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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1070850-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh 651-431-3444 Christine.Cavanaugh@state.mn.us Suspected Maltreatment Reported: It was reported that facility staff persons failed to provide clinical oversight and seek medical attention regarding a vulnerable adult’s (VA’s) diarrhea and weight loss. The VA was hospitalized for a bowel obstruction. It was also reported that facility staff persons did not provide personal cares for the VA including nail trimming and shaving. Date of Incident(s): Ongoing prior to June 2, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 12, 2025; from documentation at the facility and medical records; and through 15 interviews conducted with four supervisory staff persons (P2-P5), five facility staff persons (P8-P12), two lead staff persons (P1 and P6), one administrative person (P7), the VA’s case manager (CM), the VA’s guardian/family member (G), and the VA’s doctor (D). The VA was unable to provide information for this report due to his/her diagnoses. The VA’s file stated the VA enjoyed spending quality time with the G. The VA also enjoyed going on community outings, running errands with staff persons, going to the park, bowling, visiting local zoos, and taking walks around the neighborhood. The VA loved music and his/her CD/DVD collection. The VA did “best” in an environment where s/he was familiar with the staff persons and did “not do well with a lot of change” or unfamiliar people. The VA was diagnosed with profound intellectual disability, epilepsy, and diabetes. Information obtained showed that the VA began receiving residential services from the license holder in September 2023. On February 20, 2025, the VA move into the facility which was operated by the same license holder. Facility documentation showed that P1, P2, P5, P6, P8, and P9 each received training on the VA’s plans. P7’s position was not required to be trained on the VA’s plans. The facility did not have documentation that P3, P10, P11, and P12 were trained on the VA’s plans which was a violation of Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2) which states in part that the license holder must maintain a personnel record of each employee to document and verify staff qualifications, orientation and training as required under section 245D.09, subdivisions 3 to 5 including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. P4 was not providing direct care while the VA lived at the facility. P1-P12 were trained on the facility’s policies and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incidents. According to facility job descriptions: · The operational manager (OM) was responsible for the management and operation of services, staff, and the physical plant. The OM was to monitor the overall quality of the program and services, initiate and maintain regular contact with persons serviced, family, and persons served identified supports and team. The OM was responsible to the director. · The operational program director/supervisor (OPD) was responsible for coordination and management of the overall program/facility and ensured supervision, orientation, and ongoing training of staff persons. The OPD ensured all aspects of the program were developed, implemented, coordinated, and monitored to the highest degree possible. The OPD was responsible for the overall quality of the program. The OPD was responsible to the director. · P1 and P6 were responsible to the supervisor and their responsibilities included: o Coordinating a variety of services including but not limited to individual healthcare/nutrition; o Assisting the supervisor in maintaining consistency in individual care and communication with staff persons and support team members; o Carrying out the responsibilities and duties of direct support staff persons during all direct care shifts. o Act as lead trainer for staff persons. o Notify the supervisor of concerns regarding staff proficiency surrounding medical cares and/or treatments. o Oversee the daily medical responsibilities of the home for the individuals and to ensure the individual’s nutritional needs were met. o Create and modified menus based on individual dietary needs and preferences, purchased and had available nutritious snacks for between meals; and o Provide training to staff persons regarding special health/nutritional needs. · Direct support staff persons (DSPs) were responsible to work cooperatively with other staff persons and the supervisor, whom they were responsible to. DSPs were also responsible to: o Provide direct services to individuals including assisting in maintaining a clean, safe living environment, meal preparation, and assist the individuals in every aspect of their lives. o Keep individuals “clean and neat” in appearance meeting hygiene needs and assisting individuals in dressing appropriately. o Be familiar with medical conditions of individuals, read all medical documentation and follow-up as indicated, document health concerns in T-Logs, and inform the supervisor of health care needs. o Weigh individuals as per health care plan or the coordinator’s/supervisor’s request. o Meet the individuals’ nutritional needs. Regarding staff persons clinical oversight and medical attention regarding the VA’s chronic diarrhea, weight loss, and hospitalization for a bowel obstruction: The VA’s file stated that the VA refused to eat anything s/he was not familiar with, was “very picky,” and ate food “based upon liking them.” The VA often needed time to decide that s/he was going to eat and preferred that his/her plate be left on the counter for him/her to take when s/he was ready. Staff were to provide the VA with “healthy carbohydrates, fiber rich foods, and fats” to help him/her maintain a healthy blood glucose level. If the VA brought his/her plate of food back to the counter, staff persons were to leave the plate there for the VA to return to later. Staff persons were to provide the VA with “balanced meals” and “limit sugary snacks.” The VA was unable to self-administer medications and preferred the medications were administered with soft foods such as applesauce. If the VA denied any medications or treatments staff persons were to reach out to the VA’s provider for further direction. The VA’s medications included polyethylene glycol 3350 (laxative powder) daily for constipation. The G provided the following information: · The VA lived with the G prior to moving into a residential setting with the license holder. However, the G still frequently saw the VA except for in the winter months when s/he was out of state (approximately five months). In the VA’s first residential setting, everything was “working wonderful” and going great” and “very seldom” there were “issues.” On February 14, 2025, a photograph was taken of the VA and s/he “looked so healthy and happy.” · On February 20, 2025, the VA moved homes/facilities, which was also during the time the G was out of state and not planning to return until the end of May 2025. During that timeframe, the G called the facility to talk to the VA and heard of no concerns regarding the VA’s physical health. · The VA was a “very picky eater” and needed his/her food cut up. The VA did not eat well if s/he did not like the food, but there was a large variety of foods s/he would eat. · On April 25, 2025, a family member brought the VA out to lunch and later told the G that the VA looked like s/he “lost a little weight,” “seemed really out of it,” and “really tired.” Additionally, the VA did not eat as much food as s/he normally did. At that time, the G had still not heard of any concerns from the facility regarding the VA’s health. · On May 30, 2025, the G heard from the VA’s behavioral specialist/positive support analyst (PSA), who did not work for the facility and had visited the home that day, that the VA was having urinary incontinence, which the VA had not had in “years.” The G then texted and called P1 and P1 told the G that the VA was rather having bowel incontinence three to four times a day. The G thought maybe the VA was constipated causing the “runny stools;” however, the VA was prescribed MiraLAX (laxative powder) daily. (Note: MiraLAX is a brand name of polyethylene glycol 3350 which will be referred to as laxative powder for the remainder of the report.) · The VA took his/her medications with applesauce, but P1 told the G that the VA was getting the laxative powder with water which was how it was directed on the bottle. The G was concerned that the VA was not taking the laxative powder but P1 told the G that the VA still took it “most of the time.” The G said that the previous home administered the laxative powder with applesauce even though the orders said to give with a “glass of water” because the staff persons said the VA would not take it with water and that the staff persons told this to facility staff persons. The G was concerned the VA was refusing and that the staff persons did not “argue” with the VA because they could not “force” the VA to take it. · Starting on May 31, 2025, the VA was in the G’s care and from that time until at least June 9, 2025, the VA had not been wanting to eat and was “pooping like crazy.” · On May 31, 2025, in the evening, the G picked up the VA from the facility for a visit and saw that the VA looked “awful,” “emaciated,” and “so skinny.” The G spoke to an unknown staff person who told the G that the VA had diarrhea for “a couple [of] months” which needed frequent sheet/bedding changes. When they arrived at the G’s home, the G assisted the VA with a shower and weighed the VA who weighed 126 pounds. In December 2024, the VA had weighed 138 pounds. At that time, the G was concerned the VA was not getting his/her laxative powder because the bottle s/he received that had 30 doses was “almost full” and was dispensed on April 21, 2025, with a refill available May 15. The G was also concerned because the VA as not hungry/eating which the G thought was from being full of stool. · On June 2, 2025, the G brought the VA to the D for the G’s concerns with the VA’s weight loss and constipation. At that appointment, the D told the G that the VA had “malnutrition;” low calcium, which the VA had no history of; and low hemoglobin. The D was also concerned the VA might have a bowl “blockage,” and ordered a computed tomography (CT) (to be completed at a later date when the VA could be sedated). · When the VA first moved into the facility, P1 told the G that the VA drank “too much” milk. However, the G said the VA “can drink a gallon of milk a day.” The G was also concerned that the VA was not drinking milk like s/he usually did. · On June 11, 2025, during the night, the G called 9-1-1 because the VA was having a hard time breathing. The VA was taken to the hospital and on June 12, 2025, received a CT scan that showed the VA was “impacted with poop” and had a “huge ball of poop” in his/her rectum that “was stretching [the] membrane.” On June 12, 2025, the VA had a procedure to “clean [the VA] out.” The VA spent the night for observation and was given antibiotics. The G stated that it was “all due to [the VA] not having the laxative powder which the home didn’t give [him/her].” The D and the VA’s medical records provided the following information: · The D stated s/he last saw the VA in September 2024, and according to the VA’s chart, the VA weighed “134 pounds.” On June 2, 2025, the VA was seen at a clinic and weighed 126 pounds with a body mass index of 20.34 kg, which was “within normal range” (between 18.5 and 24.9) for the VA’s age. The D stated the VA lost “at least 10 pounds” since September 2024 and looked “less healthy” than s/he had previously. · The G told the D that in February 2025, the VA weighed 146 pounds so s/he thought that the VA lost “20 pounds” and felt the VA was not “getting good care” and looked “thin” and “pale.” The G also stated that the VA had diarrhea for three months and the G was not notified of it. · At the appointment, the VA had lab work done which showed abnormalities with albumin, protein levels, liver function, and calcium. The VA’s A1C went up, which was always “well-controlled,” so the D wondered if the VA was not getting his/her unidentified medications, because typically A1C would be lower if losing weight. The G told the D that s/he thought maybe the VA has having “underlying constipation” with “overflow diarrhea.” The D stated that a “plug of stool” can stay inside the bowels and then the intestine “tries to make things move” so it causes “looser stool to go around the plug,” hence the diarrhea. The D ordered a CT scan to be completed under sedation and that if the VA had ongoing diarrhea, the G should notify the D, and the D would order stool testing. · On June 12, 2025, at 1:56 a.m., the VA arrived at the emergency department via emergency medical services (EMS) from home for bloating, diarrhea, and fatigue. The VA had abdominal distention and a change in bowel habits. The VA was having diarrhea, “thought to be from poor nutrition according to EMS, but with diet changes recently, the patient has not been having bowel movements.” · The VA had a CT which showed was “significant stool” in his/her colon and rectum as well as “rectal stool ball and associated inflammatory changes.” At that time, medical staff could not “exclude stercoral colitis,” an inflammatory condition in which feces collect and cause pressure to build up within the colon and lead to further complications. The VA was admitted for “bowel cleanout.” · The VA “did not tolerate manual disimpaction without sedation” so on June 12, 2025, the VA “underwent disimpaction in the OR [operating room].” The rectal disimpaction was “successful.” · On June 14, 2025, the VA was “stable” and discharged from the hospital. The VA was to follow up with his/her primary care provider. P1-P12, the VA’s Medication Administration Records (MARS) from February through May 2025, and the facility’s Investigation Report and Summary (IRS) provided the following information: · The VA took laxative powder because s/he had a history of bowel issues. At the previous home, the VA was administered the laxative powder with applesauce, but at the facility, it was administered with water as stated on the prescription. (Note: The prescription bottle stated to mix “in 4-8 ounces of liquid.”) The VA took the laxative daily and there were no instructions to withhold it. The pharmacy confirmed the laxative powder was ordered and delivered to the facility on March 22, April 23, and May 19, 2025. · The VA’s MARs dated February to May 2025, were reviewed, and the laxative powder was documented as administered daily, with two exceptions: May 14 and 20, 2025. · Staff persons were to document the VA’s bowel movements (BMs) on the MAR three times a day (8 a.m., 4 p.m., and 8 p.m.) and in the health tracking intake/elimination module in “Therap.” Staff persons consistently documented the VA’s BMs in the module. In April 2025, documentation identified that the VA had one BM a day, with “normal diversity” of “stool types.” In May 2025, the VA experienced four BM’s a day, with the “vast majority” of the movements “consisting of soft, loose, or diarrheal stools.” · T-Logs dated May 1 to 31, 2025, were reviewed. May 2-16; 19-20; and 23, 2025, documented frequent BMs, loose stools, or diarrhea. Additionally, the VA refused meals on May 1-3; 5 -9; 12-13, 16, 21, and 30, 2025. · P5 and P6 worked at the previous home the VA lived and when staff persons offered the VA a meal, if the VA refused, staff persons set the food on the counter and the VA often returned later and brought the meal to his/her room to eat. P5 said new meals were often introduced, but if the VA refused to eat them, staff reverted to the VA’s “favorite meals.” Sometimes after the VA returned from visiting the G, the VA had a temporary reduction (a day or two) of food intake. At the previous home, there was no concern regarding the VA’s bowel movements or any incontinence; however, P6 said “most of the time” the VA used the restroom by him/herself and from P5’s “understanding,” the VA’s bowel movements were “consistent and normal,” and the VA took the laxative powder regularly. P5 stated that when the G returned to Minnesota, sometime in May 2025, s/he told P5 that the VA was “in really bad condition,” had experienced weight loss, and believed the VA’s laxative powder was being administered incorrectly. P5 thought the VA’s weight was documented at the previous home, but staff persons at the facility stated the VA’s weight was not required to be checked. · There was no documentation or orders stating that the facility was to weigh the VA. · At the facility, the VA sometimes refused meals that were on the menu, so staff persons made alternative options. The VA liked Lunchables, noodles, corn, green beans, pizza, fries, chicken nuggets, mac and cheese, meat, biscuits, crackers, bread, and mashed potatoes. Sometimes the VA initially declined to eat but then later would do so. The VA might decline breakfast but then eat lunch and dinner. P5 said that when the VA lived at the previous home, there were times that the VA ate “less” but the VA never went without eating for an entire day. P1 said the VA’s food intake depended on how big the meal was. Staff persons documented if the VA did not eat. Additionally, the VA drank a lot of milk each day—several glasses or multiple gallons. P1 said the VA could drink three to four gallons of milk a day and then might skip a meal because of it. When the VA moved into the facility and P1 saw how much milk the VA drank, s/he was concerned and texted the G. The G said it was “not a problem” and that the VA was a “huge milk drinker.” Milk was always available if the VA wanted it. · P1 stated that when the G returned to Minnesota, the VA stayed with the G for an unidentified time and while the VA was gone from the facility, P1 reached out to the G to see how the VA was doing. (Note: The IRS did not provide a date or by what means P1 contacted the G. However, based on information obtained, it was likely sometime towards the end of May 2025). At that time, the G said that staff persons were “starving” the VA and that the VA lost “25 pounds” and was “pooping like crazy.” P1 denied the VA was “being starved” and that while the VA often refused meals that were cooked, the VA “was an avid eater of cereal, as well as bread.” P1 estimated the VA ate two meals a day, often “skipping lunch” and drank “up to 3 gallons of milk a day.” P1 stated the VA would have “zero BMs on one day, and several on another” but did not have diarrhea or “watery stool” from what P1 saw when s/he worked with the VA. Staff persons did not weigh the VA. · P3 did not work direct care shifts at the facility and was not aware of any of the G’s concerns. P3 stated that there were “no observations” from staff persons indicating the VA was “feeling unwell;” however P3 heard that the VA had “loose” stools, but that they were not “runny.” · P4 was not aware of any changes with the VA’s BMs. · P7 stated that on June 1, 2025, s/he and another administrative person received an email from P1 regarding the G’s concerns. Prior to that, P7 did not know of any concerns with the VA’s weight or bowels. P1 denied to P7 that the VA was experiencing “long-term” diarrhea and said the VA was not being weighed, so P1 could not corroborate or refute the G’s concern of weight loss. Staff persons were to report to their supervisor of any changes in a residents’ health condition and/or abnormal bowel movements. P7 thought staff “did what they needed to do” by documenting, but the information should have also been reported to a supervisor. From P7’s perspective, s/he thought that staff “normalized” it. · P8 only worked evenings and did not administer the VA’s laxative powder. P8 said that the VA drank a “significant amount of milk” and sometimes refused food; however, staff persons left the food on the counter if that occurred. P8 stated that “earlier on,” the VA was “always constipated” and had a bowel movement “every one or two days,” which were “very large.” However, at some point, the VA’s bowel movements became “looser,” and sometime around May 2025, staff persons were changing the VA’s undergarments because of fecal incontinence. According to P8’s interview in the IRS, P8 told P1 about the loose BMs as well as concerns that the VA was losing weight. (Note: There was no date or time reference provided in the IRS of when that was communicated to P1.) · P9, who worked day shifts at the facility, said that the VA was a “picky eater” and “sometimes [s/he] ate, sometimes [s/he] didn’t.” P1 talked to the G and staff from the previous home to obtain information regarding the VA’s food preferences. P9 said that at some point prior to June 2025, the VA had a “bad bout of diarrhea” and “stomach trouble.” When P9 worked with the VA, s/he did not “often” see the VA “poop at all” so s/he did not observe any changes in the VA’s BM “habits,” or anything that “would have indicated weight loss.” However, overnight staff persons complained how often the VA needed to change his/her pants and undergarments and told P9 that the VA went to the bathroom “10 times” and was “pooping all over” going through his/her pants. · P10 said that s/he did not observe the VA refusing meals during his/her shifts and that staff persons offered meals to the VA based on what was being cooked. If the VA refused to eat then staff persons provided alternative options and left it on the counter for the VA. If the VA did not initially eat the food, s/he returned later for it and “regularly” ate food in his/her bedroom. The VA “often” refused breakfast, but “usually” ate by 11 a.m. P10 denied that the VA experienced diarrhea and stated, “They were just small stools,” and “not watery.” According to information in the IRS, P10 “did not endorse” an increase in bowel movements or frequency of needing to change the VA’s clothing. However, in P10’s respective interview, s/he said that at some point s/he was changing the VA’s bedding four times a day because of bowel incontinence, but that it was not diarrhea. P10 thought it was due to the laxative powder the VA took. · P11 said the VA was a “picky eater” who often refused to eat what was on the menu; however, there were food items available that the VA enjoyed eating and the VA pointed to communicate and direct staff persons on what s/he wanted to eat. P1 had reached out to P6 to obtain a list of the VA’s food preferences. P11 said that at some point after the VA moved into the facility, but not in February 2025, the VA went to the bathroom “all the time” and staff had to clean the VA. P11 was concerned about that and told P1, who said s/he thought it was due to the VA’s milk intake or the VA’s laxative powder. P11 was not concerned with the VA’s health and never saw the VA “sick.” · P12 said s/he changed the VA’s undergarments multiple times due to fecal incontinence; however, it was not diarrhea, “just poop.” · On May 30, 2025, a positive supports analyst (PSA) visited the facility and noted there was nothing that “warranted neglect” in his/her opinion. However, staff persons talked about the VA’s “bed wetting” and “identified a strategy” of changing the VA’s sheets when s/he was in the shower. The PSA then reached out to P6 to schedule a training on how to “effectively provide cares” for the VA. The VA’s BMs were tracked on the VA’s MARS and on a separate BM tracking log. The tracking log showed that staff persons started documenting the VA’s BMs on February 20, 2025, and there was no mention of “loose” stool until April 7, 2025. April 7 through May 31, 2025, showed the following information that was documented by staff persons: · For April 2025, loose stools were documented between April 7 and 22, 2025. During that time, the VA had a total of seven loose stools on five different days, with instances occurring on average between one to two times each of the five days. · Between May 4 and 6, 2025, the VA had approximately nine occurrences of diarrhea, averaging two to four instances each day. Between May 2 through May 31, 2025, the VA had loose stools on 14 days averaging between one to seven occurrences each of the 14 days and totaling approximately 42 instances. T-Logs dated February 20 to May 31, 2025, provided the following information: · (Note: There were several entries where the VA initially declined a meal, but later on ate it or had an alternative option. Additionally, documentation showed the VA drank a lot of milk.) · Between February 22 and 27, 2025, the VA did not eat dinner two times despite alternative options given. · Between March 1 and 28, 2025, the VA did not eat approximately 11 meals. · Between April 1 and 30, 2025, on separate dates, the VA did not eat approximately eight meals and on April 21, 2025, the VA only ate crackers and milk after refusing both what was made and an alternative option. Not included in the eight meals not eaten, on April 1 and 20, 2025, the VA did not eat any meals. During approximately 16 overnight shifts, the VA used the bathroom several times and changed his/her undergarments. The information varied as to the VA having a BM, loose stools, or no BM—four instances were documented with “loose” stools. Additional staff entries stated that several times per day the VA’s pants and undergarments were changed, some relating to urinary incontinence. · Between May 1 and 31, 2025, the VA did not eat approximately 17 meals—on average one to two meals were declined on each date. However, on two different dates the VA did not eat all three meals and ate either chips or snacks instead. The VA had several BMs per day averaging between three and seven occurrences and mostly during the overnight shifts when the VA was in and out of the bathroom several times. There were 16 different overnight shifts where staff documented that occurring and three dates that “loose” stools were documented. The VA needed his/her undergarments changed almost daily as well as his/her bed sheets. There were three occurrences where staff documented that the VA had feces “all over” his/her body. The CM said s/he heard about the concerns from the G and that s/he only saw the VA twice a year and last saw him/her February 25, 2025. Regarding the VA’s personal cares including nail trimming and shaving: The VA’s file stated the VA needed help with daily hygiene and dressing. Staff were to assist the VA with all daily living skills as necessary. (Note: There was no specific information on trimming nails or shaving.) The G and photos provided by the G provided the following information: · The VA needed help from staff persons for all of his/her cares including nail care and shaving. The G stated that from the day the VA moved into the facility, staff persons “didn’t do anything in that home” for the VA. The VA would not let a podiatrist cut his/her toenails and needed someone who was familiar with him/her to do so. Staff persons at the previous home were able to provide nail care and shave the VA, but after the move, the VA refused those cares. The G stated s/he did not think the staff persons “worked very hard at it.” · A photo taken of the VA the end of December 2024, showed the VA clean-shaven and s/he did not appear to have untrimmed fingernails. A photo taken on April 25, 2025, when the VA went out to lunch with a family member, showed the VA’s fingernails were not trimmed and the VA’s facial hair was longer than it had been in the December 2024 picture. Photos taken on May 31, 2025, showed the VA’s facial hair was more grown out and the VA’s finger/toenails were long and untrimmed. · The G talked to P1 about his/her concerns and P1 told the G that staff persons could not “force” the VA to get his/her. The G agreed with that but said there were “other ways” to ensure the cares were done. P1 told the G, “We are trying our best.” · On May 31, 2025, when the G picked up the VA at the facility, the VA was not shaved, and his/her nails were “really long.” The G stated the nails did not “look healthy” and there was a “lot of redness” on the cuticles that the G had not seen prior. P1-P12 and the IRS provided the following information: · While the VA lived at the previous home, staff persons usually cut the VA’s fingernails after the VA’s shower so that they were “soft” and “easy to cut.” Staff persons cut the VA’s toenails as well but they were sometimes “hard” and so the G sometimes cut them. If the VA refused nail cares or staff persons were unsuccessful with it, P6 “stepped in” and did them. The same applied for shaving the VA’s facial hair. · P5 stated that the VA was “clean-shaven” while at the previous home. Occasionally, the VA refused to have his/her nails trimmed, but “never completely.” The G normally completed the VA’s cares on weekends when the VA was with the G and the staff persons did them when the G was on vacation. · Staff persons at the facility attempted/offered to cut the VA’s fingernails and shave him/her on several occasions, but the VA always declined/refused. Because of the VA’s diabetes, a podiatrist was needed to cut the VA’s toenails. · P1 stated the VA “consistently” refused cares while living at the facility and would often run away from staff persons when they attempted to provide the cares. Due to the VA’s diabetes, P1 wanted to “be careful” with his/her nails and at one point reached out to P6 to “seek guidance” on how to successfully complete nail trims. P6 told P1 that it “took some time” for the VA to “get comfortable” in his/her previous home that s/he had lived for three years and that s/he trimmed the VA’s nails after the VA showered. P1 called and tried to find a podiatrist for both fingernails and toenails, but the podiatrists s/he contacted only cut toenails. Additionally, the provider would not accept insurance, only cash or check, and the G, who was responsible for payment, refused, stating the previous home was able to complete the nail trims. In May 2025, P1 was working with P7 on identifying a podiatrist that would trim the VA’s toenails. · P7 stated that according to P1, the facility contacted a podiatrist for the VA; however that specific podiatrist did not accept the VA’s insurance and so it was recommended that P4 find another podiatrist who did. However, by that time, a decision was already made for the VA to move from the facility. · P2 said that upon the VA transitioning homes and moving into the facility, s/he and the facility staff persons coordinated with the G to “get some training on how best to work alongside [the VA] to minimize [maladaptive] behaviors.” P2 stated that nail clipping was only documented in the MAR if it was doctor ordered. · P3 heard conflicting information about who was responsible for the cutting the VA’s nails and P3 thought that the G usually did it. · P8 said the VA refused cares and that s/he tried “several techniques” to “encourage” the VA but the VA continued to refuse. · P9 said the VA “always refused” nail trimming and grooming cares since living at the facility and “signaled” that s/he wanted to have facial hair similar to P9’s. · P10 said that “despite frequent prompting” the VA refused to allow any staff person to trim his/her nails or shave him/her and that any time staff persons attempted, the VA “would slap” staff persons and “run away.” · P11 said the VA had a history of refusing nail trimming and shaving cares. · The PSA provided information in the IRS that when s/he visited the facility on May 30, 2025, the VA’s nails were “long” but did not appear to be “medically unwell.” The PSA also noted the VA’s facial hair but was told by staff persons that the VA “seemed fond of one or two staff members’” facial hair. The PSA requested that the staff persons attempt to complete nail trimming and shaving cares over the weekend. · The IRS and T-Logs from May 1-31, 2025, provided the following information: o On May 1, 2025, the VA refused nail trimming from two staff persons including P1. P1 then reached out to a podiatrist about providing home services and was informed that they did not accept insurance. P1 contacted the G about possible payment, but the G refused and stated the previous home was able to complete the cares. o There were several entries stating that the VA refused cares by multiple staff persons. Additional T-Logs showed that on March 31, 2025 (approximately one month after the VA moved into the facility), staff persons offered to shave the VA and trim the VA’s fingernails. The VA “declined” and “shoved” staff out of his/her room and “shut the door.” “Staff will continue making those offers until [the VA] can get a shave and fingernails trimmed.” During April 2025, the VA was offered shaving and nail trimming cares by staff on approximately five different dates, but the VA refused. On May 1, 2025, P1 documented that the VA’s nails were “long” and due to the VA’s diabetes, s/he needed a podiatrist to cut his/her toenails. A podiatrist was contacted, but the provider did not take insurance. Staff reached out to the G for self-payment options/approval, but s/he said s/he cannot pay for the service and that the previous home staff persons were able to get the VA’s nails cut, and did not “understand” why the new staff persons could not get it done. P1 told the G that due to the VA’s diabetes, they had to be “careful with [the VA’s] skin,” thus requiring a professional. On May 2, 2025, P1 tried to trim the VA’s fingernails several times, but each time the VA refused. The VA also refused shaving. The VA was offered nail trimming cares on two more occasions in May 2025, but they were “unsuccessful.” The CM said that the G told him/her about the G’s concerns and also stated that after the VA moved into the facility, it would take some time for the new staff persons to build rapport with the VA. When the CM saw the VA on February 25, 2025, s/he had no concerns at that time regarding the VA’s appearance. Conclusion: Regarding staff persons clinical oversight and medical attention regarding the VA’s chronic diarrhea, weight loss and hospitalization for a bowel obstruction: On May 31, 2025, the G picked up the VA from the facility for a visit and thought the VA looked “awful,” “emaciated,” and “so skinny.” The G spoke to an unknown staff person who told the G that the VA had diarrhea for “a couple [of] months” which needed frequent sheet/bedding changes. The VA was prescribed daily polyethylene glycol 3350 (a powdered laxative) and although the G was concerned that it was not administered to the VA as prescribed, the VA’s MAR dated February 20, to May 31, 2025, showed it was administered daily with the exception of two days. Although the G was concerned that the VA was not eating, the VA was a “picky” eater and information obtained showed that there were several meal/food options s/he enjoyed, and when the VA did not like something, staff persons made/offered the VA a different food. In addition, while there were several days when the VA did not eat a meal(s), but then a majority of the time the VA ate and/or drank several glasses of milk up to three gallons of milk a day. Although the G was concerned that the VA lost weight and was “emaciated,” and “so skinny,” and that the VA’s medical records showed that from September 2024 to June 2, 2025, the VA lost 12 pounds, the medical records also showed that the VA’s weight of 126 pounds had a body mass index of 20.34 kg, which was “within normal range” (between 18.5 and 24.9) for the VA’s age. Information obtained showed that starting in early April 2025, the VA had an increase in bowel movements including several bouts of “loose” stools that continued through the end of May 2025. Between May 4 and 6, 2025, staff persons documented that the VA had diarrhea. Additionally, the VA frequently changed his/her pants due to incontinence as well as needing frequent bedding changes. On June 2, 2025, the G brought the VA to the D and while the D was concerned the VA might have a bowl “blockage,” and ordered a CT scan, a CT scan was not completed until June 12, 2025, at the hospital, after the G called 9-1-1 the day before, because the VA was having a hard time breathing. The CT scan showed the VA was “impacted” with stool, and the VA underwent a successful disimpaction and was discharged. Given that over approximately three months the VA’s laxative was administered as prescribed for all but two days, that the VA ate and/or drank several glasses of milk a majority of the time, that the VA’s body mass index for his/her weight was “within normal range,” and that the VA’s disimpaction was successful, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Regarding the VA’s personal cares including nail trimming and shaving: Although the VA’s facial hair had not been trimmed and his/her fingernails and toenails were long, information from all sources was consistent that the VA frequently refused cares such as nail trimming and shaving and that it took time for the VA to develop a rapport with staff persons to allow them to provide him/her the cares. Staff persons made multiple attempts to cut the VA’s nails and trim the VA’s facial hair, but they were unsuccessful in doing so, and attempts were also made to set up podiatry/nail care. Additionally, there was no information that the VA’s nails needed the care of a physician or that the VA needed medical care for any infection or injury. Therefore, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with reasonable and necessary care. It was not determined whether neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). Action Taken by Facility: The facility completed an Internal Review and stated that their policies and procedures were adequate but not followed because the supervisory staff persons did not ensure training on the VA’s plans was completed with all staff persons which was a responsibility identified in their job descriptions. Additionally, staff persons did not notify the supervisor that the VA was experiencing an increase in bowel movements which was a responsibility in their job description to report a change regarding individuals health care needs. All staff persons received retraining and counseling reports. Action Taken by Department of Human Services, Office of Inspector General: On November 4, 2025, the facility was issued a Correction Order for the violation outlined in this report.
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