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

When Riya Roberts put her grandmother Anna Marie Boswell into a nursing home, it was only supposed to be temporary — physical therapy, learn to walk and then come back home.

“That didn’t happen,” Roberts says. “She went in and she was there until the day she died.”

Anna Marie Boswell, Roberts’ grandmother, was a joyful woman with an infectious smile, who loved animals and spending time in nature, even when she was confined to a wheelchair later on in life. When she suffered a stroke in late 2014, Boswell’s family came to the painful realization many families across the country come to: She needed 24/7 care while she healed. After a long discussion, the family placed her in Provo Rehabilitation and Nursing, which was close to their home.

From the day her grandmother was admitted, Roberts recalls numerous issues with Provo Rehabilitation and Nursing and its staff. From bladder and skin infections to falls, denture issues and payments going missing, Roberts says her grandmother endured a major lack of care and compassion during her stay, which came to a head on April 14, 2019, when her grandmother was eating dinner with other residents. Roberts says a bite of food got lodged in her throat.

“My grandmother began to choke on her food,” Roberts says, “and since there was no one there, the resident — her friend and roommate — had to wheel herself out from the lunchroom, which is at the front of the building, to nearly the back of the building to find one of the nurses at the nurses’ station.”

Roberts said nurses rushed to the lunchroom to help her grandmother and called an ambulance. She was then taken to the hospital, where she was pronounced dead.

“They weren’t even taking the basic measures to protect her safety and it ended up killing her,” Roberts says.

As the world reels from a global pandemic, no population appears to be more vulnerable than senior citizens confined to nursing homes, often in close contact with other seniors with multiple underlying conditions that put them at risk of contracting the COVID-19 virus.

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 like Provo Rehabilitation and Nursing that are owned by Beaver Valley Hospital, comprising 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 wheelchair-bound woman screaming and delusional 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 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 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.

• At Parkdale Health and 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.

Kathy Eby worked as a Director of Nursing at two different homes owned by Beaver Valley Hospital between 2017 and 2019. She worries about the threat of COVID-19 in these homes, since in both the facilities she worked there had inadequate sanitation supplies well before the pandemic and overworked staff did not have time to clean up in 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 healthcare 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 to 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, that 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 says. “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.

Despite tens of millions of additional funding flowing into Beaver Valley Hospital, during inspections conducted by the Utah Department of Health, the same violations arise year after year. The Utah Investigative Journalism Project reviewed hundreds of pages of inspections, found serious problems to be reoccurring, and that 23 of the facilities — just over half — had 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 and Nursing had three times more health deficiencies than the national average.

Roberts says she didn’t know why no staff members were in the lunchroom while on the day her grandmother died. But at Provo Rehabilitation and 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.”

Issues with residents losing weight or not being properly fed are not limited to one nursing home, but have been reported in multiple Beaver Valley Hospital facilities. In September of 2019, a health report states 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 only two and a half months. At Parkdale Health and Rehab in Price, one resident lost 8 percent of their body weight, and another lost 20% in a matter of weeks.

Roberts said she had similar problems with her grandmother’s dentures at Provo Rehabilitation and Nursing. She said that the staff of the nursing facility decided to remove all of her grandmother’s bottom teeth, without letting the family know of the decision.

“We just came in for a visit one day and they had decided to pull all of her teeth,” Roberts said. “There was no one there to advocate for her because at this time, her dementia was getting worse and she didn’t have anyone there.”

Following the procedure, Roberts says it took months, and a threat of legal action from her family for the nursing home to get her grandmother dentures.

“Finally, my parents had to say, ‘You know what, if you don’t get us those dentures, we’re going to get a lawyer,’ ” Roberts says.

Provo Rehabilitation and Nursing has been troubled by inspections. Among other facilities owned by Beaver Valley Hospital, often times a problem year for inspections will at least see a modest decrease in violations reported at the next year’s review.

In 2018 the Provo facility reported 26 violations, nearly three times the national average. In 2019 the facility racked up 25 violations, again three times the national average.

In 2019 an inspection dinged the facility for everything from unhygienic food storage and medication errors to not providing adequate care to prevent urinary tract infections. Understaffing was also a key issue.

The inspector in Provo spoke to a resident who said, “when he had a bowel movement, he had to wait 30-45 minutes for someone to answer his call light and clean him up. [The resident] stated that having to wait and to sit in his bowel movement that long was disgusting and that he felt very indignant about sitting in his bowel movement.”

Provo wasn’t the only Utah County facility owned by Beaver Valley to face scrutiny.

In March 2019 a lawsuit was filed against Orem Rehabilitation and Skilled Nursing over the death of a resident related to infected lesions on the resident’s legs and buttocks.

According to the complaint, the resident was suffering from dementia and needed assistance from staff to use the bathroom, but that family members on multiple occasions observed “feces on his buttocks and backs of his legs” and once found him “lying in a urine-soaked bed.”

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 said. “We address the issues upfront, which we do the very best that we can, and when a survey comes in and finds a deficiency, we correct that deficiency.”

Eby, who worked as a Director of Nursing at two different facilities owned by Beaver Valley Hospital between 2017 and 2019, says that in both facilities staff worried more about looking good for inspections than learning from them.

“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 says. The overall result she says is tragic in terms of resident care.

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

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 to the audit, Beaver Valley Hospital says 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 resident 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 family members of residents like Roberts and her family, this desertion of ethics translates directly into a lack of respect for the lives of their loved ones.

“When you put the care of someone you love in the hands of others, I feel like that’s such an important thing,” Roberts says. “When people take it lightly, your loved ones die. I feel like my grandma suffered a death that could have been prevented, and I feel like she suffered more than we will ever know.”