The following story was written and reported by The Utah Investigative Journalism Project in partnership with The Salt Lake Tribune, the Daily Herald and the Standard-Examiner.
“It was horrible. It was one of the worst buildings I’ve ever seen.”
That’s how Nigel Kooyman, a certified nursing assistant and phlebotomist with eight years of experience working in nursing homes, describes Pine Creek Rehabilitation and Nursing, a facility turned into a dedicated COVID-19 care center in April after the virus killed a resident.
Kooyman said he saw so many problems with the Salt Lake City nursing home when he was employed there last June that he quit. From issues like residents being left in briefs for days to nursing staff sleeping during night shifts, Kooyman said Pine Creek Rehabilitation had such a disturbingly low quality of care he didn’t want to be a part of it.
“I ended up looking at the situation as one I needed to get out of,” Kooyman said.
Pine Creek, which has acknowledged that two residents died after testing positive for COVID-19, is one of dozens of facilities owned by Beaver Valley Hospital, one of Utah’s largest operators of nursing homes. Despite receiving hundreds of millions of dollars of public funding, the company has a long history of substandard patient care and sanitation, according to legislative auditors, interviews with former employees and hundreds of pages of inspection reports reviewed by The Utah Investigative Journalism Project.
(Leah Hogsten | The Salt Lake Tribune) The Pine Creek Rehabilitation and Nursing facility, April 4, 2020.
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, comprising nearly half the state’s Medicaid-certified nursing homes. Last year, inspection reports warned that nine of the homes needed to implement infection control programs because of unhygienic practices.
Many other reports documented serious instances of lack of care. Among these, just from 2019 reports:
• Nine patients at Rocky Mountain Care in Logan contracted urinary tract infections — five from E. coli — despite the facility being warned in 2018 about hygiene issues that could lead to infection.
• An inspector at St. George Rehabilitation observed a woman, screaming and delusional, using a wheelchair asking for help only to have a nurse wheel her in front of a television and then walk away.
• Nurses at Millcreek Rehabilitation mistakenly coded a resident as “do not resuscitate” — the opposite of what the person had requested. One nurse’s response? “Oops, that’s bad,” according to the report.
• A hospice resident at Provo Rehabilitation and 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.
Beaver Valley domination
In 2014, Beaver Valley Hospital, owned by and located in the southern Utah city of Beaver, started buying up long-term nursing facilities throughout the state — lots of them. In the span of just five years, it acquired a string of 44 nursing homes stretching 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 residents at its many facilities. But hospital administrators say Medicaid funding alone isn’t enough to keep the doors open.
That’s where a state program created by the Utah Department of Health comes in. Called the Nursing Facility Non-State Government-Owned Upper Payment Limit Program (UPL Program), it provides additional federal funding each year aimed at keeping the homes open and improving 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, that amount 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 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 five. A 2019 report of financial statements said 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, said the hospital decided to acquire nursing homes throughout Utah to help keep the homes from shuttering and the hospital running in the black.
“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 federal dollars flowing to Beaver Valley Hospital each year, inspections by the Utah Department of Health show many of its facilities continue to struggle keeping up with standards.
The Utah Investigative Journalism Project’s review of inspection reports revealed that 23 of the facilities — just over half — were cited for health violations at a rate 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 and Nursing — had three times more health deficiencies than the national average.
Riya Roberts said a lack of care and oversight in Provo Rehabilitation and Nursing caused her grandmother’s untimely and preventable death. Anna Marie Boswell had lived in the home for several years after suffering a stroke. Then, in April of last year, she died after choking on food while eating in the facility’s dining room, Roberts said in an interview. She is convinced that had a staff member been present, her grandmother would probably still be alive today.
“We thought at least she was generally safe,” Roberts said. “As it turns out, they weren’t even taking the basic measures to protect her safety and it ended up killing her.”
(Courtesy) Anna Marie Boswell, grandmother of Riya Roberts, is pictured at her son's Provo home in 2017. Boswell passed away last year. Roberts said she choked while eating in a nursing home were she was living.
An inspection report dated two months later, June 20, 2019, noted staffing issues at the facility. The nursing home and Beaver Valley Hospital referred questions to the management company that runs Provo Rehabilitation and Nursing. A request for comment was not immediately returned.
Among the worst inspections was a 2017 review of Rocky Mountain Care-Hunter Hollow. The West Valley City center was dinged for 35 violations, 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, dropping from 103 pounds to 85 pounds in four months.
Despite that violation and its serious health implications, a similar violation was documented in Hunter Hollow’s most recent inspection.
Issues with residents losing weight or not being properly fed have been reported in multiple Beaver Valley Hospital facilities.
At Parkdale Health and Rehab in Price, a resident lost 28 pounds in 33 days despite having specific guidelines for feeding.
A September 2019 health report said that two residents at Cascades at Orchard Park in Orem lost an abnormal amount of weight, with one resident going from 186 pounds to 153.9 pounds in 2½ months.
Kooyman said that during his time working at Pine Creek Rehabilitation and Nursing, he saw instances where residents needing assistance eating meals had their food left in their rooms with no one to help them.
“Obviously that’s heartbreaking," Kooyman said, “because they get to sit there and stare at their food.”
Asked about issues coming up again and again in inspection reports, Davidson said Beaver Valley Hospital works with its operators to come up with solutions.
“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.”
Training day
Kathy Eby’s first indication something was wrong with her new job was the training — or lack of it. In 2017, she was hired as a director of nursing at Rocky Mountain Care’s nursing facility in Heber, receiving about a day’s worth of training.
From there, it was a crash course in running a facility that maximizes profits through understaffing, she said. 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 said, the nurse is lucky to get all residents their medication, let alone actually care for anyone’s needs.
Eby said the lack of staff meant some patients would be left unattended for hours unable to feed or clothe themselves or use the restroom. The overwhelmed employees ended up cutting corners where they could — and that included hygiene and hand sanitization.
As director of nursing, she was supposed to be able to turn residents away if they had health needs that the facility couldn’t handle, but said she was repeatedly overruled by administrators accepting high-needs residents to ensure beds were filled to qualify for maximum federal reimbursement.
Eby eventually left the facility in disgust in 2018, only to take a director of nursing position at Crestwood Rehabilitation and Nursing in Ogden. What she didn’t realize at the time was that it was another Beaver Valley Hospital facility. What she found there were the same problems as in her previous job.
Ethics 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 that 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 UPL 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 UPL participation.
After those administrative expenses, between 9% and 11% goes toward providing health care to Beaver residents, including allowing the hospital to buy 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.”
Eby, the former nursing director, said it was this sort of just-enough-to-get-by attitude she witnessed in the two Beaver Valley Hospital-owned homes where she worked.
“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 P’s and Q’s,” Eby said. The overall result, she added, is tragic in terms of the care for residents.
“I would never put my worst enemy in a place like that," Eby said, “let alone a family member.”