TOWER— The Minnesota Department of Health has substantiated multiple charges of neglect or abuse of residents at the former Golden Horizons assisted living facility in Tower. An investigation of the allegations, completed April 28, found that an overnight aide at the facility repeatedly failed to provide required care for three residents with dementia who needed assistance using the bathroom. The aide also took advantage of a fourth resident, by reportedly stealing a pain-killing medication from the resident, and was believed to be involved with missing drugs from at least two other residents at the facility.

According to the MDH investigation, Golden Horizons failed to discipline the aide, failed to conduct its own internal investigation of the abuses, and failed to report the maltreatment.

The aide, who is not identified, was not fired, but eventually left by his or her own choice.

The investigation found that the aide had repeatedly failed to provide toileting assistance for three residents suffering from varying types of dementia, or help changing their “briefs”. Morning aides suspected the night aide was failing to provide required care because they repeatedly found the residents “completely saturated in urine, through to the bed linen,” on mornings after the night aide had worked. All three of the residents had cognitive issues that prevented them from reporting the lack of assistance directly.

The daytime aides told the investigator that they had reported the situation to the facility’s administrator, but that nothing appeared to have been done about the situation. The daytime aides sought to verify that the night aide was failing to change the residents’ briefs by marking them before leaving for the night, an effort that helped to document the night aide’s lack of assistance.

The documentation did prompt the center’s administrator to draft a disciplinary notice but the aide never signed it and took both copies. The aide was allowed to continue to work until leaving voluntarily some time later.

The investigation also concluded that the aide was involved in the theft of 96 tablets of a controlled substance prescribed to a separate resident who remained mentally sound. The investigator determined that the aide was reporting that the resident was taking the drug (tramadol) when, in fact, the aide was systematically stealing it.

Facility staff became suspicious because the resident rarely asked for tramadol. A review of the medication record showed that virtually all of the drug was reportedly administered during shifts worked by the alleged perpetrator and that an entire card of 30 pills had gone missing. Staff immediately notified the administrator, who failed to contact law enforcement over the missing drugs and failed to suspend the suspected aide or order an investigation.

The investigation found that four months earlier, the same aide had been involved in the disappearance of 588 tablets of hydromorphone left over after a resident at the facility died. When questioned, the aide claimed to have disposed of the medication, but other medications in the room were not touched. The aide’s personnel file, however, lacked any documentation of the incident.

The violations are considered Level Three, which includes incidents that harmed a resident’s health or safety.

The assisted living facility was recently sold and the new owners of the facility, renamed Vermilion Senior Living, had no comment on the findings of the investigation.