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SOUTH SALT LAKE — Even though Thaes Webb Jr. was 90 years old, he was still sharp.
Despite his advanced age, Webb was still working as a certified public accountant. But because of a heart condition he had recently been treated for, and because his wife was in the early stages of dementia, Webb decided to move into an assisted living center.
"He could take care of himself but needed help taking care of his wife and wanted to be close to her, so he moved in with her," said attorney Peter Mifflin with Robert J. DeBry & Associates.
Just 18 days after moving into the facility, Webb was being transported by the facility's executive director to a local hospital for a routine checkup for his heart. His wheelchair tipped over as the van made a left turn less than two minutes after leaving the assisted living home.
Webb's head hit the wheelchair ramp on the floor. He died not long after arriving at a local hospital.
Webb's family has since filed a lawsuit against the individuals and companies running Twin Oaks Assisted Living and Memory Care, 654 E. 3300 South, saying it was apparent that Webb was not properly secured in the van.
But Mifflin said the incident also highlights a bigger problem regarding the oversight of assisted living facilities that all Utahns should be concerned about.
"Our government has correctly created laws to regulate this industry," he said. "The problem is when those rules are violated, there's not a big enough bite to incentivize a change in behavior, and I think that's a matter of public concern."
Webb's injury and subsequent death resulted in a $1,300 fine for Twin Oaks by the state, which Mifflin believes is not enough of a penalty to convince a company to make any changes that might be necessary.
Twin Oaks was fined $1,300 on Aug. 19, and a four-month conditional license — which is the equivalent of being put on probation — was issued, according to state records. The fine, according to the records, was for four "class I deficiencies," which included "one for not treating residents with dignity/respect; one for not having enough staff on duty to meet the needs of the residents, one for not having qualified staff to meet resident needs (lack of training) and one for not having a staff person on the secured unit at all times. In addition, a higher number than average of class II deficiencies were cited."
Twin Oaks was fined an additional $1,250 on Oct. 24, according to state records, and was allowed to continue operating with a "conditional license."
"That is not a lot of money that is likely to change behavior. Because how long does it take (a company) to have that additional profit by breaking the rules?" Mifflin said.
Mifflin says it is his belief, based in part on other reports by the media, that the state views the assisted living care industry as a thankless job, but one that is necessary. Because of that, he surmises that the state doesn't want to be overly aggressive in enforcing some regulations or come down too hard on facilities to the point of breaking them.
But he believes that "at some point, the penalty for not following the rules needs to be substantially high enough that it is cheaper for them to follow the rules and provide good care and the minimum levels of staffing (rather) than to financially incentivize breaking those rules."
Death of Thaes Webb
About 9:45 a.m. on April 25, 2023, Webb was to be driven by Twin Oaks to a local hospital for a routine checkup following surgery to have a pacemaker installed. The executive director of the facility, Matthew Cielo, was the driver that day and loaded Webb and his wheelchair into the transport van.
Mifflin said there are supposed to be a series of straps that are self-tightening to secure a person being transported in a wheelchair in the van, in addition to seat belts and shoulder belts.
"Thaes Webb Jr. was not seat-belted into his wheelchair, meaning the available lap or shoulder belts were not employed," the lawsuit states. "Mr. Cielo did not attach the straps available in the van to properly secure the wheelchair to the van. The straps were not in fact attached to the frame of the wheelchair, let alone tightly."
At the intersection of 3300 S. State, "as Matthew began his left turn, he heard a loud thump in the back of the transport van. Upon looking back, Matthew observed Thaes had fallen from his wheelchair, which was situated in the rear of the transport van where the assisted lift gate is located," according to a South Salt Lake police report. "Upon pulling over and checking on Thaes, Matthew observed Thaes lying on the floor of the van, bleeding from the right side of his head."
But rather than call 911, the first call Cielo made was to the head nurse at Twin Oaks, the report states. Cielo then made a second call to the nurse asking her to bring his wallet when she comes to the scene, and then called 911, according to the lawsuit.
At that point, Mifflin says there is a dispute over whether Cielo was instructed to move Webb and sit him up or if did that on his own. However, the lawsuit contends that once Webb was moved, his condition rapidly worsened.
"As soon as that movement happens, Thaes' condition starts to deteriorate. He starts having more difficulty breathing. He's no longer talking. At some point the nurse from Twin Oaks arrives on scene and sees him turning blue," he said.
Webb was taken to a local hospital. But based on the information emergency crews had received, doctors at the hospital thought they were about to treat a patient who had just suffered a heart attack, the lawsuit contends.
"EMS got the false impression that Thaes Webb Jr. had a heart attack and fell over due to the heart attack," according to the lawsuit. "The ER doctor at Intermountain Medical Center reported to family that they believed that Thaes Webb Jr. had a heart attack. Upon review of the CT images, the ER doctor's opinion changed: 'I am now clinically suspicious that the patient fell while sitting (in) his wheelchair and likely broke his neck. This may have led to respiratory arrest given that a spinal cord injury at this level may make it impossible for him to control his diaphragm to breathe.'"
Webb was pronounced dead just before 11 a.m., the police report states.
No criminal charges have been filed in the case.
The lawsuit
In October, Webb's estate filed a lawsuit against Kim's New Star LLC, Joong J. Kim, "an individual doing business as Twin Oaks Assisted Living and Memory Care also known as Twin Oaks Senior Living," and Cielo. The wrongful death suit alleges the defendants are guilty of negligence, gross negligence and reckless endangerment. Because of questions that were raised as the lawsuit was being prepared about whether Twin Oaks is a limited liability or owned by sole proprietorship, all of the possible parties are listed as defendants, Mifflin said.
Among the allegations, the lawsuit contends that Twin Oaks and its ownership and management "made a conscious decision to undercapitalize Twin Oaks Assisted Living and Memory Care with inadequate staff, financial resources and training to provide a specialized set of services to a set of clients with special needs. Specifically, defendant Joong Kim is not a licensed medical provider of any type and routinely works the night shift in violation of state law, rather than hiring minimally acceptable levels of licensed staff. Mr. Cielo knowingly undertook to load wheelchair bound residents into a specialized vehicle, without any training or requisite knowledge of how to appropriately secure a wheelchair in the company van. ... Upon information and belief, no one at Twin Oaks prior to Thaes Webb Jr.'s death had ever received training on how to use the wheelchair restraints nor actually knew the proper method of how to use the restraints."
The lawsuit also accuses Twin Oaks of "violating mandatory staff-to-resident census ratios" and "falsifying care records and other records kept in the ordinary course of business."
"Twin Oaks, through its ownership and management ... made a conscious decision to undercapitalize Twin Oaks Assisted Living and Memory Care with inadequate staff, financial resources and training to provide a specialized set of services to a set of clients with special needs," the lawsuit contends, while adding that Twin Oaks administrators took payment from the Webbs and then "breached these fiduciary duties designed to benefit them and did not actually provide the degree and type of care paid for" and "instead used the proceeds of those funds to enrich themselves at the direct expense of vulnerable individuals in need of care."
Attorneys listed in court records representing Kim did not respond to KSL.com's request for comment, though in a response filed in 3rd District Court, Kim denied most, if not all, of the allegations. The attorney representing Cielo declined comment.
Mifflin's hope is the lawsuit will prompt the state to impose larger fines to licensed care facilities that break the rules.
But that may happen before his case even goes to trial.
According to the Utah Department of Health and Human Services, SB229 was recently amended and will take effect on May 1. The amended piece of legislation will give the Division of Licensing and Background Checks "the authority to issue up to (a) $10,000 civil money penalty fine for a single violation on all types of licensed facilities. Fines are one of several tools DLBC can use to encourage compliance."
Safety taken seriously
As for the notion that the state doesn't want to over-penalize care facilities, a department spokeswoman told KSL.com that the health and safety of residents in licensed facilities is taken seriously.
"Our role in ensuring the health and safety of those in licensed programs is to make sure programs are complying with administrative rules and regulations designed to provide a healthy and safe environment for those in care. DHHS works to provide the best possible service within the scope of our regulatory authority. The facilities DLBC licenses, and the people who work there, are a vital part of our state's overall service system. We want to make sure all Utah licensed providers are giving the highest level of care and ensuring safety of those in services. When we substantiate noncompliance with state rules and regulations, we do not hesitate to take appropriate action. ... Facilities with severe and/or repeat noncompliance can have their license revoked," the department said in a prepared statement.
The state says licensed providers are required by the state to "supply a sufficient number of staff to meet the care needs of the resident," and also notes that the division of licensing is continually improving its rules and processes.
Mifflin also hopes the lawsuit by the Webb family also prompts all Utahns to look at certain areas when picking a care facility for their elderly loved ones beyond whether it's clean and has decent meals. He says families should also be looking at the staff-to-resident ratio at such facilities, what insurance they have, whether there have been any prior violations at the facility and what the current status of their license is. He says sometimes information about whether a facility's license is on probation is not easy to find, but is public record.
Mifflin anticipates the case will receive a jury trial sometime next year.
