Speaking out for People with
 Intellectual and Developmental Disabilities

Widespread Abuse, Neglect and Death in Small Settings Serving People with Intellectual Disabilities - 2011 & 2012



The Seattle Times, December 18, 2012

Report: State ignoring abuse at group homes

A watchdog organization says the state is failing to protect some of Washington's most vulnerable people — those with developmental disabilities who live in group homes. Disability Rights Washington says overworked investigators focus on rule compliance, often overlooking the substance of complaints.

Of almost 3,000 abuse, neglect or safety-violation complaints filed in the past two years, more than 1,000 were closed by the Department of Social and Health Services (DSHS) without any investigation, according to DRW.

Even those cases that were opened often sat for weeks or months before an investigation began.

“What we found is an abuse-response system that is fatally flawed,” said David Carlson, DRW’s director of legal advocacy. “We need a safety net that keeps people safe. DSHS is not doing that.”



Fox News, August 16, 2012

House Fire At Special Needs Group Home Kills Three

Arson investigators are on the scene of a house fire right now sifting through what`s left of a group home for special needs men. The San Antonio Fire Department says the fire started just before 11 pm. One person died inside the house and two others died at the hospital. There is one other person being treated at the hospital and they are in stable condition. Fire investigators say they don`t know how the fire started. Neighbors called in the fire after seeing flames coming from the home last night. Several residents were trapped in the home as the fire spread. There are reports that some of the residents were jumping from windows to save themselves. 13 mentally disabled adults were living at the home at the time.


Associated Press, July 22, 2012

Ex-group home employee sentence to 20 years

A former group home employee has been sentenced to 20 years in prison in the beating death of one of the home's residents. Tyler Brock, who is 22, pleaded guilty in June to second-degree manslaughter in the 2011 death of 35-year-old Shawn K. Akridge, a disabled resident at a group home. Judge Hunter Daugherty called the attack "heinous" and said it "defies explanation" on Friday before issuing the sentence.


Belleville News-Democrat, June 27, 2012

Hidden suffering, hidden death: State agency won't investigate after 53 deaths of those in its care

The state agency created to prevent neglect and abuse of disabled adults who live at home rejects hundreds of hotline calls for help each year and doesn't investigate when people die after severe mistreatment. The Office of the Inspector General for the Illinois Department of Human Services received broad powers through legislation in 2000 that expanded its responsibility for protecting physically and mentally disabled people who live outside community facilities and state institutions. The OIG, which operates independently, investigates neglect and abuse complaints made to a statewide hotline operated by the agency. But when the subject of a hotline call is hospitalized and dies soon after, the OIG closes the case without investigating the circumstances surrounding the death because of the agency's interpretation of state law. According to OIG documents, the agency is prohibited from investigating the moment a death occurs. The OIG considers such an investigation a "service," and the dead are "ineligible for services" under the agency's interpretation of Rule 51 -- a legislative directive that governs the Adults with Disabilities Abuse Project, the OIG documents state. 53 cases since May 2003 that fit this pattern: Neglect or abuse of a critically ill, disabled adult in their home, followed by an ambulance ride to an emergency room and death, usually within a few days or weeks. In some cases, disabled, often critically ill people were starved, left to suffer in pain, denied medication or forced to lie for days in their own feces and urine. Some who died were unable to move when ambulance attendants found them.



Hartford Courant, June 15, 2012

State Investigating More Charges Against Group Homes Operator

An organization that receives about $2 million per year in public funds to care for developmentally disabled people in several group homes in Hartford and Glastonbury is again under state review over allegations of poor care. In an unsigned letter to the executive director of Humanidad Inc. and to the state Department of Developmental Services, a group of Humanidad employees allege that staffing shortages are creating a dangerous situation, that the homes lack basic resources such as groceries and activity programs, and that clients in general are receiving subpar treatment.



The News & Advance, June 11, 2012

Investigator sees problems in private group homes

A Lynchburg-based investigator for the state Department of Social Services, testifying in a federal court hearing Friday, opened a window into the little-viewed world of what can happen inside Virginia’s system of caring for people with disabilities. The investigator, Ted Campbell, said he has encountered incidents involving unexplained injuries to intellectually disabled people, caregivers who are fired and investigations cut short. Among the incidents Campbell described in testimony before U.S. District Court Judge John Gibney was one involving a woman who had moved from Central Virginia Training Center in Madison Heights into a privately operated home within the past few years. She left the training center in good health, but a couple months later was found to have a large bedsore that hadn’t been cleaned. Investigators’ attempts to follow up on the case ran into roadblocks. The incident is a single case involving just one of the 8,000 or more Virginians with intellectual disabilities who have left training centers over the past several years to receive care from other providers. A report from Adult Protective Services, a branch of the state Department of Social Services, indicated 1,200 residents were victims of abuse or neglect during fiscal year 2011 in privately operated nursing facilities, assisted-living facilities and other living places. That report did not specify which of those victims were former residents of Virginia’s training centers.



WSLS-10 (NBC), May 23, 2012

Home caretaker charged with abusing disabled patient in Grayson County

Her title was in-home caretaker with Wall Residences, Inc. (a 10 year employee), but Melanie Melton was doing anything but her job, according to sheriff’s officials. Court documents show she was indicted on charges of abuse against an incapacitated person and investigators highlight that the abuse was, “So gross, wanton, and culpable as to show a reckless disregard for human life.” The person Melton was caring for was “dehydrated from improper feeding, and had unattended bed sores so bad they turned to gangrene,” said Chief Deputy Mike Hash, with the Grayson County Sheriff’s Department. The abuse is said to have happened between April 1 and April 25, at Melton's home in the Baywood Community of Grayson County. We went to her house to ask her about the charges, but no one answered the door. She turned herself into authorities more than a week ago after being indicted by the grand jury. The victim was treated at a nearby hospital and is said to be recovering.


Atlanta Journal-Constitution, May 22, 2012

Lax enforcement in personal care homes

Deficiencies in care, living conditions and record-keeping have piled up in scores of Georgia personal care homes (35,000), with the state rarely shutting down violators or levying heavy fines (just 544 cases with an average fine of $500), The Atlanta Journal-Constitution has found. An analysis of five years’ worth of inspections found numerous troubling instances — from live cockroaches in the kitchen of one home to another in which eight residents were out of medication. Unlike nursing homes, personal care homes do not provide intensive medical care. Instead, they provide lodging, food, bathing and other grooming services, and can help residents manage their medications. Many are in individual homes in residential neighborhoods. Common problems included residents who were so frail or ill that they needed services beyond those provided by personal care homes. Other common issues were failure to document required employee training, failure to conduct regular fire drill evacuations, failure to obtain background checks on employees and inadequate staffing. But some cases were far more serious, leading to resident death.


New York

New York Times, May 8, 2012

Monitoring Care for the Disabled

 The stories of abuse, suffering and unexplained deaths among those sent to homes for the disabled in New York State are horrifying. A worker sits on an autistic boy and crushes him to death. Another worker sexually abuses a 54-year-old disabled woman. A quadriplegic drowns as an aide leaves him in a tub of water. As reported in The Times over the last year, there have been numerous cases of abuse and at least 1,200 deaths attributed to unnatural or unknown causes in publicly financed homes for the disabled in the last decade. Many cases have barely been investigated, with incompetent workers often being moved to a different facility, without being prosecuted.



Virginia Attorney General's Office news release, May 7, 2012

Martinsville group home owner guilty in abuse, death of Parkinson's patient

Attorney General Ken Cuccinelli announced today that Richard C. Wagoner, Jr., was found guilty of abuse and neglect of an incapacitated adult that resulted in death. Wagoner owned and operated The Claye Corporation, a group home for adults in Martinsville. The victim, Joseph Tuggle, 57, an intellectually disabled adult suffering from Parkinson's disease who received care in a group home operated by The Claye Corporation, was placed under a faucet running scalding water and suffered second- and third-degree burns on his legs, face, buttocks, and arm. Ten days later, Mr. Tuggle was found dead in his bed with scabbed burns. The medical examiner determined that Tuggle died from sepsis and pneumonia secondary to thermal injury. His death was ruled as a direct result of the injuries he sustained on February 8, 2011. Caregivers failed to call 911 and, at Wagoner’s orders, did not transport Tuggle the hospital. "Not only did Wagoner fail to properly prevent conditions in which an incapacitated and helpless patient could suffer from such abject neglect and abuse, he also explicitly and deliberately deprived Mr. Tuggle of the care he needed to survive these injuries," said Virginia’s Attorney General Ken Cuccinelli. "This kind of gruesome irresponsibility and depravity is despicable, and it's my hope that today's announcement will send a clear, stern message that this behavior simply will not be tolerated in Virginia." The case was investigated by the Martinsville Police Department and the attorney general's Health Care Fraud and Elder Abuse Section. The Elder Abuse section specializes in investigating allegations of abuse and neglect of incapacitated adults, employing both nurse investigators and criminal investigators to assist localities in determining the root cause of injuries and holding responsible persons accountable for their crimes.


Associated Press, May 5, 2012

Verdict in Illinois Group Home Death Leaves Questions

The violent death of Paul McCann led to improvements in how Illinois intends to protect the mentally disabled in group homes, but the trial of the first man accused of killing him suggests to some that justice and equality are still a challenge for them. Jurors trying the case of caretaker Keyun Newble, 26, charged with killing McCann at an eastern Illinois group home, heard about the brutal injuries the 42-year-old suffered. He had 13 broken ribs and lungs filled with fluid, part of what a doctor called "massive internal injuries" suffered as apparent punishment for stealing cookies. Newble was charged with murder, which would have sent him to prison for at least 20 years. But the judge allowed the option of a lesser charge, involuntary manslaughter, and the jurors took it, making him eligible for a sentence as short as three years. For advocates of the disabled, the April 27 verdict was insulting. McCann's family reacted with confusion. Both are trying to make sense of the verdict's message just as officials are trying to better safeguard the lives of disabled people who need care from the state. Gov. Pat Quinn has made it a priority to close institutions for disabled people like McCann and transfer them into situations closer to their families, such as in group homes. But the effort has drawn criticism from some affected families.



COFAR Blog, May 4, 2012

Commonwealth’s DPPC faults care plan in group home resident’s death

A state investigative agency (the Disabled Persons Protection Commission) has concluded that a Tyngsborough group home resident died last year as a result of having ingested an inedible object, and that there was sufficient evidence to conclude that his death was due to a lack of adequate supervision by caregivers. The 50-year-old man, who had formerly lived at the Fernald Developmental Center, had reportedly ingested a plastic bag. The July 6 death of the resident is one of three cases of death involving former developmental center residents, all men in their 50s. In both of the sudden death incidents, the men had been transferred to state-operated group homes operated by Northeast Residential Services, a division of the Department of Developmental Services. DDS has refused to discuss or provide any information about these deaths, citing confidentiality and privacy regulations. In a third case, a 51-year-old resident of a Northeast Residential Services home died on February 7, 2012 after having been sent back to his residence twice by Lowell General Hospital. That man had formerly lived at the Fernald Center as well.



Dallas Morning News, May 4, 2012

Group homes need city standards in Dallas

City Councilmen are considering reforms to improve the quality of life of individuals in group home care. Calls for finally moving beyond the status quo of just regulating zoning and building code violations and do something to ensure that these vulnerable citizens have a decent place to live are being debated. Council members discussed how poorly run group homes are one of the worst problems in their districts, noting that some operators in southern Dallas are in “the business of housing,” that is, caring more about making money off needy residents than in providing services. Other council members and Mayor Mike Rawlings also seem to understand that the city can no longer ignore the mediocre care, crowded sleeping quarters and shoddy facilities that characterize some of the 300-plus group homes in Dallas. City staffers, however, appear to be resisting the ordinance. As things stand, too many group home residents here lack access to decent services, live in facilities where operators take their money and give them little to live on, and confront drugs or violence in their quarters. These residents are the ones who too often are wandering the streets, panhandling and sometimes becoming a menace to themselves and others.


Advocacy Center, March 20, 2012

Investigation Reveals Serious Neglect at Group Homes Across State

The Advocacy Center has released the results of a three year investigation into conditions at group homes for people with intellectual and developmental disabilities across the state. The report, “When A House Is Not A Home: An investigation into conditions, care, and treatment in select group homes for people with intellectual disabilities in Louisiana,” reveals that residents in the surveyed group homes live in dismal, unsanitary surroundings, they learn very little and have limited exposure to the community. These residents experience problems with receiving appropriate and timely health care, they face poor transportation opportunities, are provided with unhealthy and unappetizing meals and generally lead a life filled with meaningless daytime activities and no chance of employment. According to Lois Simpson, Advocacy Center Executive Director, “Thirty years ago, when group homes for people with disabilities, were first conceptualized, they were supposed to be family-like, comfortable environments where people with disabilities could live and be a part of the greater community. Instead, many of these homes exist as isolated, poorly maintained, inadequately staffed, and unsafe environments where people merely exist.”

Continue to 2007 - 2010

Widespread Abuse, Neglect and Death in Small Settings Serving People with Intellectual Disabilities - 2013 & 2014



17 Deaths Raise Questions About Care Of Oklahoma Developmentally Disabled

November 1, 2014


The deaths of 17 developmentally disabled people transferring or already transferred out of two large state-run institutions are raising questions about whether the closing of the centers put residents' health at risk.

The deaths occurred after the state decided in November 2012 to shutter the facilities in Enid and Pauls Valley over the objections of some of the residents' guardians and parents. Almost all of the nearly 230 adult residents were to move to small, privately owned "community homes," where services are offered by various providers.

State Sen. Patrick Anderson, R-Enid, said he wants to know whether the impending closure of the facilities and the residents' transition into community homes contributed to the deaths.

Anderson wrote a letter to Attorney General Scott Pruitt on Oct. 24, one day after the most recent death. He called for a review of the deaths, which occurred in 2013 and 2014. The residents began moving out of the Northern Oklahoma Resource Center of Enid, or NORCE, and the Southern Oklahoma Resource Center in Pauls Valley, or SORC, in March 2013.

Among those who died, seven were living at NORCE, two were living at SORC, and eight had transitioned into community homes.

By comparison, there were seven total deaths at NORCE and SORC in 2012, four in 2011 and one in 2010, at the Enid facility, state officials said. The deaths in 2013 and 2014 occurred as the population of residents and staffing levels were being reduced.


New York

Sex offenders in group homes, July 31, 2014 WHEC News (NBC)

 Convicted sex offenders moved quickly into neighborhood group homes. A dozen sex offenders had been staying at the Monroe Developmental Center in Brighton until the state closed it down. News10NBC tracked seven of those sex offenders to two group homes in West Seneca with families living on the same street. News10NBC is learning how many times police have been called to those group homes since the sex offenders moved in. News10NBC discovered since the beginning of the year, police have been called to two group homes dozens of times. On two occasions, the calls were for sex offenders who had gone missing.

(The link to this article is no longer active)


Mentally disabled suffer in moves from Georgia institutions: State unlikely to meet deadline from federal settlement    June 21, 2014

By Alan Judd, Atlanta Journal-Constitution

482 people have been deinstitutionalized since 2010. About three-fourths of the facilities have been cited for violating standards of care or investigated over patient deaths or abuse and neglect reports since 2010. Officials documented 76 reports of physical or psychological abuse, 48 of neglect, and 60 accidental injuries. In 93 other cases, group home residents allegedly assaulted one another, their caregivers or others.   Forty people died after moving into group homes. At least 30 of those deaths had not been expected.



Department of Human Services Statement of Deficiencies and Plan of Correction Watertown Police Department Incident Report

May 9, 2014 and June 4, 2014

The Wisconsin Department of Human Services (DHS) rewarded an Intermediate Care Facility $12,000 for each resident moved out of its Intermediate Care Facility to one of its group homes if the resident did not die within the first 6 months of being transferred.

Two residents did die.

Chuck died 3 days after his transfer after falling down the steps while strapped and seated in his wheelchair. The DHS investigated but not fine was issued. Theo only penalty for Chuck’s death was to install a lock. See, https://www.forwardhealth.wi.gov/prod/kw/dqa/CMTX11POCS.PDF.

Another resident died of pneumonia about 2 weeks after being transferred. Because the death was deemed to be of natural causes, DHS did not investigate at all.


Report: Developmentally disabled need better care, April 10, 2014 Georgia Health News

A U.S. Justice Department Settlement Agreement with the State of Georgia calls for the transfer of nearly 1,000 residents with intellectual and developmental disabilities (I/DD) and the closure of all state-operated ICFs/IID, and the transition of 9,000 individuals with mental illness from facility-based care. Hundreds of individuals have been transferred a result of the October 2010 Settlement Agreement. An independent reviewer now reports that Georgia is failing to provide adequate supervision of individuals with developmental disabilities who are moved from state hospitals to community group homes. The reviewer, in a report dated March 23, says there is an “urgent need to ensure competent and sufficient health practitioner oversight of individuals who are medically fragile and require assistance with most aspects of their daily lives.” The reviewer, Elizabeth Jones, notes in the report that two individuals with developmental disabilities died shortly after being moved from Southwestern State Hospital in Thomasville, which recently closed, to community settings. The report also points out that state officials terminated three providers of services for poor quality of care.

Related Georgia News: In February 2014, the Georgia Department of Behavioral Health & Developmental Disabilities Office of Quality Management released its Annual Quality Management Report finding that, in 2013, there were 82 unexpected deaths, 1,200 hospitalizations, 318 incidents requiring law enforcement services, 305 individuals who were expectantly absent from a community residential or day program, and 210 alleged instances physical abuse of mentally ill and developmentally disabled individuals.



State Fights back against abuse of disabled adults (“Broken Trust” series)

The Tennessean, February 27, 2014

The beating of an intellectually disabled young man by his caretaker, captured in disturbing cellphone video footage obtained by The Tennessean, is a rare occurrence, "something so egregious and so horrendous it bothers every one of us to know it's occurred," the Department of Intellectual and Developmental Disabilities' chief attorney said Wednesday. Yet, problems have increased significantly among former residents of Tennessee’s developmental centers.


U.S. Department of Justice’s Bureau of Justice Statistics

U.S. Census Bureau’s Crime Victimization Survey, February 25, 2014 Crime Odds Nearly Triple For Those With Disabilities

The U.S. Census Bureau’s National Crime Victimization Survey found that there were 1.3 million nonfatal violent crimes against persons with disabilities in 2012, up from the roughly 1.1 million estimated for 2011, reported the U.S. Department of Justice’s Bureau of Justice Statistics. The Survey asks about experiences with crime — whether reported or unreported to police — among those age 12 and older living in the community.

Individuals with disabilities encountered violent crime at nearly three times the rate of those in the general population, the report found. Simple assaults were the most commonly cited crime against this group followed by robbery, aggravated assault and rape or sexual assault.

Those with cognitive disabilities had the highest rate of victimization and about half of violent crime victims with disabilities had multiple conditions, the Bureau of Justice Statistics said.



When people with intellectual disabilities leave facilities, results can fall short (“Broken Trust” series)

The Tennessean, February 10, 2014 

An audit by the state comptroller last fall, and a federal court monitor’s report tracking former residents of three of the state’s institutions, found that troubling problems trail many of the state’s formerly institutionalized residents. While the state saves millions of dollars each year by serving people outside institutions, officials at private agencies concede that a lack of adequate state funding has at times hampered their efforts to help people achieve the best quality of life. Identified problems include 257 reported allegations of abuse, neglect and exploitation; isolation; delays in doctor-recommended treatments in some cases and “numerous instances” of inadequate dental care; and a dramatic increase in deaths after people leave institutions (deaths among people with intellectual disabilities transferred from institutions nearly doubled between 2009 and 2013, from 19 to 34); incarceration; and missing former residents.


Georgia Department of Behavioral Health & Developmental Disabilities, February 2014 Annual Quality Management Report for January 2013 – December 2013

Outcomes due to Settlement implementation, which requires the downsizing and closure of facilities for people with intellectual and developmental disabilities and mental illness, are troubling. According to the Georgia Department of Behavioral Health & Developmental Disabilities’ "Annual Quality Management Report," January 2013 - December 2013, there have been 1,200 hospitalizations of individuals (mental health and developmental disabilities) residing in community residential programs; 344 individuals requiring treatment beyond first aid; 318 incidents requiring law enforcement services; 305 individuals who were expectantly absent from a community residential or day program; and 210 alleged physical abuse of an individual. A total of 82 unexpected deaths of individuals with mental illness and developmental disabilities were reviewed during 2013.


Reader’s Digest, February 2014 (reprinted from Mother Jones, May/June 2013) Schizophrenic. Killer. My Cousin.

It's insanity to kill your father with a kitchen knife. It's also insanity to close hospitals, fire therapists, and leave families to face mental illness on their own. "You can call the police," the deputy director of Sonoma County's National Alliance on Mental Illness (NAMI), David France, said when I asked him what options are available to a parent whose adult child appears to be having a mental breakdown. "The police can activate resources," like an emergency psych bed in a regular hospital, or transport and admission to a psychiatric hospital in a county that, unlike Sonoma, has one. But only if the police decide your child is a danger to himself or others can they arrest him with the right to hold him for three days—what in California is called a 5150, after the relevant section of state law. Otherwise you can be turned away for lack of space even if your loved one is willing to be admitted, or be left no good options if they're not. Ninety-two percent of the patients in California's state psych hospitals got there via the criminal-justice system. Timeline: Deinstitutionalization And Its Consequences: How deinstitutionalization moved thousands of mentally ill people out of hospitals - and into jails and prisons. Map: Which States Have Cut Treatment For the Mentally Ill the Most?




Police: Embezzlement from disabled went on for years

The Press Democrat, February 22, 2014

For at least seven years, embezzlement suspect Larry Gene Sark forged signatures onto the backs of thousands of checks made out to developmentally disabled clients of the North Bay Regional Center, a case management agency which arrange for community-based services for people with developmental disabilities. He then deposited them (totaling more than $400,000) into his personal bank account, according to a Santa Rosa police investigation. The money was taken from 51 Sonoma County residents.


Parent Hospital Association / Sonoma Developmental Center, More Information Needed on Level of Abuse and Neglect at Community Homes    February 20, 2014

Concern is growing among family members and advocates that the safety of those developmentally disabled folks still resident in California's state-run developmental centers is threatened -- not because of conditions at the centers but by the prospect losing the centers' protections when residents are moved into the community.



L.A. Suit Accuses Unlicensed Care Facilities of Abuse

Los Angeles Times, February 18, 2014

Los Angeles City Atty. Mike Feuer has filed a lawsuit against the two unlicensed assisted-care facilities and their owners, a pastor and his wife, for allegedly abusing their physically and mentally disabled residents by forcing them to live in "deplorable, overcrowded and substandard living conditions" and taking the residents' government benefits." Among the allegations are: Swarms of flies filled the living areas. Broken furniture was scattered, bedroom doors were missing and plaster was falling off the walls, according to court documents.

Some residents slept in bunk beds crowded into small rooms with 1-inch pads instead of mattresses. One resident lived in a "storage room" and others in an attic.


Olmstead Resources

The Supreme Court, in its landmark Olmstead v. L.C. ruling, recognized the need for a range of services which respond to the varied and unique needs of the entire disability community: “We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings...Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.”  119 S. Ct. 2176, 2187 (1999).

Olmstead & ADA Documents

VOR's Olmstead Resources

Documents and articles that you can use to summarize key points in Olmstead