Investigation: Brookings care home resident smelled of 'rotting flesh'
PORTLAND, Ore. (AP) — A national corporation shuttered a Brookings group home for people with disabilities last month after state regulators found that managers repeatedly ignored caregivers' concerns about a disabled person's festering pressure wound, including that it smelled of "rotting flesh."
State regulators for the Department of Human Services moved to revoke the home's license before the company's local affiliate, Mentor Oregon, closed the facility along the Southern Oregon coast Dec. 11.
Overarching safety concerns also prompted officials to temporarily prohibit the company from accepting new residents at any of its 28 homes across Oregon, including six in the Portland area. In some cases, a ban for accepting new residents wasn't lifted until December.
The state rarely takes such aggressive action, issuing similar restrictions only a handful of times in recent years.
State regulators found that Mentor Oregon managers failed to train staff, provided minimal care and made medically inappropriate decisions as a disabled person who couldn't walk or communicate deteriorated for months in 2017, according to an investigative report from May 2018 obtained by The Oregonian/OregonLive through a public records request.
The person was eventually moved to a new home and immediately hospitalized for surgery to remove dead and decaying tissue, according to state records.
State reports don't provide the person's name, age or gender.
Toni Larson, state ombudsman for people with disabilities, said the official findings are "disturbing" because they show the facility failed to provide a basic level of care.
"It wasn't one missed mistake or one missed opportunity," Larson said.
Mentor Oregon's director, Yvette Doan, said in a statement that the company has taken extensive steps to train staff and worked closely with the state to make changes.
While the company is proud of its work in Oregon, Doan wrote, "if we are going to accept any small measure of credit for a job well done for those we support, we must also acknowledge when our services may fall short."
The five managers named in the report no longer work for the company, Doan said.
Because regulators substantiated abuse allegations against those former employees, they would be unlikely to pass a background check to work at a similar home in Oregon, said Lilia Teninty, director of the state Intellectual and Developmental Disabilities division.
Neglect at the Brookings group home lasted multiple months in late 2017, an investigator found, and continued after the investigation began. The victim was moved to a different group home in November, nearly two months after Community Living Case Management, a state contractor that oversees disability services in southwest Oregon, launched its investigation.
The investigation found that the person lost more than a quarter of his or her weight because the home didn't have a scale; staff members were trained improperly or not trained at all; and employees likely didn't do enough to treat the person's pain.
The state in November 2017 initially prohibited new admissions at all Mentor Oregon homes because of concerns about resident safety, Teninty said. But regulators lifted that restriction for most homes in late January 2018.
Mentor Oregon told the state the company has addressed the problems the state identified, Teninty said. The state removed remaining limitations for accepting new residents at six Curry County facilities last month just as Mentor Oregon closed its Brookings home.
Teninty said state regulators will continue monitoring the company's work.
The Brookings facility is at least the fifth specialized group home the state said it has effectively shut down since 2013. Mentor Oregon is the seventh provider in the same period to face company-wide restrictions on accepting new residents.
There are 861 group homes for people with intellectual or developmental disabilities in the state.
The Mentor Network is a publicly-traded company that operates homes for with people with disabilities in 36 states serving nearly 13,000 people, according to public filings. The company also provides for-profit child foster care, a program that faced congressional scrutiny following reports of numerous child deaths.
U.S. Sen. Ron Wyden, D-Ore., and former U.S. Sen. Orrin Hatch, R-Utah, led a two-year investigation that found that foster children in the company's care died at a rate 42 percent higher than the national average.
State regulators ask people to report suspected abuse of a child or adult by calling 1-855-503-7233.
Information from: The Oregonian/OregonLive, http://www.oregonlive.com