPL funds in the past fiscal year.

“All these dollars are strengthening the delivery of health care,” Davidson said. “So is there a better use of those funds? I say absolutely not.”

Dean Sanpei, a former state lawmaker and now a senior executive at Colorado’s largest health care provider, initially called for the audit of Beaver Valley Hospital. He said that although the audit didn’t find that Beaver was operating outside of federal rules, it appeared it was operating with a lack of integrity.

“While the audit did justify my concerns and highlighted the financial and quality risks, it came down to Beaver was exploiting a federal loophole, but it was not clear that they were actually breaking the law. But as a former lawmaker — if the law is your only standard for behavior then you have long ago left ethics and responsibility behind.”

For Kathy Eby, the law is not enough. She says the law needs to mandate ratios for nurse to resident care and crack down on unsafe homes.

“I would never put my worst enemy in a place like that, let alone a family member,” Eby says.

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