Salt Lake City, Utah — A man in a Millcreek nursing home made three suicide attempts over 13 months. He left the facility on his electric scooter each time, and police intervened each time. According to federal inspection records, staff gave him just two psychosocial evaluations during his entire stay and failed to arrange mental health services — even as his records showed a clear pattern of worsening suicidal behavior.
It wasn’t an isolated failure. A review of thousands of pages of federal inspection reports found at least 18 incidents since 2019 where Utah nursing facilities were cited for failing to support residents who attempted suicide, expressed thoughts of self-harm, or engaged in self-injurious behavior. Experts say what happened in those cases reflects a system-wide problem that stretches well beyond state lines.
A System Never Designed for This
Between 65% and 91% of nursing home residents have some form of mental disorder, according to research cited by the National Institutes of Health — and the share with serious mental illness has been growing. But nursing homes weren’t built to handle it.
“I see missed opportunities all the time,” said Anne Asman, a gerontologist and program manager at the Huntsman Mental Health Institute at the University of Utah. “When you’re going to a nursing home — whether you have a physical issue or a mental health issue — the mental health issue always gets set aside.”
That gap has roots going back decades. During the deinstitutionalization movement of the 1960s and ’70s, many people with serious mental illness were moved out of state psychiatric hospitals and into nursing facilities. The number of older adults in nursing homes with mental illness more than doubled during that period. They’ve been there ever since, often without the specialized support they need.
What the Inspection Reports Reveal
In one case, a resident told staff she had been hearing voices for weeks. She had a documented history of self-harm and prior suicide attempts. Nursing notes from the facility — 21 of them — described her as “needy, attention seeking and medication seeking.” A month later, she was hospitalized after a suicide attempt.
Federal regulators cited the facility for failing to provide behavioral health services. The director of nursing acknowledged the resident was “probably more psych than we can handle — but everyone else has refused taking her.”
Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, said insufficient mental health resources have been a chronic problem in long-term care. The COVID-19 pandemic, which isolated residents from their families for extended periods, made it worse. “Many lost their will to live,” she said. “It’s a real problem in long-term care facilities.”
Looking for Fixes
Some Utah facilities have begun contracting with private therapy companies, and the state legislature recently appropriated funding to support a behavioral health program for nursing home providers. CMS has also been tightening requirements around antipsychotic prescribing and behavioral health services in nursing homes, though experts say enforcement alone won’t close the gap.
“Sustainable solutions will require continued collaboration among providers, policymakers, and the broader mental health system,” said Allison Spangler, president and CEO of the Utah Health Care Association.
For now, advocates say the most urgent need is training — helping staff recognize the warning signs they’re currently missing. Without it, they say the cycle of citations, hospitalizations, and missed interventions will keep repeating.
“If a resident is showing signs of depression or talking about self-harm,” Smetanka said, “they really need education on what steps to take, who to call, and that they need to be taking it seriously.”
