When state investigators were called into the Brainerd, Minn., nursing home in late 2008, administrators said one aide might have mistreated several residents with dementia.
What they found was far more troubling: A "pattern of resident abuse'' by at least 20 nursing assistants that included belittling elderly patients, telling a man to urinate in his incontinence briefs and removing a call-light from a confused female resident.
"This was a systemwide failure," said Stella French, who oversees state Health Department investigators. "It's a situation that the administration should have known about and should have stopped."
The home's owner, Good Samaritan of Sioux Falls, S.D., is the nation's largest nonprofit chain of nursing homes and the owner of the Albert Lea nursing facility where abuse of several elderly residents led to criminal charges against two aides last year -- a fact that caused some soul-searching at the organization.
"This is not another Albert Lea," said spokesman Mark Dickerson. "It's not that level of problem. Still, coming so soon after Albert Lea, both the state and we swooped in right away to get to the bottom of things.
"You have to realize, we have made a lot of changes, done a lot of training," Dickerson added. "It's not the same place."
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Brainerd Nursing Home is Cited for Abuse