Ki Soon Hyun, 83, died outside after her memory care facility allowed her to slip outside. Her family is suing the facility and the state in a wrongful death lawsuit. (Family photo)
Ki Soon Hyun died alone last year of hypothermia on a frigid winter day in a wooded area about half a mile from her memory care facility in Sandy.
The 83-year-old with dementia had wandered outside the day before, and staff at Mount Hood Senior Living didn’t notice that she left. Search crews found her body on Christmas Day.
Hyun’s death has sparked a sweeping look at how the state cares for its vulnerable senior citizens – and how the Oregon Department of Human Services regulates the long-term care industry. Her story – and other accounts – offer a starting point for potential legislation in the 2025 session to improve the system.
An independent report and investigation by the Oregon Long-Term Care Ombudsman released in April faulted the state agency for its delayed response to complaints at Mount Hood Senior Living – and found state regulators could have prevented Hyun’s death. The state shut down the facility a month after she died, but had received complaints in July and August – months before she moved there.
“There is an emptiness in my heart that will never be filled,” Tim Hyun, her grandson, told the Senate Human Services Committee on Wednesday.
The panel, chaired by Sen. Sara Gelser Blouin, D-Corvallis, heard from Hyun’s family members and others about their experiences. Their insights could lead to changes in the state’s long-term care system and the Oregon Department of Human Services.
Alex Smith, one of Hyun’s daughters and a behavioral health nurse, said the facility and state failed her mother.
“I come to you today as an Oregonian and a health care worker urging our elected leaders in Salem and the Oregon Department of Human Services to do better safeguarding vulnerable seniors,” Smith said.
Smith encouraged state leaders to hold the Oregon Department of Human Services accountable with stricter regulations and an immediate safety review of all facilities to make sure they are properly secured and locked to keep vulnerable people with memory conditions from slipping out.
Smith also asked lawmakers to consider other requirements, such as GPS tracking devices for residents and halting new admissions into facilities that lack adequate staffing.
“Our mother’s death should not have happened,” Smith said.
‘Lack of urgency’
Smith said she supports the ombudsman’s report’s recommendation for an independent audit that looks at Oregon Department of Human Services and its licensing of facilities to ensure all laws are followed.
Fred Steele, the state’s long-term care ombudsman, said the shortcomings uncovered in his office’s investigation point to wider problems.
“There’s a lack of urgency within the system,” Steele said. “I want to be clear: I’m not trying to blame individuals within the Department of Human Services. This is, I believe, a systemic problem within the Department of Human Services.”
Oregon ombudsman report says DHS could have prevented woman’s death
Hyun’s family filed a wrongful death lawsuit in Multnomah County Circuit Court against the Oregon Department of Human Services and the facility in April. Citing the pending litigation, Oregon Department of Human Services officials have declined to say anything about Hyun’s case – even before lawmakers.
Nakeshia Knight-Coyle, director of the agency’s Office of Aging and People with Disabilities, shared brief comments with lawmakers by acknowledging the families.
“There are no words,” she said, as she pivoted back in her chair and looked at family members who just testified before her.
Noting legal advice, Knight-Coyle said she cannot speak about the case or its related topics. And no lawmakers asked her questions, though she said she would try to take any questions to her team and the Oregon Department of Justice, which defends state agencies in lawsuits, to see what they could answer.
“When it is possible, I look forward to partnering with you all,” she said.
Gelser Blouin said it’s important for policymakers to talk about potential action for next year’s session and get input from the state, industry officials, workers and families.
‘Treated by ODHS like cattle’
Steele, who led the report, found that problems with the Oregon Department of Human Services’ oversight of the Sandy facility persisted after the death.
On Jan. 26, a month after Hyun’s death, DHS officials told residents in the afternoon they would shut the facility by midnight. With just hours to prepare, residents were moved that night to other licensed facilities, hospitals and family homes.
It didn’t have to be that way. Steele said that by law the state agency could have taken the facility over and gradually shut it down over an extended period of time to avoid traumatizing residents.
The Oregon Department of Human Services moved 13 of the 18 residents to potentially dangerous settings, including eight of them to facilities that had been previously cited by the state for having serious problems, Steele’s report said. Some residents were moved without care plans, medications or wheelchairs, he said.
Bonnie Everett, 72, was among those forced to move out. Her niece, Melissa Fisher, told lawmakers about the experience.
They moved her to a facility that reeked of urine – one they did not approve of. Nor did the facility have Everett’s doctor’s order to check her blood sugar levels because she is diabetic.
“If the state had done a better job of planning to move residents, besides working with families before acting, not just hours before late on a Friday, all this could have been avoided,” Fisher said. “ODHS was negligent in its actions and added to the danger.”
Fisher said the state agency took away the rights of people at Mount Hood Senior Living – as well as their family members.
“The Mount Hood Senior Living residents were treated by ODHS like cattle, not people,” Fisher said.
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