Report alleges lack of oversight of care facilities after patient with mental illness died by suicide

SALT LAKE CITY — A week after the owners of a Midvale care center were charged with multiple counts of exploitation of vulnerable adults, a new report sheds light on the chaotic aftermath of that care facility being shut down.

The report, released Monday by the Disability Law Center of Utah, focuses on Chien Nguyen, a resident at the Ririe Care Center, or Evergreen Place, who died by suicide last year after he was transferred to another facility.

“It seemed that nothing happened when (Chien was) killed,” Nguyen’s brother Nick Nguyen said in a statement. “I am still angry with people (who) don’t care my brother died. I am still crying now.”

Nguyen was one of 17 men who were living at the facility in January 2022 when it was shut down by the Salt Lake County Health Department. Prosecutors last week alleged the residents were without heat at the time because of a broken furnace, and say raw sewage had flooded the basement and backed up into the upstairs living space.

According to a report from the nonprofit law center which is designated by the governor as Utah’s protection and advocacy agency, Evergreen was an unlicensed board and care home housing individuals with severe and persistent mental health disabilities. When the facility was shut down, state and county officials “scrambled” to find housing for the residents, who were sent to a variety of places, including homeless shelters, nursing homes and homes of family members.

In the charges filed last week, prosecutors said Jorge Gustavo Gonzalez Sr., 54, owned Evergreen from July 2017 through January 2022. The facility was managed by his son, Ignacio N. Gonzalez-Villarruel, 23.

“It’s just troubling that it could go on for this long and that people lived there,” said Nate Crippes, public affairs supervising attorney for the Disability Law Center. “And that it took the county, essentially, finding out about it eventually and saying, ‘OK, we have to shut this place down.’ And then it led to some more problems because they didn’t have anywhere for people to go.”

“The state is supposed to provide oversight and supposed to protect the vulnerable citizens,” he continued.

In a statement, Utah Department of Health and Human Services officials said they were still reviewing the report.

“Our hearts go out to those mentioned in the report who lost a loved one in one of Utah’s long-term care facilities,” the statement said. “Helping Utahns live safe and healthy lives is our priority, and we are always open to working with partners and advocates to identify ways we can better accomplish that goal.”

Nguyen, who had been diagnosed with schizophrenia and schizoaffective disorder and was “consistently experiencing suicidal ideation,” was sent to Hidden Hollow Care Center, a private intermediate care center and nursing facility in Orem, along with three other Evergreen residents.

The report called this placement “strange because Hidden Hollow is licensed to serve only individuals with intellectual and developmental disabilities, whereas individuals living at Evergreen were all diagnosed with severe and persistent mental health conditions.”

Based on interviews and documents the Disability Law Center obtained from the Department of Health and Human Services, staff members in the department and at Hidden Hollow expressed concern with Nguyen’s placement because he didn’t have a developmental disability, but “he needed to stay because there were no other facilities available to him.”

The other three men were quickly discharged, but Nguyen was given a diagnosis of an intellectual disability and admitted to Hidden Hollow officially on March 24, 2022. The Disability Law Center said the diagnosis was “curiously given” because Nguyen “successfully attended high school and had no record of disability prior to age 18 as required by the care facility admission rules.”

Due to switching facilities, Nguyen lost access to previous mental health providers and had delays in accessing his medication, leading to worse psychiatric symptoms, the report says. Nguyen told his brother that he wasn’t being cared for and went 1-2 weeks without his medications that could help reduce suicide ideation.

On April 10, 2022, Nguyen ran out of the facility and lay down in a busy road in front of the care center. The report says an administrator pulled him out of the road but didn’t notify management of the attempted suicide or take precautions to monitor Nguyen.

Nick Nguyen also visited that evening and was not told of the attempt, according to the report.

Chien Nguyen died the following morning after running in front of a vehicle driven by one of the staff members.

“Chien Nguyen’s death is just one example of the deficient oversight of Utah’s long-term care system,” the report says. “State regulators seem to operate in a culture of protecting businesses rather than protecting people from harm when they levy insubstantial fines and prioritize keeping troubled facilities open.

“This practice is not only dangerous for the individuals served in these facilities, but also threatens federal funding allocated to the state for oversight of these services.”

The Disability Law Center said that Hidden Hollow had been cited by the Division of Licensing and Background Checks prior to Nguyen’s arrival, but said “despite serious violations, fines for these deficiencies ranged only from $200 to $1,000.”

In one instance in March 2021, a resident who required line-of-sight supervision was left alone in a room with his roommate. The resident “inflicted serious bodily harm on the roommate,” blinding him in both eyes, the report states.

“When things happen, it does seem that at the end of the day, the business always continues to operate. The license doesn’t seem to be removed,” Crippes said of the Evergreen facility.

In light of Nguyen’s death, Hidden Hollow was not allowed to admit more residents for one month, and assessed a fine of $8,000, which also covered a separate incident where a staff member assaulted a resident and broke his tooth, the report alleges.

Representatives for Hidden Hollow declined to comment for this story.

“Unfortunately, the lack of oversight and poor conditions in long-term care for people with mental health disabilities are not unique to Evergreen,” the report continues. “Advocates, professionals, and state/local government workers cite a lack of access to appropriate residential services for individuals with severe and persistent mental health conditions as an ongoing issue and as a reason officials are reluctant to shut down facilities that provide inadequate care.”

“The fact that there isn’t coordinated care for this population is frustrating, and that he went without his medication for so long that he attempted suicide once, and they were able to stop it, but then couldn’t prevent the second attempt,” Crippes said. “We need to do better for those with serious and persistent mental illness. We need to build a community-based system so people have a place to go so that somebody isn’t living in filth for months.”

The report highlighted several other incidents at similar facilities and said “Utah licensing and state agencies have failed to protect people with disabilities.”

“Time and time again, facilities that mistreat vulnerable residents and fail to provide them with appropriate treatment or even human living conditions continue to operate. With the threats long-term care residents face from abuse, neglect and lack of treatment and the potential loss of federal funding, it is imperative that the state of Utah act now to ensure appropriate oversight of long-term care facilities,” the report states.

KSL TV’s Ladd Egan contributed to this report.

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Suicide prevention resources

If you or someone you know is experiencing suicidal thoughts or exhibiting warning signs, call, text, or chat the 988 Suicide and Crisis Lifeline at 988 which is answered 24/7/365 by crisis counselors at the Huntsman Mental Health Institute. All calls to legacy crisis hotlines, including the old National Suicide Prevention hotline, 1-800-273-8255, will also connect to a crisis care worker at the Huntsman Mental Health Institute as well.

Additional resources

• SafeUT: Parents, students, and educators can connect with a licensed crisis counselor through chat by downloading the SafeUT app or by calling 833-3SAFEUT (833-372-3388)
• SafeUT Frontline: First responders, including firefighters, law enforcement, EMS, and healthcare professionals can chat with a licensed crisis counselor at no cost 24/7/365 by downloading the SafeUT Frontline app.
• SafeUTNG: Members of the National Guard can chat with a licensed crisis counselor at no cost 24/7/365 by downloading the SafeUTNG app.
• Utah Warm Line: For non-crisis situations, when you need a listening ear as you heal and recover from a personal struggle, call 1-833 SPEAKUT 8:00 a.m.-11:00 p.m., 7 days a week, 365 days a year.
• The Huntsman Mental Health Institute offers a wide variety of programs and services including suicide prevention and crisis services, hospital treatment, therapy & medication management, substance Use & addiction recovery, child & teen programs, and maternal mental health services including birth trauma, pregnancy loss, infertility, and perinatal mood and anxiety disorders.
• LiveOnUtah.org is a statewide effort to prevent suicide by promoting education, providing resources, and changing Utah’s culture around suicide and mental health. They offer resources for faith based groups, LGBTQ+, youth, employers, firearm suicide prevention, and crisis and treatment options.

Counties in Utah provide services for mental health and substance use disorders. Centers are run by the thirteen Local Mental Health and Substance Use Authorities all across the state and offer therapy, substance use disorder treatment, support groups, mobile services, youth treatment, and more. 

These resources and more information can be found here: https://www.uacnet.org/behavioralhealth.

Other community-based resources

• NAMI Utah provides education, support and advocacy for individuals and families impacted by mental illness.
• American Foundation for Suicide Prevention offers prevention programs, public education, support for loss survivors, and fundraising for research.
• Encircle Utah: LGBTQ+ family and youth resource center.
• Utah Pride Center empowers Utah’s diverse LGBTQ+ community.
• The Trevor Project: LGBTQ teen resource center.
• U.S. Department of Veterans Affairs Mental Health
• Latino Behavioral Health Services
• Center for Workplace Mental Health offers suicide prevention and response for employers.