Mouy Tang didn't talk much, but she did talk about going home. Sometimes, Tang, who emigrated from Cambodia, talked of long-ago memories of rice paddies.
On Sept. 3, the 46-year-old woman disappeared from Unique Living, a troubled adult care home in Cleveland County.
Following her disappearance, state officials shut down the home.
But Tang, who has schizophrenia and requires insulin to control diabetes, remains missing. Family members fear she may be dead, and they blame state officials for failing to act sooner.
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“They've failed us and our family,” says SueLee Waller of Raleigh, Tang's niece. “The problems run much deeper than losing my aunt. It's a reflection on the health system and how people view and treat the disabled.”
A new report, released this week, details violations the state found after Tang's disappearance, including broken door alarms and a staff that wasn't properly supervising its 60 residents.
Unique Living administrators couldn't be reached Thursday.
The report also describes Tang, who escaped Cambodia's brutal government in 1983, but spent much of her life in America struggling with schizophrenia.
She was usually confused, Unique Living staff members told state inspectors. She needed to be reminded to come for meals and medication. Sometimes, she put her clothes on backwards or tried to wear pants on her arms.
She spent most of her waking hours with a male resident, her best friend.
A facility administrator told inspectors that up until Tang disappeared, she never left Unique Living alone. One resident said otherwise: Sometimes, Tang would go into the front yard alone.
Tang had lived at Unique Living since 1993, when the facility was called Yelton's Health Care. After one resident died from choking on a sandwich and another died from scalding in a tub, Yelton's reopened in 2005 under different ownership as Unique Living.
The facility, near Fallston, about 50 miles west of Charlotte, had been repeatedly accused of poor patient care and unsafe conditions. Though most of its residents were mentally ill, it was licensed to care for elderly adults. It housed mentally ill people on Medicaid because the state didn't have anywhere to put them.
In 2006, the state fined the home $16,000 after a man with diabetes and dementia wandered from the facility and died. Some mental health advocates had argued then that it should be closed.
In June, Cleveland County Department of Social Services officials told the state that utility companies were threatening to cut services because the facility hadn't paid its bills. It asked the state to take over management of the home, warning it was “only a matter of time” before a resident was injured or harmed.
The letter “reflected what we thought was a collapse of the supervision and the management of the facility,” Cleveland Social Services Director John Wasson says. “They couldn't the pay bills. We felt if they couldn't pay the bills, they couldn't do anything else.”
The state responded with a July inspection. It found nine exit doors that lacked alarms to alert staff when a resident was walking out. Mattresses were ripped and stained. Pillows were soiled with brown stains.
But those violations weren't serious enough to warrant a management takeover, state officials say. And many of the problems the county listed in its June letter couldn't be verified, said Jeff Horton, acting director of the state Division of Health Service Regulation.
On the morning of Sept. 3, Tang wandered away from the home. She was spotted about two miles away, near Burns High School. Since then, family members have organized searches and offered a $15,000 reward, without success.
“It's just been very traumatic and heartbreaking for us,” Waller says.
One day after her disappearance, state officials returned to Unique Living.
They found that door alarms hadn't been fixed, even though they'd given the home an Aug. 29 deadline. The executive director told state inspectors that the electrician hired to fix the doors had stopped work “due to non-payment for previous work.”
But on this visit, inspectors also found that staff members weren't properly supervising residents, putting them in imminent danger, according to the new report.
That plus the broken door alarms prompted the state to suspend the facility's license, Horton said Thursday.
Cleveland County officials see the Unique Living saga differently.
They say staff members' inability to supervise residents is a longstanding problem.
Residents went in and out of the facility all the time, to smoke, or take a walk or blow off steam, says Teala McSwain, program manager for Cleveland's Department of Social Services.
Though many workers cared about the residents, staff monitoring of everyone “would have been almost humanly impossible,” she says.
What finally persuaded the state to close Unique Living, says Cleveland County's Wasson, is Tang's family – “a very caring family who advocated for her in Raleigh. When you have an active, involved family, I think it was really hard for them to blow this thing off like they usually do.”
Wasson maintains that Tang might now be safe with her family if the state had heeded Cleveland County's June letter.
“Just given everything that's gone down, I think the (Department of Health Service Regulation) makes Wall Street regulators look efficient.”