Mr. Reaves' fingernails have not been cut since last year. According to Dr. Angeles, Mr. Reaves refuses to let certain staff members cut his nails. Dr. Angeles also testified, however, that Mr. Reaves does allow a podiatrist to cut his toenails. In addition, there is nothing in Mr. Reaves' treatment plan that indicates who should trim his nails or how often they should be cut. Mr. Reaves testified that he does not refuse to have his nails cut. His fingernails are currently so long that they curl into the palms of his hands and are causing skin breakdown. He has a fungal infection in one fingernail and several toenails.5 The overgrown nails also increase Mr. Reaves' likelihood of developing Autonomic Dysreflexia.
*203Dr. Angeles testified that she never noticed his fingernails were long.6
In addition to his overgrown nails, Mr. Reaves' overall hygiene is incredibly poor. His bedding is often soiled and covered in dead skin from his legs and feet. His hair and beard are caked with dead skin and food. According to Mr. Reaves, no one offers to brush his teeth or cut his fingernails and he cannot perform these actions himself.7
From January 27, 2019 to February 21, 2019, Mr. Reaves did not move his bowels. While Dr. Angeles indicated in her treatment plan that she must be notified if Mr. Reaves goes more than one day without a bowel movement, she is often unaware when Mr. Reaves goes several days without a bowel movement. Dr. Angeles met with Mr. Reaves four times between January 27, 2019 and February 21, 2019. See Ex. 16, at 33-34, 82-83, 123-24, 155-56. Nonetheless, she testified that she was unaware that Mr. Reaves had gone twenty-six days without a bowel movement.8
Dr. Morse testified that Mr. Reaves' bowel program is inadequate. According to her, after several days without a bowel movement, treating physicians should order an x-ray, followed by magnesium citrate taken orally, and then another x-ray. This severe constipation puts Mr. Reaves at risk of developing Autonomic Dysreflexia. It also puts Mr. Reaves at risk of a bowel rupture, stroke, fistula, and can impact the function of other organs
On several occasions, DOC staff have ordered medical staff to leave Mr. Reaves' room while providing care. Consequently, staff has left Mr. Reaves while bathing him, leaving him naked and wet without clothes or blankets. Mr. Reaves cannot put on his clothes or pull up his blankets. Instead, he is forced to wait until the next shift starts before staff can assist him.
Mr. Reaves is a difficult patient. He admits that he often swears at staff. When he has an outburst, correctional officers often remove medical staff from Mr. Reaves' cell. Mr. Reaves testified that on several occasions, this has occurred during his bath. See e.g. , Ex. 21, at 1. Consequently, Mr. Reaves was left naked, wet, and without blankets until the next shift assisted him.9 Mr. Reaves also regularly refuses care. See generally Ex. 35. Often, those refusals occur, when care is offered by certain staff members. For instance, Mr. Reaves does not accept care from RN Kayla Hall or CNA Coleen Johnson.10 He has filed grievances informing Dr. Angeles that he will not accept care offered by *204those staff members.11 The Court appointed monitor repeatedly recommended that CNA Johnson no longer offer care to Mr. Reaves. See, e.g. , Docket No. 225, at 2 ("Again, I reiterate that in the best interests of all parties involved, Ms. Johnson should not have any further contact with Mr. Reaves." (emphasis in original)). Defendant Collins testified that the DOC failed to comply with these recommendations despite knowing that they were akin to orders from this Court.
The monitor also recognized some of the deficiencies in Mr. Reaves noted above. For instance, on October 31, 2016, the monitor noted that "Mr. Reaves has still not been seen by a spinal cord case specialist since this Honorable Court's Order" and that "too much time has passed without this examination occurring. On numerous occasions, this Honorable Court has placed significant emphasis on this occurring, yet to date it has not." (Docket No. 113, at 2). On April 6, 2017, the monitor noted photographs "supportive of [the] allegation" that Mr. Reaves received "a lack of appropriate care." (Docket No. 155, at 2). The same day, the monitor noted that "Dr. Cho's recommendations are not followed as vigorously as might be expected given this Court's Order and impending trial." Id. Specifically, the monitor repeatedly reported that the DOC has still not provided an air mattress overlay recommended by Dr. Cho. See Docket No. 200, at 2; Docket No. 203, at 1; Docket No. 207, at 2; Docket No. 209, at 2; Docket No. 212, at 1; Docket No. 225, at 2. The Defendants contended that the overlay would interfere with the ability to effectively weigh Reaves, since the scale was in his bed. (Docket No. 207, at 2). However, the monitor seemed to question the sincerity of this rationale by observing that "it doesn't appear that Mr. Reaves is weighed on a regular basis." Id.
Before testifying at this trial, Dr. Morse again examined Mr. Reaves. She concluded that he presently suffers from severe complications of his injury. She also noted a marked decline in his condition since she last saw him in December 2015, which she attributes to a lack of proper medical attention.
Rulings of Law
The purpose of injunctive relieve is to prevent future violations. United States v. W.T. Grant Co. , 345 U.S. 629, 633, 73 S.Ct. 894, 97 L.Ed. 1303 (1953) ; Swift & Co. v. United States , 276 U.S. 311, 326, 48 S.Ct. 311, 72 L.Ed. 587 (1928). "[T]he determination whether circumstances warrant injunctive relief lies in the discretion of the trial court, and the burden of persuasion lies with the moving party." Lovell v. Brennan , 728 F.2d 560, 563 (1st Cir. 1984) (citation omitted).
To issue a permanent injunction, the Court must find that: "(1) plaintiffs prevail on the merits; (2) plaintiffs would suffer irreparable injury in the absence of injunctive relief; (3) the harm to plaintiffs would outweigh the harm the defendant would suffer from the imposition of an injunction; and (4) the public interest would not be adversely affected by an injunction." Asociacion de Educacion Privada de Puerto Rico, Inc. v. Garcia-Padilla , 490 F.3d 1, 8 (1st Cir. 2007) ; see also Ciba-Geigy Corp. v. Bolar Pharmaceutical Co. Inc. , 747 F.2d 844, 850 (3d Cir. 1984) ("In deciding whether a permanent in *205junction should be issued, the court must determine if the plaintiff has actually succeeded on the merits (i.e. met its burden of proof). If so, the court must then consider the appropriate remedy." (citation omitted)).
"All it takes to make the cause of action for relief by injunction is a real threat of future violation or a contemporary violation of a nature likely to continue or recur." United States v. Oregon State Med. Soc'y , 343 U.S. 326, 333, 72 S.Ct. 690, 96 L.Ed. 978 (1952). "[W]hile not necessary as a matter of law, a showing of past violations may be crucial in practice to a suit for injunctive relief." Lovell , 728 F.2d at 563.
1. Deliberate Indifference (Counts I)
"Prisoners retain the essence of human dignity inherent in all persons." Brown v. Plata , 563 U.S. 493, 510, 131 S.Ct. 1910, 179 L.Ed.2d 969 (2011). The Eighth Amendment, which prohibits "cruel and unusual punishment," U.S. Const. amend. VIII, is the source of "the principles that govern the permissible conditions under which prisoners are held," including "the medical treatment those prisoners must be afforded." Kosilek v. Spencer , 774 F.3d 63, 82 (1st Cir. 2014), cert. denied sub nom. Kosilek v. O'Brien , --- U.S. ----, 135 S. Ct. 2059, 191 L.Ed.2d 958 (2015).
"To incarcerate, society takes from prisoners the means to provide for their own needs," rendering each inmate entirely dependent on the State for his or her medical care. Brown , 563 U.S. at 510, 131 S.Ct. 1910. "Just as a prisoner may starve if not fed, he or she may suffer or die if not provided adequate medical care." Id. at 510-11, 131 S.Ct. 1910. "Undue suffering, unrelated to any legitimate penological purpose, is considered a form of punishment proscribed by the Eighth Amendment." Kosilek , 774 F.3d at 82 (citing Estelle v. Gamble , 429 U.S. 97, 103, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976) ). A prison that deprives inmates of adequate medical care "is incompatible with the concept of human dignity and has no place in civilized society." Brown , 563 U.S. at 511, 131 S.Ct. 1910.
Because the Eighth Amendment is focused on punishment, however, "not all shortages or failures in care exhibit the intent and harmfulness required to fall within its ambit." Kosilek , 774 F.3d at 82. Moreover, "[c]ourts must be sensitive to the State's interest in punishment, deterrence, and rehabilitation, as well as the need for deference to experienced and expert prison administrators faced with the difficult and dangerous task of housing large numbers of convicted criminals." Brown , 563 U.S. at 511, 131 S.Ct. 1910. Nevertheless, courts "must not shrink from their obligation to 'enforce the constitutional rights of all persons' " and "may not allow constitutional violations to continue simply because a remedy would involve intrusion into the realm of prison administration." Id. (quoting Cruz v. Beto , 405 U.S. 319, 321, 92 S.Ct. 1079, 31 L.Ed.2d 263 (1972) ); see also Brown , 563 U.S. at 511, 131 S.Ct. 1910, ("If government fails to fulfill this obligation, the courts have a responsibility to remedy the resulting Eighth Amendment violation.").
In order to prove an Eighth Amendment violation based on inadequate medical care, a prisoner must satisfy two elements: "(1) an objective prong that requires proof of a serious medical need, and (2) a subjective prong that mandates a showing of prison administrators' deliberate indifference to that need." Kosilek , 774 F.3d at 82 ; see Estelle , 429 U.S. at 106, 97 S.Ct. 285. When analyzing an Eighth Amendment claim, "the subjective deliberate indifference inquiry may overlap with *206the objective serious medical need determination," and "similar evidence ... may be relevant to both components." Kosilek , 774 F.3d at 83 n.7 (quoting Leavitt v. Corr. Med. Servs., Inc. , 645 F.3d 484, 498 (1st Cir. 2011) ).12
a. Objective Prong: "Serious Medical Need"
To satisfy the objective prong of the deliberate-indifference inquiry, a prisoner must have a serious medical need and must show that the medical care provided by the prison "is not 'adequate,' as measured against 'prudent professional standards.' " Nunes v. Massachusetts Dep't of Correction , 766 F.3d 136, 142 (1st Cir. 2014) (quoting United States v. DeCologero , 821 F.2d 39, 43 (1st Cir. 1987) ). A serious medical need is "one that has been diagnosed by a physician as mandating treatment, or one that is so obvious that even a lay person would easily recognize the necessity for a doctor's attention." Kosilek , 774 F.3d at 82 (citation omitted). There is no question that Mr. Reaves has serious medical needs stemming from his spinal cord injury.
The Eighth Amendment does not impose upon the Defendants "a duty to provide care that is ideal, or of [Reaves's] choosing." Id. ; see also Perry v. Roy , 782 F.3d 73, 78 (1st Cir. 2015) ("[A] serious medical need does not require that an inmate receive the best possible treatment that money can buy." (quotation marks and citation omitted)). Rather, Defendants must provide medical services that are "on a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards." United States v. Derbes , 369 F.3d 579, 583 (1st Cir. 2004) (quoting DeCologero , 821 F.2d at 43 ). "[I]t's the particular risk of harm faced by a prisoner due to the challenged deprivation of care, rather than the severity of the prisoner's underlying medical condition, considered in the abstract, that is relevant for Eighth Amendment purposes." Smith v. Carpenter , 316 F.3d 178, 186 (2d Cir. 2003). Accordingly, "an Eighth Amendment claim *207may be based on a defendant's conduct in exposing an inmate to an unreasonable risk of future harm." Id. at 188 ; see also Helling v. McKinney , 509 U.S. 25, 33, 113 S.Ct. 2475, 125 L.Ed.2d 22 (1993) (holding that correctional officials may not ignore medical conditions that are "very likely to cause serious illness and needless suffering" in the future, and that such prospective harm may form the basis of an Eighth Amendment claim, even where the inmate has "no serious current symptoms"); Leavitt v. Corr. Med. Servs., Inc. , 645 F.3d 484, 501 (1st Cir. 2011).
Dr. Morse testified that treating serious spinal cord injuries like Mr. Reaves' requires specialized training. Further, she testified that almost every organ system is impacted, and these secondary conditions and complications require specialized training as well. Specifically, complications commonly arise from skin breakdown, loss of function due to contractures, osteoporosis, neurogenic bowel and bladder, and all require specialized training to treat appropriately. Not only is Mr. Reaves not receiving specialized care for these complications, the care that he is receiving can be charitably characterized as negligent. For instance, Mr. Reaves went over ten days without a bowel movement on three different occasions without Dr. Angeles knowing, his hygiene (which is critical) is appalling, and his diet is non-responsive to his nutritional and digestive needs.
Dr. Morse stressed that Mr. Reaves is severely malnourished, his nails are curling into his palms and causing skin breakdown, he has fungal infections in his fingers and toes, a pressure ulcer on his sacrum, and venous stasis ulcers on both of his legs. Further, when Dr. Morse examined Mr. Reaves, his bedding was soiled and there was bloody drainage from his sacral wound.
If his sacral wound progresses, Mr. Reaves will be prone to infection. According to Dr. Morse, the most effective treatment for his sacral ulcer would be to maximize hygiene, improve his nutritional intake, and comply with Dr. Cho's recommendations. The DOC, however, has not complied with any of Dr. Cho's recommendations. The DOC has failed to rectify Mr. Reaves' inadequate bedding, increase the fiber in his diet, send him for a urodynamic study, or an evaluation with a gastroenterologist. And while the DOC claims to provide Mr. Reaves with Range of Motion therapy, as noted above, video footage demonstrates this therapy is deficient.
Significantly, Mr. Reaves' caretakers do not respond appropriately to symptoms of Autonomic Dysreflexia, nor do they evidence an appreciation of its seriousness. Dr. Morse observed several instances of blood pressure changes indicative of Autonomic Dysreflexia. Further, Mr. Reaves has complained of other symptoms of Autonomic Dysreflexia such as headache, visual disturbances, or sweating. According to Dr. Morse, staff at MCI Shirley did not respond appropriately to these symptoms. According to Mr. Reaves, when he reports symptoms such as lightheadedness, dizziness, or spots in his vision, medical staff does not do anything. Dr. Morse testified that these symptoms should be treated as a medical emergency.
Mr. Reaves is presently suffering from the consequences of deficient medical care. His emaciated frame, coiled nails, caked beard, and raw wounds make this finding inescapable. Moreover, the DOC is putting Mr. Reaves at grave risk of catastrophic future harm.
b. Subjective Prong: "Wanton Disregard"
"The subjective prong relies entirely on whether the [the defendant] had a purposeful intent while neglecting *208[the plaintiff's] treatment." Perry , 782 F.3d at 79 ; see also Estelle , 429 U.S. at 105, 97 S.Ct. 285. "[E]ven if medical care is so inadequate as to satisfy the objective prong, the Eighth Amendment is not violated unless prison administrators also exhibit deliberate indifference to the prisoner's needs." Kosilek , 774 F.3d at 83 (citing Estelle , 429 U.S. at 105-06, 97 S.Ct. 285 ). To be deliberately indifferent, a defendant typically must have had "actual or constructive knowledge" of a "grave risk of harm" and failed to take "easily available measures to address the risk." Camilo-Robles v. Hoyos , 151 F.3d 1, 6-7 (1st Cir. 1998) ; see also Kosilek , 774 F.3d at 83 ("[D]eliberate indifference 'defines a narrow band of conduct' ... and requires evidence that the failure in treatment was purposeful." (quoting Feeney v. Corr. Med. Servs. Inc. , 464 F.3d 158, 162 (1st Cir. 2006) ). "The typical example of a case of deliberate indifference would be one in which treatment is denied in order to punish the inmate." Perry , 782 F.3d at 79 (quotation marks and citation omitted).
Deliberate indifference may also be demonstrated, however, "by a 'wanton disregard' to a prisoner's needs." Kosilek , 774 F.3d at 83 (quoting Battista v. Clarke , 645 F.3d 449, 453 (1st Cir. 2011) ). That disregard "must be akin to criminal recklessness, requiring consciousness of 'impending harm, easily preventable.' " Id. (quoting Watson v. Caton , 984 F.2d 537, 540 (1st Cir. 1993) ). A prisoner can show wanton disregard by presenting evidence of "denial, delay, or interference with prescribed health care." Battista , 645 F.3d at 453 (quoting DesRosiers v. Moran , 949 F.2d 15, 19 (1st Cir. 1991) ).13
Defendant Collins has actual knowledge of Mr. Reaves' condition and the complaints relating to his care. She received several letters from, and on behalf of Mr. Reaves expressing concerns about his medical care. See Ex. 22. One letter was sent before this case was filed and outlined claims against Defendant Collins. Another dated January 29, 2016, attached Dr. Morse's 2014 report concerning Mr. Reaves' declining health and deficient care. See id. at 3. Defendant Collins also received a copy of the Complaint and is aware of this Court's lengthy and detailed Preliminary Injunction against the DOC. Thus, she was aware that Dr. Morse believed that a spinal cord injury specialist was "an absolutely critical component of Mr. Reaves' care" in order "to avoid premature death." Reaves , 195 F. Supp. 3d at 396. Further, Defendant Collins was aware of this Court's conclusion that Mr. Reaves was likely to succeed on his deliberate indifference claim and that "[w]ithout significant changes to his care, his condition will continue to deteriorate." Id. at 416-17. In addition, Defendant Collins oversees the provision of medical services and monitors contract compliance with companies contracted to provide services. She received monthly status reports submitted by the DOC's previous medical contractor regarding Mr. Reaves' care and had the authority to require staffing changes to meet his evolving medical needs and penalize contractors for deficient care.14
*209Defendant Collins also received a copy of each of Dr. Cho's reports and their attendant recommendations for changes in Mr. Reaves care. Therefore, Defendant Collins was aware that Dr. Cho repeatedly recommended that the fiber in Mr. Reaves' diet be increased, that he be evaluated by a gastroenterologist, that he undergoes a urodynamic study, and that he be provided a mattress topper to mitigate the risk of potentially fatal ulcers. When asked if she carries out the recommendations of outside experts, Defendant Collins responded: "Not all the time." In the case of Mr. Reaves, the more accurate answer is "never."
I find that Defendant Collins was clearly aware of facts from which she could infer the substantial risk of serious harm to Mr. Reaves. As that inference is nearly inescapable, I also find that Defendant Collins made that inference. See Farmer v. Brennan , 511 U.S. 825, 837, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994). And despite making that small inferential leap, she failed to ensure that Mr. Reaves received adequate medical care.
c. Appropriate Remedy
Typically, "[t]he federal courts will not interfere in the internal operation and administration of a prison unless its authorities have abused their discretion resulting in mistreatment of the prisoner-applicant." Haggerty v. Wainwright , 427 F.2d 1137, 1138 (5th Cir. 1970). Where courts do find a constitutional violation, however, they have "broad discretion to frame equitable remedies so long as the relief granted is commensurate with the scope of the constitutional infraction." Todaro v. Ward , 565 F.2d 48, 54 n.7 (2d Cir. 1977) ; see also Milliken v. Bradley , 433 U.S. 267, 280, 97 S.Ct. 2749, 53 L.Ed.2d 745 (1977).
As noted above, on July 15, 2016, this Court issued a preliminary injunction against the DOC mandating several changes in Mr. Reaves' care and appointing a monitor to oversee the implementation of the injunction and the care of Mr. Reaves. See Reaves , 195 F. Supp. 3d 383. In that order, because of the deficient care the DOC was providing Mr. Reaves at the time, the Court found that Mr. Reaves was likely to succeed on the merits of his deliberate indifference claim. Id. at 416. Almost three years later, Mr. Reaves' condition has further deteriorated, and it is obvious that the DOC is unwilling to provide appropriate care for him.
District courts have used their broad equitable powers to order the transfer of inmates to facilities better equipped to provide for their medical needs. See, e.g. , Johnson v. Harris , 479 F. Supp. 333 (S.D.N.Y. 1979) (ordering prison to either transfer inmate to facility equipped to provide for his medical needs or, if such a facility is not available, insure he is provided with adequate care as a result of deliberate indifference to inmate's serious medical needs by continually ignoring special diet requirements for inmate with serious diabetic condition);
*210United States v. Wallen , 177 F. Supp. 2d 455, 458 (D. Md. 2001) (ordering a pretrial detainee to be transferred to an infirmary or a hospital where "the Marshal's Service cannot assure this Court that it will provide the medical care that the Constitution mandates so long as he is held at MCAC"); see also ABA Standards for Criminal Justice, 23-6.2 (3d ed. 2011) ("A prisoner who requires care not available in the correctional facility should be transferred to a hospital or other appropriate place for care.").
Here, MCI Shirley is neither able nor willing to provide for Mr. Reaves' medical needs. His treating physician, Dr. Angeles, has no training in spinal cord injuries and the record is replete with consistent deficiencies in Mr. Reaves' care. Further, beyond the lack of appropriate expertise, Defendant Collins has demonstrated a woeful disregard for Mr. Reaves' well-being by repeatedly refusing to implement the recommendations of specialists. As a result, Mr. Reaves' condition has needlessly and significantly declined to the point that he may soon die.
Accordingly, the appropriate remedy is for Mr. Reaves to be transferred to a non-DOC facility where he will be treated by a physician with the training to care for his substantial and numerous medical needs.
2. ADA and Rehabilitation Act (Counts III & IV)
Transfer of Mr. Reaves from MCI Shirley moots his claims pursuant to Title II of the ADA and the Rehabilitation Act for a permanent injunction against the transferring facility. See Ford v. Bender , 768 F.3d 15, 29 (1st Cir. 2014) ("A prisoner's challenge to prison conditions or policies is generally rendered moot by his transfer or release."); Prins v. Coughlin , 76 F.3d 504, 506 (2d Cir. 1996) ("[A] transfer from a prison facility moots an action for injunctive relief against the transferring facility."). Further, the Court does not find that that there is "a reasonable expectation that the same complaining party [will] be subject to the same action again." Murphy , 455 U.S. at 482, 102 S.Ct. 1181 ; see also Washington v. Harper , 494 U.S. 210, 219, 110 S.Ct. 1028, 108 L.Ed.2d 178 (1990) (holding that prisoner's claims were not moot despite transfer to a non-offending facility because "[t]he alleged injury would likely recur").
Order
For the reasons stated above, Mr. Reaves shall be immediately transferred to a non-DOC facility that treats spinal cord injuries and has a spinal cord injury specialist on staff with the appropriate training to care for his medical needs.
SO ORDERED.