Infighting ensued, with some residents fiercely committed to keeping the hospital open and others favoring closure, perhaps replacing it with a small clinic. Jean Bilodeaux, 74, a local journalist, says board members often kept the public in the dark, failing to show up for their own meetings and sometimes making decisions outside public view.

When Bilodeaux raised questions about the hospital’s finances in the Modoc County Record, a weekly newspaper, she recalled, board members “started screaming at me,” she said. Now “I don’t even step foot in that hospital.”

Ben Zandstra, 65, a pastor in Cedarville, says that while Cornwell was in charge, he too got a chilly reception at the hospital, where he had long played guitar for patients on Christmas Eve. “I became persona non grata. It’s the most divisive thing I’ve seen in the years I’ve lived here.”

Even residents who say they have experienced poor care at Surprise Valley Community believe its continued existence in some form is crucial—for its 50 or so jobs, for its ER, and because it puts the region on the map.

Eric Shpilman, 61, a retired probation officer, says his now-deceased wife received “unspeakable” treatment at Surprise Valley. But to shut it down? “It would take out the heart of Surprise Valley, the heart out of Cedarville.”

Last summer, the board turned to an outside management company for help.

Jorge Perez, the CEO of Kansas City–based EmpowerHMS—which promises on its website to “rescue rural hospitals”—agreed to take over Surprise Valley’s debt and operate the hospital for three years, according to a management agreement with the board.

In the two months after EmpowerHMS took over management, Surprise Valley’s revenue more than doubled, according to financial documents provided by the hospital.

Then, according to hospital officials’ public statements, the company stopped making the promised payments, and they haven’t been able to contact EmpowerHMS or Perez since. In January, when Surprise Valley filed for bankruptcy, documents filed in court said EmpowerHMS had “abandoned” the hospital.

Around the time Perez took over, he and companies with which he was involved were dogged by allegations of improper laboratory billing at facilities in Mississippi, Florida, Oklahoma, and Missouri, according to ongoing lawsuits by insurers and others, a state audit, and media reports. Missouri’s attorney general in May opened an investigation into one of the hospitals Perez managed, and the Democratic Senator Claire McCaskill of Missouri recently called for a federal investigation into lab-billing practices at one of the hospitals.

Medicare rules and commercial insurance contracts, with some exceptions, require people to be treated on an inpatient or outpatient basis by the hospitals that are billing for their lab tests. But insurers have alleged in court documents that hospitals Perez was involved with billed for tests—to the tune of at least $175 million—on patients never seen at those facilities. Perez has maintained that what he is doing is legal and that it generates revenue that rural hospitals desperately need, according to Side Effects Public Media.