Ki Soon "Harmony" Hyun, an 83-year-old woman with dementia, had been at Mt. Hood Senior Living for less than 24 hours before she wandered away from the memory care facility.
A day later, on Christmas Day 2023, she was found dead from hypothermia in a forested area less than half a mile from the Sandy facility.
Hyun’s family has now filed a lawsuit against the memory care facility and the Oregon Department of Human Services, alleging negligence in care and inadequate state oversight led to Hyun’s death.
An investigation released earlier this month by the Oregon Long-Term Care Ombudsman found that Mt. Hood Senior Living failed to have enough staff on duty, properly train staff, or secure doors — something required in memory care facilities, as people with dementia have a tendency to wander and can easily become lost and disoriented, with catastrophic results.
Mt. Hood Senior Living shut down in January after DHS suspended its license. Hyun’s daughter Soo Hyun said the family is glad DHS took action after their mother’s death, but it was too late.
“We didn't want our mother to be a sacrificial lamb. We just want our mother here with us because we love and miss her so much,” Soo Hyun said on April 17, the day the family lawsuit was filed.
Alex Smith, a nurse case manager and one of Ki Soon Hyun’s daughters, said that what happened to her mother was not an isolated incident.
“The truth is that seniors going missing at their care homes is a rising problem nationwide,” Smith said. “Mom fell through the cracks in the Oregon DHS system — a system that should protect and preserve the life of dignity of all Oregonians, particularly our loved ones at the end of their lives.”
The ombudsman report also found that despite red flags emerging well before Ki Soon Hyun’s death, DHS failed to take urgent action.
Finding a high-quality nursing home for aging parents is a challenge for many adult children, even without the added needs of dementia patients.
When her children found Mt. Hood Senior Living, it seemed to check all the boxes, Soo Hyun said. It was small, with just 50 beds, and nearly brand-new, having opened in spring 2023.
John Hyun visited the facility multiple times to ensure it was as-advertised before his mother moved in, Soo Hyun said. Their mother’s care was expected to cost between $7,000 and $9,000 each month.
The family told Mt. Hood Senior Living staff that Ki Soon Hyun had started wandering off. Staff assured the family that they had the security features necessary to keep their mother safe, like door locks, passcodes and security cameras, according to the lawsuit.
“This death didn't have to happen. And it has traumatized us to the core. We were robbed of our time with our mother and grandmother for our children. Despite her dementia, she was physically healthy,” Soo Hyun said. “We wanted to cherish the time we had with her and that was taken from us by the carelessness of the facility.”
The lawsuit seeks $17 million from Mt. Hood Senior Living; facility owner Yi Zhou; Avant Senior Housing Managers and Consultants LLC, which assisted with staffing and compliance for the facility; and Avant owner Tammy Thwaite.
“They placed more importance on making money, cutting corners than the precious lives of our loved ones who were entrusted with them,” Soo Hyun said.
The facility did not take quick action after Ki Soon Hyun left. Staff did not notice she was missing until around lunchtime, but security camera footage showed her wandering outside at 8:47 a.m. Staff still didn’t notify police until 2:50 p.m., “which cost valuable time and light of day,” Soo Hyun said. Family members were not notified until law enforcement contacted them later that afternoon.
The hours between when they learned their mother was missing and when her body was found were the worst hours of their lives, Soo Hyun said, “knowing our mother was lost, scared, cold and just alone by herself, wondering where her family was.” The family tried to maintain hope “that she could survive the elements, because she had survived so much in her life.”
Ki Soon Hyun “loved her family wholeheartedly and unconditionally,” Smith said. “Mom taught me to work hard, give more, take less, and to treat everyone with respect and dignity. I miss her deeply. Our mom deserved better.”
Through the lawsuit, the family is also seeking roughly $20 million from the State of Oregon. The family’s attorneys with Kafoury & McDougal said they are also seeking reforms to how the state regulates these facilities.
In July and August 2023, DHS had received complaints about Mt. Hood’s staffing from another state program. DHS did not conduct an inspection until Nov. 6, 2023. That investigation found some staff did not have legally-required training, some did not have legally-required background checks and the facility was understaffed for the number and needs of patients. But DHS took no real action based on that inspection, the ombudsman report found. The only action taken was on Dec. 28 — after Ki Soon Hyun’s death — when DHS issued what was “effectively a reminder” to use a tool to determine staffing needs.
Avant had given Mt. Hood Senior Living a 30-day notice of termination before Ki Soon Hyun’s death, but the contract was still active through the end of December 2023. In the termination notice, Thwaite said she “must also express my concerns regarding compliance with the policies and procedures we have established.” State law requires that new care facilities engage with a consultant like Avant for at least the first six months, but the law does not require that the consultant provide any status reports to DHS. Prior to Ki Soon Hyun’s death, DHS did not know Avant hadn’t provided on-site services since September 2023.
Mt. Hood Senior Living had three administrators in the short time it was open. The facility had no administrator in early November, despite the fact that an administrator is required under state law. The facility’s business manager then became interim administrator. In mid-November, that employee told DHS that she did not have “the credentials, training or education to fill in as interim” and wanted to know what she should do. DHS told the interim administrator a qualified administrator was needed, but did little else.
“What you do is you close down until you have somebody that’s qualified. And if the state doesn’t know that, well, then I don’t know what a law can do to change the mentality of people that can email like that,” attorney Mark McDougal said. “They had items on the books that should have shut this place down. And they didn’t. It was sloppiness … We cannot trust our regulators of memory care facilities.”
There are both regulatory and legislative shortfalls in overseeing care facilities. In some situations, DHS does not have the authority to demand pertinent information or shut down facilities. Legislative action is required to change that. But even where DHS does have authority, it does not always exercise that authority to protect patients.
“Memory care patients, people with dementia, are not capable of being their own advocates. As a result, they are easily victimized,” attorney Greg Kafoury said. There’s a pattern of memory care centers that “present a great front about how your family member, your loved one, is going to be cared for.” But once the family is gone, Kafoury said, “the patients are entirely in the care of people who are not held accountable when they make mistakes and whose treatment does not have effective oversight unless the state is there, overseeing it to see that they’re safe."
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