EDITOR’S NOTE: Part 4 of a five-part series.

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Grants Pass resident Liana Duffield said she witnessed “shockingly high staff turnover” in the year she spent as a regional HR manager at Partnerships in Community Living.

The Monmouth-based nonprofit operates a series of group homes for developmentally disabled minors and adults in Oregon — including the Medford home where caregiver Bobbie Kolada was fatally injured Feb. 20. 

For a second year at PCL, Duffield worked as a house manager, and that’s when she learned why caregiver turnover was so high.

Duffield is one of nearly a dozen former and current PCL employees interviewed by the Rogue Valley Times following the March 27 death of Kolada, a 66-year-old grandmother who was seriously injured in an apparent attack by a developmentally disabled resident in the group home where she worked.  

Kolada, who suffered a broken neck and a severe head trauma, succumbed to her injuries after a five-week fight for her life. The man blamed for her injuries has a history of violent behavior and still lives in the house.

High employee turnover, Duffield said, stemmed from “newbie” employees being assigned to houses known for being dangerous. Those who stayed were often forced to work double shifts that too often turned into days-long shifts when relief staff failed to show up. Duffield said she once worked five months of mostly 18- to 20-hour days.

“They don’t hire the right staff most of time, and when they do hire the right staff, they push them out because that staff starts holding them accountable,” Duffield said.

State licensing officials once found a resident’s care had not been documented for 85 days, she said. Duffield worked at a home for developmentally disabled teen boys on Edwina Avenue in Central Point, the home where Duffield’s colleague, Valina Rivera-Schaefer, was injured so severely by a 17-year-old boy that she suffered a miscarriage.

“One of (PCL’s) tactics is, ‘If you don’t work out here, we can move you. But when you ask to be moved, it can take a couple months. Meanwhile, (the residents are) beating the s**t out of you,” she said.

“I came in at the end of June, and by September, we had literally had 20 (staff) in and out of that house. There was a ton of physical abuse happening there, between residents and caregivers.”

Duffield said she was attacked four times by two different residents. In addition, she witnessed — and in some cases helped intercede in — more than a half-dozen violent attacks on other employees. Duffield said it’s common for staff to work alone with individuals whose care plans require more than one staff, but caregivers often feel devoted to the care of the residents and feel obligated to try and “tough it out.”

Both Kolada, a former PCL employee of the month, and Rivera-Schaefer were working alone when they were injured, said Duffield. 

“With Bobbie, I wonder if she had a chance to call for help. … (The resident) that hurt Bobbie had a violent history. I was scared s**tless when I walked into that house for the first time. A second person would have been able to take the situation down a notch. There’s a chance Bobbie would still be alive,” she added.

PCL responds

PCL co-owner Joanne Fuhrman, in an email to the Rogue Valley Times this week, said, “The care plans for these two individuals (in the house where Kolada was injured) do not require two staff to be present. Each individual we work with has a care plan that includes specific, approved intervention plans in cases where one caregiver is present and in cases where two caregivers are present. The care plan for the individuals in the home at the time the incident occurred does not require two caregivers to be present.”

On an Accident/Fatality Intake Form PCL submitted to Oregon OSHA Feb. 21, the day after Kolada was hurt, and again March 27, when Kolada died, PCL maintained that Kolada was an “accident victim.”

“Currently the mechanism of injury is unknown,” PCL wrote on the form sent to OSHA Feb. 21. “The employee was found unconscious and bleeding from the head by co-workers during a shift change. No one is known to have witnessed the accident,” PCL said.

On the day Kolada died, PCL updated its report with the sentence, “Oregon OSHA was notified accident victim had passed away as of the morning of 3/27/2023.”

This week, Fuhrman reiterated that there’s no proof that Kolada was hurt by a resident.

“As far as PCL is aware, there has not been a medical or legal conclusion that Bobbie was injured by a resident,” Fuhrman said Tuesday in an email to Rogue Valley Times.

‘I warned them time and time again’

White City resident Ken Monk, a former behavior support coordinator for PCL, said he and others repeatedly warned PCL about staffing levels for group homes where residents requiring higher levels of support were housed.

Monk, who counted Kolada as a close friend when they worked together, said his heart sank when he learned this week of Kolada’s death. Monk was responsible for assessing residents and writing Positive Behavior Support Plans, which determine de-escalation techniques as well as physical intervention methods permitted for each resident.

Monk said he regularly worked with the man believed to have fatally injured Kolada.

“I was livid. And for it to have happened to Bobbie …,” he said Monday, taking a slow breath and wringing his hands.

Monk, who worked in the disabilities field since 1998, said he became a thorn in the side of PCL and ultimately left because of his concerns over unsafe conditions, which he said put both caregivers and residents at a disadvantage, were ignored.

“The guy who killed Bobbie — and I have no doubt he hurt Bobbie, as I’ve been beat up by him before — is what we call a Tier 5 and 6, which is related to the level of support he required. I worked with Bobbie during many of the times that she got hurt. And she got hurt a lot,” he said.

“She was concussed several times by him, but she was a trooper and she loved those boys. … I would not have kept her there. As a behavior specialist, I knew that it was not a good situation, and I told PCL that many times.”

Monk said he felt bad for the resident for being left in a situation where his needs, such as staffing levels or behavioral assessments, were “not likely being met.”

“It’s one of those cases where — 99% of the time — they can be great. The other part of the time, things can go catastrophically wrong,” he added, noting that the resident believed to have injured Kolada was moved from another home in Medford in order to be in a more secure setting — with securable doors — to permit one staff, instead of two, to staff the home overnight.

“What I saw, and one of the reasons I left, was the level of risk the staff is being put under and the constant lack of adequate staffing. … I had become a thorn in their side because I warned them time and time again. It was never a matter of if, but when,” he added.

“There are a lot of people that have been expecting something like this to occur for a long time. This coming to light was like a scab that needed to be ripped off.”

‘I was scared to death’

Former PCL employee Kim Demar, house manager for the group home where Kolada was injured, said violent attacks by residents in the home were common. Demar was in charge of the house the night Kolada was fatally injured.

“(Bobbie) was my employee. … I was at home the night it happened, and we had been communicating via text around 7:30 that evening, about her filling a shift for one of the other employees,” Demar said. “I eventually went to bed and woke up to a phone call at 8:30 the next morning from the individual who found her.”

Demar said she was outraged at the lack of an investigation into Kolada’s injuries, and that PCL told employees that Kolada had likely fainted or fallen. When the company told Kolada’s daughter, Jessica Bandy, that evidence of a previous injury Kolada suffered just weeks before the Feb. 20 incident that led to her death didn’t exist, Demar sent proof that it did.

Fuhrman, PCL’s co-owner, refused to discuss specifics of the attack that led to Kolada’s death, and denied that staffing was a factor.

“We meet all the required staffing patterns that are required through our Office of Developmental Disabilities. We follow those guidelines to make sure people are well supported and our staff are well trained,” Fuhrman told the Rogue Valley Times in an interview.

Demar said she was injured twice by the same resident who attacked Kolada — a bite injury to her right bicep Jan. 11, and a bite to her left forearm Feb. 21, the day after 911 was dispatched to the house for Kolada.

“The day after her accident, I had to cover her shift … from 3 p.m. to 10 p.m. That was the last time he attacked me. I was sitting on the couch and he came out of the bedroom and threw his body on top of me. He had his mouth open and was trying to bite any part of my body he could get a hold of.”

When she was able to get out of the man’s grasp, Demar said, she crawled away and tried to utilize her Oregon Intervention System training.

“He’s so quick and so maliciously intended … he was going to hurt me. He reached out and grabbed my arm and wailed a bite onto it. … I don’t know what was going on in his mind. I just know that he wanted to hurt me. …  After that second time, I would hide from him while he escalated. … I was scared to death.”

Demar quit working at PCL March 27, the day Kolada died.

“I planned to leave because I felt I was not safe and protected by the company with the level of dysfunction of the residents. The final straw for me was that the last day I worked, I received notification from the company that they had completed their investigation — and I say investigation, but they didn’t even come to the house. They did it all by phone. They basically said they could not find any cause (for Kolada’s injuries).”

‘She probably didn’t even put up a fight’

Katherine Colwell, a Merlin resident, worked for PCL between 2017 and 2020. She remembers long shifts and frequent injuries in what seemed like a culture of disregard for employees. A kind co-worker named Bobbie Kolada urged her to be careful.

“Bobbie actually trained me. And I worked in the house she was injured at. I was also hurt on the job, and they made me finish my shift while my face was bleeding because they told me they couldn’t find coverage,” Colwell said.

“I got bit in the face by the same gentleman” who hurt Kolada, she said.

Colwell said she was heartbroken to learn that Kolada had died.

“Bobbie, when she trained me, she told me, ‘If it becomes overwhelming, whatever you do, just don’t show your emotions, because he will attack you and he will hurt you,’” Colwell said.

“I felt like I was prepared for it, but when I would see him pouncing around her — and then he bit her one of the times I was there — I remember feeling like, ‘What the hell have I gotten myself into?’ What sucks the most was knowing Bobbie, and the kind of heart she had. He had been targeting her for a while, and PCL knew it.”

Colwell said PCL should acknowledge what happened to Kolada.

“The company knows damn good and well what happened to Bobbie. And all the employees know damn good and well.

“Bobbie gave her heart to the company. No matter what hell they put her through, she never said anything negative about PCL. She saw everything — the ups and downs — and she ended up giving her life. Literally,” she added, fighting back tears.

“It just breaks my heart because I knew her and who she was … and she probably didn’t even put up a fight. Because she wasn’t allowed to.”

Coming Thursday — Part 5:  ‘I don’t want her to have died in vain’

Part 1: ‘Did somebody do this to her?’

Part 2: Who is investigating Bobbie Kolada’s death?

Part 3: ‘I remember thinking I was going to die’

Part 4: ‘Culture of disregard for employees’

Part 5: ‘I don’t want her to have died in vain’

OSHA reports: Five years of injuries

The Rogue Valley Times filed a public records request with Oregon OSHA for five years’ worth of inspections and complaints pertaining to PCL group homes in the Rogue Valley. The documents outlined a pre-existing concern for employee safety and, according to one report, “a culture” of allowing employee injuries to continue.

A summary of the reports include:

February 2019: A former employee described an unsafe situation where the complainant was bitten several times and said she and others feared being injured. In response to the complaint, PCL said residents of the home communicate via biting, hitting, kicking and pushing. PCL implied that employees had not properly worked to de-escalate the violent resident.

April 2019: An employee reported that a resident at a PCL group home was biting staff members deep enough to draw blood and that employees were not provided personal protective equipment. On several occasions, the resident head-butted staff members. In a response provided to OSHA, PCL stated that staff were encouraged to wear long sleeves to prevent the individual from fixating on protective Kevlar sleeves and that employees were encouraged, since the resident “had been known to bite in other places than just arms,” to utilize situational awareness and follow other procedures put in place.

January 2020: From the final week of December 2019 and through January 2020, 10 violent incidents were reported, according to documents provided to the Rogue Valley Times by Oregon OSHA officials.

April 2022: A letter from PCL attorneys acknowledged five employee injuries in a six-month window, prior to April 2022. In a November incident, the caregiver ended up in the emergency room after an extensive beating by a resident, during which “he grabbed my neck with both hands and head-butted me” and went on to kick, bite and hit the caregiver.

December 2022: A complaint was filed with OSHA stating staff of PCL were “routinely attacked by the clients, with ineffectual corrective actions taken by the company.” The complainant stated that PCL “has a culture of allowing abuse of their direct support staff by individuals being supported,” and “does not effectively change practices to reduce danger.” 

In a stack of reports from the PCL Safety Committee, numerous injuries were detailed over the past five years. Examples included:

• In May 2018, employees reported being struck by a chair and an individual who had their hair grabbed while being pinched
• In May 2019, an employee missed 15 days of work after being kicked in the stomach and ribs by the resident for whom they were providing support
• In June 2021, an employee missed seven days of work after multiple “impacts” across their body from closed fists and from being pushed into various objects
• In November 2021, three injured employees reported situations of “bites to both arms,” “struck on left side of neck and shoulder” and “head-butt to the forehead”
• In January 2022, an employee was kicked and hit in the head with closed fists
• In March 2022, two caregivers were injured by a resident using a piece of wood containing staples. That same month, other caregivers were “choked with a sweatshirt hood,” “kicked in the left side of the face,” and an employee suffered “impact to knee, thigh, shin, chest and face” while a co-worker had impacts and bites to their face, arm and legs.
• In April 2022, an injury was reported to state officials after a caregiver was “poisoned by another person with cleaning chemicals.”