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Iowa family sues nonprofit care center after nonverbal teen dies

December 27, 2019


An Iowa family is suing a Nebraska-based nonprofit after a nonverbal 14-year-old died in the organization's care and an autopsy found possible, but unconfirmed, signs of sexual abuse.

The lawsuit raises issues with the staffing, communication and training at Mosaic — a residential medical care company with a location in Forest City — and the lack of action by health care professionals leading up to the 2018 death of Samantha Wellik.

Wellik, diagnosed with multiple conditions including asthma and cerebral palsy, was pronounced dead Jan. 23, 2018, after several Mosaic staffers raised concerns about changes in her health, according to the lawsuit and a report from the Iowa Department of Human Services.

That DHS child abuse report shows that at least three layman-type employees told supervisors that Wellik needed medical attention late on Jan. 22. An on-call nurse practitioner told workers to give the girl Tylenol and water and that she’d check on the teen in the morning.

A Mosaic employee sat in the girl's room that evening, doing homework and talking on her cellphone, the lawsuit states. That worker was not trained to do CPR once she noticed breathing problems.

Investigators, after interviewing those working while Wellik died, determined the girl was denied critical care that night, according to the DHS report. Ben Novotny, an attorney with Trial Lawyers for Justice who is representing the Wellik family, said Wellk’s death was one of the worst neglect and abuse cases he’d seen.

“(Her death) was heart-wrenching, especially when you think that things are fine and then to find out they weren’t fine for quite some time," Josh Wellik, Samantha's father, told the Register. "It’s really hard when you have a child that cannot communicate, so she can't tell me, 'Dad, I'm hurting,' or, 'I don't feel good.'

"To me, there should have been some way of the staff knowing that she wasn't well for several months so something could've happened to prevent the outcome."

Wellik died from "complications of ruptured bowel in the setting of Fournier gangrene,'' according to the medical examiner’s report. The manner of death was undetermined.

The lawsuit seeks punitive damages from Mosaic. A spokesman for the organization said Mosaic, which says it supports 4,500 people in 11 states, was reviewing the suit, but could not yet comment.

Carol Mau, Mosaic's vice president of Iowa operations, said in a statement provided Thursday that the company welcomes the DHS investigations and conducts its own as well. She could not comment on the lawsuit or allegations, according to the statement.

"We want to know if our policies, procedures and training have a gap, or if human error or oversight was involved," the statement reads. "Our work is about creating relationships with people, and our staff members often feel the grief of loss in any death. We grieve with the family and offer our sympathy for their loss."

Josh Wellik said it "blew him away" to learn his daughter had died. Samantha had lived at Mosaic for more than five years, and he was not aware of any pressing medical concerns.

He said the grief of losing his daughter was compounded by the medical examiner's finding that the girl had injuries consistent with sexual abuse. The examiner noted the damage could have been done by "forceful" enemas, though fluid that appeared to be semen was also found in the girl, Wellik was told.

"I was continuously following up once I heard (they were doing a) rape kit," he said. "So ... then they said there was a trace of semen but there was no DNA found, so they couldn't come to a conclusion that that’s what it was.”

The state medical examiner's office did not respond to questions about the possibility of sexual assault.

What happened the night she died?

Numerous Mosiac employees were in contact about Samantha Wellik’s condition late on the night of Jan. 22 and into the early morning hours of Jan. 23, according to a DHS Child Abuse Assessment Summary. Wellik lived with another nonverbal resident at 105 Kelly’s Court, an intermediate care facility in Forest City.

The DHS report details escalating concerns raised by several employees over seven hours, beginning at about 10:30 p.m. on Jan. 22. Those employees said they initially observed and reported that Wellik had severe diarrhea, was breathing differently and appeared to be in pain or uncomfortable.

One employee later noticed strange noises from Wellik’s abdomen as the girl moaned and screamed and had bowel movements for 45 minutes straight. By 3 a.m., the girl was “panting” and restless. Another employee reported that the girl’s stomach was hard and her toes were blue.

But despite being contacted by caregivers and supervisors throughout the night, the on-call licensed practical nurse (LPN) did not attend personally to Wellik. Instead, over numerous calls, the nurse instructed employees to give the girl Tylenol, to give her water and tuck her in, and to apply calming cream to soothe Wellik’s pain and bleeding from her repeated bowel movements. The nurse said Wellik was probably getting sick and that she would check on her the following day.

Wellik’s monitor in those early morning hours noticed when the girl’s breathing slowed, but she thought the girl was at last settling down and going to sleep. The employee watched as Wellik gasped, then exhaled.

“She was watching her breath and then there was no breath out,” according to the DHS report.

The girl stopped breathing around 6 a.m., and the panicked employee called a coworker and then the on-call nurse, who told her to call 911, DHS said in its report. Shortly after, the nurse and other supervisors ran to Wellik’s room but were unable to revive her.

The nurse told investigators that Wellik had a history of issues with bowel movements and did not have a fever, so she did not think the teen needed immediate medical attention, according to the DHS summary.

She also said her instructions throughout the night were standard for someone who didn’t have a fever and was “fussy,” “irritable” and “stuffy.” A program manager told authorities that when she saw Wellik, the girl was whining but had no fever, vomiting or labored breathing.


In its report, DHS found Mosaic at fault in Wellik’s death by not providing critical care. It identified staffing shortages and a lack of training as contributing factors.

But DHS also said the medical staff that treated Wellik in the months before she died —as well as workers changing and bathing her — should have noticed a prolapsed anus and trauma to the vagina, as well as intense “diaper rash.”

Novotny says that experts he’s consulted say that the infections that killed Wellik were a product of fissures near her bottom. The tearing allowed stool to get into her body cavity, which caused a deadly case of Fournier’s gangrene. The infections were present for as long as two months, the attorney was told.

“My main feelings were, I guess, grief and sadness, because I really didn’t know what happened,” Josh Wellik said. “That was probably the toughest part of it; the month of waiting to finally find out it was something that, I feel, could have been prevented.”


On the night of Jan. 22, 2018, and into the morning hours, snow moved across northern Iowa. One Mosaic supervisor told DHS that the facility was understaffed that night, and the weather further threw off workers’ schedules.

Issues of understaffing were rampant at Mosaic. The organization was forced to close two of its Forest City homes later in 2018 because it wasn’t able to staff them properly, according to a Mason City Globe Gazette story.

Mosaic did not respond to questions from the Register about staffing levels.

A Mosaic spokeswoman told the Gazette in December 2018 that the lowest number of open positions the company had in Forest City was at about 50. However, in recent months, there have been close to 70 open positions in Forest City.

In its report, the DHS called Mosaic “understaffed” and its employees “undertrained.”

“At the time when I (found out about Mosaic), things were a lot different than they were when (Sami) passed,” Josh Wellik said. “I got to know the old manager and the people who worked there, but when she passed, it was not the same staff.”

Wellik said some people who worked with his daughter reached out after she died, but he was upset that administrators did not communicate with the family, which lived nearby, more.

Many employees who help feed and clean Mosaic residents are not medically trained, Novotny said.

Some employees told DHS investigators that Mosaic’s daily operations were fine; others were frustrated by the difficulties in contacting medical staff, the constant understaffing and the general lack of training for lower-level workers.

One of these employees told investigators that she did not know what a CPAP machine was or that Samantha Wellik used the device for her asthma. The machine was later found in a closet.

“This place is notorious for being understaffed, and this night was one of those times where they’re understaffed,” Novotny said. “One person said they were understaffed because they’d fired a bunch of people because they were sleeping on the job.”

A supervisor told investigators that several changes were made because of employee conduct, including napping while on shift. An employee said two people typically would work one house during third shift, but fewer were available because workers had been fired and not yet replaced.

Josh Wellik said a manager he liked left Mosaic a couple of years before his daughter died, and that since then, there was a “revolving door” of new employees.


“Once she left, it just seemed like there was a lot of turnover, as far as the staff,” he said. “It didn’t really have a family-friendly or home environment toward the end there. There just wasn’t a lot of consistency.”


Questions about staffing and protocols aside, Josh Wellik said the most upsetting aspect of his daughter’s treatment and death is the possibility of sexual abuse.

“Originally, they told me they were doing rape kits, so then, of course, as a father, anger sets in,” Josh Wellik said. “It was inconclusive, but to even know that there was a chance that something like that could have happened, that’s enough to wreck a father.”

The doctor who performed the autopsy noted “apparent trauma” to the 14-year-old’s vagina and damage to her rectum. Her hymen was “not visible,” according to the report.

The cause of the injury is not known, but “a component of trauma (e.g. sexual assault and/or forceful enemas) cannot be excluded,” according to the autopsy.

Samantha did regularly receive enemas, the medical staff told investigators.

But that would not explain the material believed to be semen found in the girl’s body. Wellik said he was told by a person in the medical examiner’s office that substance appeared to be semen, but no DNA was detected.

No criminal charges have been filed against Mosaic in Winnebago County, according to online court records. Novotny said his client is hopeful the lawsuit can bring accountability to Mosaic, among other things.

“You can’t change the past. So he really has three things he wants to accomplish,” Novotny said. “No. 1, justice for his daughter; No. 2, making sure this doesn’t happen to anybody else; and No. 3, seeing if the DA will take a second look at this.

“If we need to protect anyone, this is the patient population we need to protect.”

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