CHISHOLM, Minn. (WCCO) — The Minnesota Department of Health is investigating after a developmentally disabled man was found unresponsive in a urine-soaked chair at an assisted living facility.

The health department released documents surrounding its investigation at Hillcrest Terrace of Chisholm determining that neglect concerns were substantiated.

According to the investigation report, the man had to be taken to the hospital after he was found unresponsive in his room earlier this year. The report says that the man was incontinent and suffered from diabetes. His care required that his blood sugar levels be monitored daily.

The health department said his blood sugar was found to be very low after being discovered unresponsive. It was determined he was suffering from a urinary tract infection.

According to the report, “the room was in terrible disarray with old cans of food, numerous ash trays with ash burns on the carpet, urinary incontinence, no linens on the bed, furniture reported to be filthy and ripped, carpeting had urine stains on it. Ambulance crew could smell urine in the hallway before they got to his room.”

There was also mold found in the room.

An employee at the facility told investigators that she was aware of a problem with the urine soaking into the carpet, and said that she would pour enzymatic cleaner straight from the bottle without diluting it to get rid of the smell.

The investigative report says that a number of attempts to get in contact with other employees were not successful, with 12 phone messages to four employees unanswered.

The man has since been returned to the facility and been given a new room.


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