On an imposing bluff overlooking the Mississippi River, the Minneapolis Veterans Home sprawls on a 53-acre campus. Several hundred elderly warriors, many with chronic illnesses or injuries from their military service, spend their final days under supervised care of the state of Minnesota. A slogan of the home is “Serving Those Who Proudly Served.”

That care is under new scrutiny amid signs that problems that plagued the home for decades — incidents that at one point prompted a federal investigation — are persisting.

In the past three years, state records show, the veterans home has been the subject of 11 state health department investigations, including four suspicious deaths.

Families often are unaware that their loved ones’ care is under investigation, and advocates say prohibitive state laws and policies that lack transparency make it difficult to get clear, full answers to problems.

Amid it all, a citizens advisory council formed to keep the home out of regulatory hot water quietly went out of business in June. It is to be replaced by a task force that reports directly to the Veterans Affairs commissioner.

“People just aren’t doing their jobs out there. They got lax,” said Jim Bain, whose brother, Jerry, died of a drug overdose last year at the Minneapolis home. “Things need to change and no one seems to be watching them.”

The Minnesota Department of Veterans Affairs, which administers all five state veterans homes, says it has made continual improvements in how the home operates. In all the suspicious incidents, it has revised policies or instituted retraining where appropriate. It also has embarked on an aggressive building campaign and will be seeking $18.9 million in state money to demolish and rebuild a wing of one building on its campus.

“We strive to provide excellent care, and I advocate that we are fortunate here in the Minnesota Veterans Homes system because we have a highly dedicated and caring medical team — of which I am extremely proud,” said VA Commissioner Larry Shellito.

Gov. Mark Dayton, asked if he has concerns about the vets home, said he had confidence in Shellito’s leadership.

Concerned about what he called “significant and persistent problems at the Minneapolis home,” Jim Nobles, the state’s legislative auditor, has been critical of how the home operates. He has suggested that the state VA should not be in the nursing home business.

“At times, I even questioned whether the state was capable of adequately managing the facility,” Nobles said.

A problematic history

With 300 beds and a waiting list of 700, the Minneapolis Veterans Home is the largest of the five veterans homes operated by the state of Minnesota. It is also by far the most problematic.

The home racked up 99 citations from the Minnesota Department of Health between 2005 and 2008. The U.S. Justice Department was called in to investigate civil rights violations of patients but eventually cleared the home. After three years of intense state scrutiny and more than $800,000 paid to state-ordered consultants at the Minneapolis home, then-Gov. Tim Pawlenty dissolved the State Veterans Board and put the Department of Veterans Affairs back in charge, appointing an independent citizen council to monitor how the homes were run.

Residents like 93-year-old Herb Gager, a Marine Corps veteran and Purple Heart recipient, have nothing but good things to say about their experience. A 10-year resident, Gager lives in a cheery room with an impressive view of the Mississippi River. He has written a book, “Willing Warriors,” profiling some of his fellow residents.

“I came to die but they keep patching me up,” he said.

But four deaths in the past three years at the Minneapolis home have prompted investigations by the state Health Department’s Office of Health Facility Complaints, which handles complaints at the state’s more than 2,000 licensed health care businesses, including the veterans homes.

In April, the home was cited for neglect in the death of Gerald Bain. Bain, a 61-year-old Vietnam-era Air Force veteran, had obtained illicit doses of methadone last year at the home and died of an overdose. An autopsy found that he died of acute methadone toxicity. The state investigation found that staff members failed to monitor Bain’s pain management in a unit where veterans often have addictions.

Bain’s family remains angry at how his case was handled.

“They’ve had so many problems this was just the nail in the coffin,” said Bain’s brother. “My brother wasn’t going to die.”

Bain’s death was the only one investigated in which a complaint was substantiated. Investigators ruled the other three complaints “inconclusive” or “unsubstantiated.”

One complaint involved the 2010 death of an 86-year-old woman with dementia who fell and fractured her hip. An alarm system fell off her collar and failed to alert staff. She died five days later. A Health Department report said VA staff gave investigators conflicting and inconsistent information and there was no witness to the fall.

In another neglect complaint, a resident was heard crying for help and staff found him lying face down in front of his wheelchair. He was taken to the hospital where a large hemorrhage was found in his brain. He was discharged back to the vets home two days later and died in hospice care the following day. The death certificate said he died from bleeding on the brain. A doctor at the home told investigators he believed the resident had a spontaneous brain hemorrhage and then fell from the chair.

For the 10 months he was a resident of the Minneapolis Veterans Home, Dick Cashman’s family thought he was getting the best of care. They thought that right up until the night in October 2011 when a nurse injected him with 10 times the amount of morphine a doctor prescribed. The 86-year-old Cashman, who had survived a German prisoner of war camp, died 10 hours later.

A doctor working at the vets’ home said it was unlikely the overdose led to Cashman’s death. He had prostate cancer and Alzheimer’s disease. But there was no way of knowing for certain. His body was released to a funeral home so quickly that the medical examiner never had a chance to examine the body.

“The little nurse who was taking care of Dick that night tried to be so on the ball,” Dick Cashman’s widow, Virginia, recalled. “I don’t know what happened. Something unfortunate.”

The home was faulted for the medication error and the home’s failure to report Cashman’s death to the medical examiner following a significant medication error.

In the Cashman case, the state veterans affairs department said it “was deeply saddened by the loss of life in 2011” and said it immediately self-reported the incident to the state Health Department and federal VA officials.

After the incident, the home revised its medication policy, including retraining and a new requirement that two nurses check every medication dosage calculation.

In the other cases, the VA office said it took action to identify areas of improvement even though the findings were inconclusive.

“Often what we do and the changes we implement go above and beyond what the Department of Health or the federal Department of Veterans Affairs recommends. We view this as a method to continuously improve our health care delivery system,” the state veterans office said in a statement.

Mistakes harder to find

Even if any of the families wanted to file a complaint or sue, it would have been difficult. Officials and advocates say it is getting harder to do.

Family members frequently have not been informed that a loved one’s death triggered an investigation, a policy that only recently changed. The Department of Health’s public reports of investigations do not include names.

More recently, the department stopped including the date of the incident in its reports. The director of the Office of Health Facility Complaints said it dropped the dates to protect vulnerable subjects and their families.

“We discovered that the public would use the incident date and back into a police report,” the director, Stella French, wrote in an e-mailed response to an inquiry by the Star Tribune.

The latest cases also show how difficult it is to hold a state-run nursing facility legally accountable, said Mark Kosieradzki, a leader in litigation involving nursing homes in the state. Minnesota’s immunity laws mean that government institutions like the Minneapolis vets home can’t be held liable for punitive damages. Compensatory damages are capped by law.

“You’ve got state investigators who are doing lukewarm investigations and you’ve got laws written in a fashion that makes it very difficult to bring a case against them,” he said. “The only way you are going to get a finding of neglect is if they admit it.”

Earlier this year, Pamela Barrows, a former deputy veterans commissioner at the state, took the unusual step of sending Dayton a letter seeking an investigation of the current deputy commissioner in charge of the homes, Michael Gallucci, for creating a hostile work environment.

“I’ve had multiple staff, in multiple locations state to me that they are fearful of this man and what he is doing to the homes,” Barrows wrote.

Shellito defended Gallucci and pointed to advances in telemedicine, the opening and accreditation of the second veteran-focused adult day care in the country, and the implementation of a safety program that has reduced employee injuries as evidence of his successes.

“Since Mr. Gallucci arrived the senior leadership team has stabilized, giving us a chance to refocus our vision and mission statement,” Shellito said in a prepared statement.

Another change in oversight

Oversight of the vets home has proved historically problematic. Gov. Rudy Perpich stripped the homes from the VA in 1987 after years of problems, and the Legislature created the Veterans Homes Board to take over. In 2007, Pawlenty dissolved that board and returned the homes to the state veterans department, but with outside oversight provided by a citizens advisory council.

That council’s term expired in June. Its first formal meeting is scheduled next month.

That change disappoints Duluth resident Brad Bennett, a Vietnam veteran who was awarded two Purple Hearts and served on the council until his term expired in 2011.

“I guess I’d be hard-pressed to say we accomplished much, except to keep the spotlight on what was going on in Minneapolis, keeping the focus on them,” Bennet said.

But the loss of the council’s independent eye, he said, is “like the chickens running the chicken coop.”