U.S. Senate investigators have discovered a pattern of neglect and poor care in an Oregon company’s group homes for people with intellectual and developmental disabilities, finding problems that persisted despite repeated state efforts to force the company to improve.
The 19-month investigation into Mentor Oregon, spearheaded by the U.S. Senate Finance Committee, was launched in response to coverage in The Oregonian/OregonLive that outlined neglect in one of the company’s homes in Curry County. State officials at the time learned of neglect so severe that a resident smelled of “rotting flesh,” according to official records.
The federal report summarizing the committee’s investigation, published Thursday, blasted the company for failing to meet its obligations towards the vulnerable people it serves.
“Scores” of the company’s homes were found to be in violation of various regulations from 2013 to 2019, the committee found after reviewing 5,000 pages of documents. The most common problems included staff failing to follow doctors’ orders, staff not getting training and residents missing medications.
While the company took steps to improve the quality of care, the committee found problems even into the final months of the investigation.
Just this May, local investigators found that a caregiver had left a 65-year-old woman to sit in her kitchen chair for hours as she picked at or hit her face. The employee falsified records, writing that the woman had been resting in her recliner, according to the Senate report. Other staff found the employee sitting at a computer, and the woman was left with bruises on her back and blood on her hands, face and shirt.
“This was pure neglect,” investigators wrote.
The significance of the investigation extends far beyond Oregon’s borders: Mentor Oregon is part of a national corporation that in 2018 operated homes in 36 states serving nearly 13,000 people. The parent company, the Mentor Network, is one of the largest human services companies in the United States, according to the committee’s findings.
Sen. Ron Wyden, D.-Ore., the finance committee’s ranking member, said in a statement that organizations such as Mentor must do more to protect the people in their care.
“It is clear that too many vulnerable Americans and their loved ones who count on caregivers to provide a safe and healthy living environment are being let down by those in a position of trust,” Wyden said. “This report shines a light on key shortfalls by Mentor Oregon in failing to meet standards of care for Oregonians they were entrusted to help.”
A parallel investigation focused on facilities in Iowa, home to the U.S. Senate Finance Committee’s chairman, Republican Chuck Grassley.
The committee’s investigation provides rare insight into the complex world of group homes for people with intellectual and developmental disabilities. Such homes have long been hotbeds of neglect. They are isolated, with no more than five residents per home, and much of the oversight has been handed over to local health agencies.
About 3,200 Oregonians get care in 980 group homes.
In a written statement, a Mentor Network spokeswoman said the company fully cooperated with the investigation and made multiple meaningful changes to improve its work, including improving training, “investing in new state leadership,” updating its homes across the state and working to hire more staff.
“Our top priority is the safety and wellbeing of the people we care for, and we appreciate the Committee’s interest in raising standards for individuals with disabilities,” spokeswoman Teresa Prego said.
And, Prego said, the company will “continue to promote a culture focused on compassion, accountability, and excellence as we believe every person in our care deserves to live life to their full potential.”
Senate committee investigators gave Mentor Oregon credit for making an effort to improve its work, including putting in place greater training requirements and disciplining staff.
But, the committee found, that work was far from sufficient.
Just weeks before finishing their report, the state discovered so many new violations at a Brookings Mentor Oregon home that it ordered it to close for good.
The lead state agency overseeing the homes has on numerous occasions hammered the company with the strictest regulatory tools it has, including forbidding the company from taking new clients and ordering homes to be shut down.
That agency, Office of Developmental Disabilities Services, credited its work for shuttering all but 10 of Mentor Oregon’s group homes, down from the 28 that were open in January 2019. The homes still in operation are not currently allowed to take new residents.
“Abuse and neglect should never happen to anyone,” agency director Lilia Teninty said in a statement. “Providers, like Mentor, are paid by the state to support people with (intellectual and developmental disabilities), including protecting their health and safety.”
For one caregiver who worked at a Mentor Oregon home, the abuse and neglect she witnessed drove her out of caregiving altogether.
Kailee Sorlien worked in a Gresham home from 2013 to 2016, she said in an interview with The Oregonian/OregonLive this week, and saw a raft of abuses, including a resident left on the toilet for hours, caregivers failing to put on gloves when showering a resident, and people getting bedsores because they were left in bed too long.
“I just felt so sad for these people,” Sorlien said. “It was mentally draining me, as a person, in how people treat people who can’t help themselves.”