PORTLAND, Ore. – U.S. Senate investigators have discovered a pattern of neglect and poor caring for people with intellectual and developmental disabilities in the homes of an Oregon company, and identified issues that persist despite repeated government efforts to force the company to improve.
The 19-month investigation into Mentor Oregon, led by the Senate Treasury Committee, was initiated in response to coverage on The Oregonian / OregonLive outlining the neglect in one of the company’s Curry County homes. The state officials at the time learned of such severe neglect that one resident smelled of “rotten meat” according to official information.
The federal report, which rounds up the committee’s investigation published this week, blew up the company for failing to meet its obligations to the vulnerable people it serves.
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From 2013 to 2019 it was found that “scores” of the company’s houses violated various regulations, the committee found after reviewing 5,000 pages of documents. The most common problems included staff who did not follow doctors’ instructions, staff who did not receive training, and residents who lacked medication.
As the company took steps to improve the quality of care, the committee identified problems in the last few months of the investigation.
It wasn’t until May of this year that local investigators discovered that a caregiver had left a 65-year-old woman to sit in her kitchen chair for hours while picking or slapping her face. The clerk falsified records and wrote that according to the Senate report, the woman was lying in her deck chair. Other workers found the worker sitting at a computer and the woman had bruises on her back and blood on her hands, face and shirt.
“That was sheer neglect,” wrote the investigators.
The importance of the research goes well beyond the borders of Oregon: Mentor Oregon is part of a national company that operated homes in 36 states and served almost 13,000 people in 2018. The parent company, the Mentor Network, is one of the largest human services companies in the United States, according to the committee’s findings.
Senator Ron Wyden, D-Ore., The senior finance committee member, said in a statement that organizations like Mentor need to do more to protect the people in their care.
“It is clear that too many vulnerable Americans and their loved ones who rely on caregivers to create safe and healthy living environments are disappointed with people in a position of trust,” said Wyden. “This report highlights Mentor Oregon’s key shortcomings in failing to meet standards of due diligence for Oregonians to whom it has been entrusted.”
A parallel investigation focused on facilities in Iowa where the chairman of the Senate Finance Committee, Republican Chuck Grassley, lived.
The committee’s investigation offers rare glimpses into the complex world of group homes for people with intellectual and developmental disabilities. Such homes have long been breeding grounds for neglect. They are isolated and have no more than five inhabitants per house. Much of the oversight has been turned over to the local health authorities.
Approximately 3,200 Oregonians are cared for in 980 group homes.
In a written statement, a Mentor Network spokeswoman said the company had fully cooperated with the investigation and made several significant changes to improve its operations, including upgrading training, “investing in new governance,” upgrading its homes entire state and hiring additional employees.
“Our top priority is the safety and wellbeing of the people we care about, and we appreciate the committee’s interest in raising standards for people with disabilities,” said spokeswoman Teresa Prego.
And Prego said the company will “continue to foster a culture based on compassion, accountability, and excellence as we believe that everyone deserving of our care deserves to live their lives to the full.”
Senate committee investigators recognized Mentor Oregon for making efforts to improve his work, including introducing higher training requirements and disciplining staff.
However, the committee found that the work was nowhere near sufficient.
Just weeks before their report was finalized, the state discovered so many new violations in a home owned by Brookings’ mentor, Oregon, that it ordered it closed for good.
The lead government agency overseeing the homes has confronted the company with the toughest regulatory tools on several occasions, including banning new customers and ordering homes to close.
That agency, Office of Developmental Disabilities Services, has credited its work in closing all but 10 Mentor Oregon group homes out of the 28 homes that opened in January 2019. The houses that are still in operation are currently not allowed to accept new residents.
“Abuse and neglect should not happen to anyone,” said agency director Lilia Teninty in a statement. “Providers like Mentor are paid by the state to assist people with (intellectual and developmental disabilities), including protecting their health and safety.”
For a caregiver who worked in a Mentor Oregon home, the abuse and neglect she witnessed resulted in her no longer caring at all.
Kailee Sorlien worked in a house in Gresham from 2013 to 2016, she said a resident in an interview with The Oregonian / OregonLive this week, and people get pressure ulcers from being left in bed too long.
“I was just so sad for these people,” said Sorlien. “I was mentally exhausted as a person, how people deal with people who cannot help themselves.”
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