James stated that residents of Van Duyn lived in unsafe conditions before, during and after the COVID-19 pandemic and that insufficient staffing led to severe neglect of vulnerable residents, who often had no help with basic daily tasks.

The attorney general cited some examples of the unsafe conditions, including:

-A resident died after Van Duyn failed to properly communicate her care plan to staff, resulting in staff failing to assist her to the bathroom. The woman fell in her room and her nightgown caught on a door handle, strangling her to death. The staff was unaware of this until they found her body.

-A resident was found dead in rigor mortis after Van Duyn failed to appropriately provide care and medication, failed to appropriately assess the resident’s skin upon admission and throughout the resident’s stay, and failed to properly assess the resident after a fall.

-Other residents were sent to the hospital with bacterial infections, bed sores, and improperly monitored and treated glucose levels.