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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: 1068930-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Beth Virden 651-431-6572 Suspected Maltreatment Reported: Allegation One: It was reported that a supervisory staff person (SP1) drank alcohol while providing care and supervision to a vulnerable adult (VA). This included driving while under the influence of alcohol with the VA in the front passenger seat and allowing the VA to drink alcohol in a vehicle that SP1 was driving. It was also reported that a supervisory staff person (SP2) was aware of SP1’s conduct but did not intervene or ensure the VA’s wellbeing. Allegation Two: It was reported that SP1 yelled at the VA more than once. During the investigation, the following licensing violations were also alleged: · It was reported that more than once, SP1 and SP2 left the VA unsupervised for longer than was allowed per the VA’s support plans. · It was reported that more than once, there was “no food” in the house for the VA to eat. Date of Incident(s): Ongoing 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 2, paragraph (b), clause (2); and subdivision 17, paragraph (a): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 July 30, 2024; from documentation at the facility; and through interviews conducted with the VA, the VA’s case manager (CM), facility staff persons (P1 and P2), and supervisory staff persons (P3, SP1, and SP2). The VA’s support plan and support plan addendum provided the following information: · In 2014, the VA moved into the facility seeking supports and services relating to his/her diagnoses, which included cerebral palsy and epilepsy. · The VA communicated verbally without issue. “[S/he] possesses adequate expressive and receptive communication skills.” The VA was not subject to guardianship. · “[The VA] has a mental and emotional condition that affects judgment and decision-making … [S/he] has difficulties with impulsivity, telling of untruths, and displays stubbornness and sullenness.” Staff encouraged the VA to talk about what was bothering him/her and prompted the VA to take a walk or listen to music when needed. Staff intervened when necessary to protect the VA’s and/or other’s safety. · There was no information preventing or limiting the VA’s access to or use of alcohol. The VA was over 21 years old, which was the legal drinking age requirement in Minnesota. The facility was a single-family, split-level home in a rural area. The upper level had a kitchen, a living and dining room combination, a bathroom, and the VA’s bedroom. The lower level had SP1’s office, SP2’s office, a living room, and a laundry room. The VA was the sole occupant. The facility provided at least one staff person 24 hours a day for the VA’s care and supervision. Facility documentation stated that P1, P2, P3, SP1, and SP2 received training on the VA’s support plan and support plan addendum, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that SP1 drank alcohol while providing care and supervision to the VA. This included driving while under the influence of alcohol with the VA in the front passenger seat and allowing the VA to drink alcohol in a vehicle that SP1 was driving. It was also reported that SP2 was aware of SP1’s conduct but did not intervene or ensure the VA’s wellbeing. The facility’s alcohol- and transportation-related policies included the following information: · The facility supported a workplace free from the effects of alcohol by any employee directly or indirectly responsible for a client. · Staff were expected to drive clients in a safe and responsible manner and to maintain a good driving record. Staff were prohibited from driving while under the influence of alcohol. · All employees were expected to respond appropriately if a coworker reported to work impaired in any way. The employee was expected to stay with the clients and immediately report their concerns to a supervisor or a member of the management team. If there was reason to suspect an employee was working under the influence of alcohol, the employee was suspended until a testing laboratory made the results of an alcohol test available. The VA provided the following information: · SP1 and SP2 told the VA they were “dating” and the VA saw them “constantly all over each other” when they were working. “They’re not professional.” SP2 was also SP1’s supervisor. · The VA suspected SP1 was “a hardcore drinker” and wanted to test if s/he was correct. On an unknown date, the VA had an unopened bottle of Southern Comfort (whiskey) in his/her bedroom. The VA asked SP1 to help open it. “I asked [him/her] to crack it. I wanted to see how bad [s/he] could not resist. And all I said was, I was like, ‘I suppose you want to take a drink.’ And, the next thing you know, [SP1] did.” “[SP1] couldn’t even hesitate. That’s how fucking bad [SP1’s] drinking habit is.” SP1 drank about “an inch and a half” of what was in the Southern Comfort bottle. “It was a good swig.” This was the only time the VA could recall seeing SP1 drink alcohol while inside the facility. All of the other times, SP1 drank alcohol was in the community with the VA. · At least one time, SP1 drank Southern Comfort “behind the wheel” or “actively driving” with the VA in the front passenger seat. The VA saw SP1 pour Southern Comfort into another container and then drink from that container while driving with the VA in the front passenger seat as SP1 drove the VA to a “fishing trip.” The VA was surprised that SP1’s driving did not seem impaired. “I have never seen someone to be so intoxicated and drive straight as a fucking arrow.” The VA believed SP1 was “so intoxicated” because SP1’s eyes were “red,” and his/her pupils were “ready to pop out of [his/her] head.” [Note: Minnesota law states that the possession of any open container inside a vehicle on a Minnesota street or highway is illegal. It is also illegal for any person to drive, operate, or be in physical control of any motor vehicle when the person's alcohol concentration at the time, or as measured within two hours of the time, of driving, operating, or being in physical control of the motor vehicle is 0.08 or more.] · The VA said that at least one time s/he drank Southern Comfort from SP1’s container as SP1 drove and the VA was in the front passenger seat. “I will admit I was in the wrong drinking in the vehicle, but I was not behind the wheel.” · One time, the VA went swimming at a lake with SP1, SP2, and SP2’s children. SP1 drove the VA, and SP2 and his/her children drove in a separate vehicle. The VA bought a case of Michelob Golden Light beer on the way to the lake. SP1 and the VA drank the beer at the lake while SP2 was with them. The VA could not remember how many drinks SP1 drank but said it was more than one. When SP1 was packing up the vehicle to leave, s/he put five or six cans of the VA’s Michelob Golden Light to the side for him/herself to take home. SP1 told the VA s/he was taking the beer cans home with him/her even though they had been purchased by the VA. “It didn’t bother me” because there were times when SP1 bought beer and let the VA have some. When they left the lake on this day, SP1 drove the VA home while SP2 was in a separate vehicle with his/her children. The VA did not specify how much time passed between SP1’s last consumed beer to when SP1 drove the vehicle; however, the VA said they spent most of the day at the lake and were drinking beer throughout the day. · One time, the VA went camping with SP1 and SP2. The VA stayed in a tent and SP1 and SP2 stayed in SP1’s camper. SP1 and the VA drank beer at the campsite. SP2 was with them and “[s/he] never fucking done a thing about it.” “[SP1] was drinking around me and [SP2] never stopped it.” · The VA did not tell anyone about SP1’s drinking until SP1 started “lying” to the VA. “When you start lying to me, I don't take that shit very lightly.” One day, SP1 told the VA that s/he had liver failure. “It bothered me so much,” and “I would start crying.” The VA’s six-month review was held virtually with SP1, SP2, the CM, and the VA. At one point, it was just the CM and the VA online, and the VA told the CM about SP1’s liver failure. “I literally broke down to where I was hyperventilating.” Just then, SP2 happened to log back into the meeting and the CM told him/her about the VA’s concern for SP1. SP2 immediately responded, “[SP1’s] not sick.” SP2 asked SP1 to log back on. SP1 then told the VA that s/he did not have liver failure. The VA later told this investigator, “Why would you lie about fucking liver failure … You don’t fuck with somebody’s head about that shit. This is the most fucked up thing.” “I don’t fucking believe a fucking word that either of them (SP1 and SP2) say.” The VA had been keeping SP1’s drinking private; however, following this, s/he told P1 and P2, and later P3. P3 provided the following information: · On July 8, 2024, the VA reached out to P3 stating s/he “needed to tell me some stuff that [s/he] had been carrying around with [him/her] and [s/he] couldn't do it anymore. It was too hard.” The VA told P3 about SP1 “drinking on the job” and about SP2 “covering up for [SP1].” [Note: P3 documented the VA’s statements and provided the documentation for this investigation. The VA told P3 information that was consistent with the information the VA told to this investigator about SP1’s and SP2’s conduct.] · The VA did not have a history of making similar statements about staff. This was the first time the VA told P3 about a concern with a staff person. · P3 supervised SP2 and SP2 supervised SP1. P3 was aware they were dating. P3 did not have prior concerns with SP2’s conduct and was not informed of any concerns with SP1’s conduct. [Note: P3 worked out of an administrative office, which was over 300 miles away from the facility. P3 was familiar with SP1 but did not routinely interact with him/her. P3 had biweekly phone calls with SP2.] The CM provided the following information: · On an unspecified date, the VA called the CM and said that s/he had something to tell him/her. The VA provided information to the CM that was consistent with the information the VA told to this investigator about SP1’s and SP2’s conduct. The VA also told the CM that s/he felt “unsafe” with SP1 and SP2 and was “afraid of repercussions” for relaying his/her concerns. · The CM was not aware of the VA making similar statements in the past about a staff person’s conduct and/or intentionally providing inaccurate information to get a staff person in trouble. P1 provided the following information: · One evening, the VA told P1 about a camping trip with SP1 and SP2 and that SP1 and the VA were drinking alcohol together with SP2 present. Shortly after this disclosure, P2 arrived at work in relief of P1. P1 asked P2 if the VA told him/her about SP1’s drinking, and P2 confirmed the VA told him/her the same information. P1 did not always believe everything the VA said, but when s/he learned the VA had said the same things to P2, P1 believed the VA. The VA wanted to be the one to tell P3 and did so the next day. · P1 previously “had beliefs” SP1 was drinking with the VA. One time, SP1 picked the VA up from the house to go golfing. Later, SP1 dropped the VA off at the house “drunk,” and then “immediately” drove away without coming inside. About one to two hours later, SP1 called P1 regarding the VA’s medications. SP1 said that the VA had been drinking alcohol and that P1 needed to check with a nurse to see if this would impact the VA’s medications that evening. SP1 and SP2 lived together and during this call, SP1 and SP2 were yelling at each other in the background of the call. “I strongly felt there was something weird. That is when it started the belief. Things were not right.” · P1 did not witness SP1 intoxicated at work or with the VA. However, P1 also “never” saw SP1 because SP1 worked between 8 a.m. and 4 p.m. and P1’s shift started at 4 p.m. Each day, SP1 was already gone for the day when P1 arrived. Then, at about 4:04 p.m., SP1 would call the VA to check in and ask if P1 was there. “I communicated through [the VA] with [SP1]. [SP1] chose not to interact with me. Not person to person, which I thought was odd.” · Regarding SP2’s conduct, there was “no support system” at the facility. If P1 had concerns about SP1 and/or SP2, P1 did not trust going to the next in command (P3). “I don’t trust it.” It was an “uncomfortable” work environment. There were also times when P1 called SP2 with concerns and SP2 “brushed [P1] off.” P2 provided the following information during his/her interview and in the Internal Review: · On an unspecified date, the VA told P2 that SP1 was “drinking on the job.” P2 had “no firsthand knowledge” of SP1 drinking on the job or with the VA. · However, P2 believed the VA and that SP1 was “drinking on the job.” P2 explained to this investigator that the VA never drank alcohol until SP1 started working at the facility. The VA had been scared to drink alcohol until s/he met SP1. “We, myself and other staff, believed it was [SP1] leading [the VA] down that road.” · That said, the VA did have a history of exaggerating events. “Usually there is some truth behind [the VA’s] tales. [SP1] was probably not always appropriate, but it’s probably not as malicious as [the VA] made it out to be.” The VA might have reason to get SP1 in trouble or exaggerate SP1’s conduct because at the time of the allegations, SP1 was placing limitations on his/her interactions with the VA, which the VA might not have liked. · Regarding SP2, the VA never liked him/her. “[The VA] doesn’t like anyone in authority,” like SP2. SP2 was a “by the book” type of person, which the VA also did not like. SP1 started in 2023 and SP2 was SP1’s supervisor. SP1 and SP2 began a romantic relationship at some point after SP1 started at the facility. “There was a conflict there. It was a weird relationship. I only saw it from afar but [SP2] did seem to dismiss [SP1’s conduct]” or “be afraid” to intervene with SP1’s conduct. · P2 stated in the Internal Review that s/he “does not see [SP1], so [s/he] hasn't witnessed” SP1 drinking with the VA; however, P2 stated that s/he believed the VA’s account of SP1’s drinking “to be factual.” SP2 provided the following information: · SP2 managed the facility’s overall operation and did the same for other similar homes owned by the license holder. SP1 was responsible for specifically managing the VA’s home and one other home. SP2’s and SP1’s respective offices were at the VA’s house. · SP2 “never observed [SP1] drinking” at work and no one, including the VA, brought concerns of such to SP2’s attention. The VA had a history of sharing his/her concerns. If the VA had concerns, s/he might not say something right away to SP2, but depending on the level of concern, “[The VA] does come around” and say something eventually. · SP2 recalled going camping and to a lake with SP1 and the VA. “[SP1] did not drink. [The VA] did.” “[SP1] has never drank on any outings with [the VA].” · SP2 had no information SP1 ever drove a vehicle while under the influence of alcohol, including with the VA present. SP2 and SP1 lived together. SP2 said, “Socially [SP1] will drink but [s/he] doesn’t drive.” · SP2 denied treating SP1 any different due to their relationship. “I have the same expectations for [SP1] as I do for others (staff).” · The VA was “not a reliable historian” and “often will change [his/her] story.” For example, on a Monday the VA might state something that happened with a staff, any staff, not a specific staff person. Then, later in the week when the VA brought it up again, his/her account “conflicted with what [s/he] said on Monday.” · Around the time of this investigation, staff were working on being “more consistent” and “maintaining boundaries” with the VA. Staff were told to encourage the VA to relay his/her concerns to the staff on shift, rather than immediately calling SP1 or SP2. SP2 wondered if this might have prompted allegations against SP1 and SP2. SP1 provided the following information: · SP1 “never” consumed alcohol while on the job or with the VA. · SP1 did not consume alcohol while driving with the VA, did not let the VA consume alcohol while SP1 was driving, and was not under the influence of alcohol while driving with the VA in the vehicle. SP1 said that these allegations were “over the top embarrassing.” · Around the time of this investigation, the VA was “mad at” SP1 for not taking him/her with on a weekend trip to the Twin Cities. SP1 was not working that weekend and was celebrating July 4th, where s/he was consuming alcohol. The VA tried to call SP1 throughout the weekend and SP1 did not answer. The VA was also “upset” with SP1 because s/he wanted to go to a vintage car show and ride there in SP1’s vintage car. However, SP1 needed new tires on his/her vintage car and so did not go to the car show. The VA did not want to go without SP1’s vintage car. SP1 wondered if these incidents might have prompted allegations against him/her. · The VA had “a lot of history” with providing inaccurate information but also “can be accurate.” “[The VA] does get over the top in [his/her] feelings.” “It’s hit or miss if it’s truth or lie.” An example was one time, a staff person waited two hours to pick the VA up from a bar outing. The VA said that it was not two hours. “We determined that the staff was sitting out there for two hours.” “Mainly, [the VA] will lie if we are getting in [his/her] privacy.” For the facility’s internal investigation, P3 interviewed two additional staff persons (P4 and P5). P4 and P5 each said that they did not witness SP1 drinking or being intoxicated at work. P4 said that s/he “rarely sees” SP1. P5 said s/he saw SP1 “one time” since P5 began working at the facility. P4 heard from an unidentified staff person, “[SP1 and the VA] drank together while golfing and that they had a really good time.” Conclusion for Allegation One: The VA provided consistent information to the DHS investigator, the CM, P1, P2, and P3 that SP1 drank alcohol at the facility and while driving with the VA in a vehicle, and that SP2 was aware but did not intervene. SP1 said that s/he did not drink alcohol around or with the VA and gave examples of why the VA was “mad” or “upset” with him/her, which might have prompted the allegations. SP2 said that s/he “never observed [SP1] drinking” at work and no one, including the VA, brought concerns of such to SP2’s attention. Although the allegation of drinking at work was concerning and inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services; no one else, including SP2, P1, P2, P3, P4, and P4 witnessed SP1 drink alcohol around or with the VA. Information regarding the VA’s credibility varied, so without any witnesses or additional evidence, it was not determined if the VA’s or SP1’s account was more credible. Information was also provided that the VA did not like SP1 and SP2. Therefore, there was not a preponderance of the evidence whether SP1 consumed alcohol while providing care and services to the VA and whether SP2 failed to intervene to ensure the VA’s health and safety. 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). Allegation Two: It was reported that more than once, SP1 yelled at the VA. The VA said that there were “a couple different times” SP1 “yelled” on the phone at the VA. “It was very unprofessional.” “I’d have to pull the phone away from my ear because [SP1] was screaming at me.” At least one time, the VA handed the phone to P1 and “[P1] heard the whole thing.” SP1 typically “screamed” about something the VA was supposed to do that included “cuss words,” like, “You need to fucking do this right now.” “It was not professional at all.” One time, the VA was talking to SP2 on the phone and SP1 was “screaming in the background, and it literally sounded like [SP1] was right next to the phone.” SP1’s “yelling” and “screaming” made the VA feel “very, very heated.” P1 said that more than once, s/he heard the VA, in his/her bedroom, “arguing” on the phone with SP1. “I didn’t mean to listen, but it was impossible not to listen.” “[The VA] would come out and hand me the phone. I’d be like, ‘Oh, is it for me?’ [The VA] would just hold the phone. I’d have to hold the phone back because of [SP1’s] yelling. [SP1] thought [s/he] was talking to [the VA] and not me. It was uncomfortable.” “I’d have to hold the phone away from my ear. [SP1] kept yelling until [s/he] realized it was me talking.” SP1 was typically “yelling” about how the VA needed to do something, like clean the garage or get rid of the lawnmower. When SP1 realized P1 was on the phone and not the VA, s/he would not really say anything. P1 got the impression that SP1 wanted to talk to P1 but that the VA declined to pass the phone along. For the facility’s internal investigation, P5 said that the VA told him/her that SP1 has yelled at him/her. P5 did not witness this. SP2 said that s/he did not witness SP1 “yelling” or “screaming” at the VA. SP1 said that s/he did not yell at the VA but s/he “might talk louder” to the VA that included statements, like “Chill out and calm down. Breath.” SP1 did not consider his/her tone during these times to be yelling. SP1 said, “I haven’t yelled at [him/her] in an inappropriate way.” Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6), states, in relevant part, that a person's protection-related rights include the right to be treated with courtesy and respect. Conclusion for Allegation Two: The VA said that “a couple of times” SP1 yelled or screamed at him/her. This included “cuss words,” like, “You need to fucking do this right now.” The VA added, “I’d have to pull the phone away from my ear because [SP1] was screaming at me.” At least once, P1 heard SP1 yelling at the VA on the phone. SP1 denied the allegation. SP2 was SP1’s supervisor and stated that s/he was not aware of, or witness to, SP1 yelling at the VA. P5 said that the VA told him/her that SP1 has yelled at him/her; however, P5 also did not witness this. Although the allegation of yelling was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6); given that the VA said it happened “a couple of times,” and that the information regarding the VA’s credibility varied, without additional details to state exactly what was said and to what extent, or additional witnesses, there was not a preponderance of the evidence whether SP1’s conduct, and included the use of repeated or malicious oral language toward the VA that could reasonably be expected to cause emotional distress. It was not determined whether emotional abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: the use of repeated or malicious oral, written or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening). Alleged Licensing Violations: It was reported that more than once, SP1 and SP2 left the VA unsupervised for longer than was allowed per the VA’s support plans. The VA’s Emergency Data Form stated that the VA could be unsupervised at home for up to six hours at a time. Staff and the VA checked-in with one another whenever they were apart and continued to inform of their plans throughout the day. The VA provided the following information: · The VA was allowed six hours of unsupervised time at home per every 24 hours, or day. However, “[SP1 and SP2] were taking it way beyond that and they were staying gone for eight hours. They would come here, check on me, and get the fuck out of here.” · SP1 was supposed to work 8 a.m. to 4 p.m. However, “every day, there was never a day that [SP1] was here at eight o’clock. Never. It was 10 or 11 o’clock. Every fucking day.” “You’re lucky if [s/he] worked two fucking hours. Sometimes [s/he] didn’t work at all … and if I had to put that into a percentage of the time that [s/he] didn’t work at all, I would say that it would be about 85% and that’s no shit.” “I would end up pretty much being alone.” P1 and P2 did not know if SP1 was always present for his/her entire shift, 8 a.m. to 4 p.m. SP2’s office was at the VA’s house and P1 and P2 did not know how much time s/he spent there. P2 added, “But, I’m pretty sure someone showed up during [SP1’s shift] because [the VA] always got [his/her daytime] meds.” SP2 said that the VA’s unsupervised time at home “never exceeded six hours in a day.” “At any point, I could be there as well as [SP1].” There was “always” an evening staff person there at 4 p.m., and the overnight staff person was “always” there too. SP1 said that the VA was “never” left unsupervised for over six hours in a day. Although there may have been times when the VA was alone longer than his/her approved six hours, given that there was a no information provided that the VA sustained any harm or injury as a result, a licensing violation was not determined. It was reported that more than once, there was “no food” in the house for the VA to eat. The VA’s Emergency Data Form stated that the VA sometimes “refused” to eat and/or to eat a balanced diet. Staff encouraged the VA to participate in menu planning. However, the VA had a history of changing his/her mind about what’s on the menu on the day of the planned meal. Staff offered alternative meals, and nutritious snacks were always available. The VA said, “There were two occasions, possibly three occasions, where they would go weeks on end without buying groceries for the house.” Each instance lasted about two weeks. “There was pretty much nothing in this house for me to eat.” P1 said, “There were times there was hardly nothing in the house. Maybe a thing of frozen meat. But no butter. No lunch meat. Maybe a few eggs. There was no structure … A few times, there was not a lot of food in the house.” P2, SP1, and SP2 each said that there was “always” something to eat in the house; however, the VA did not always like the food and/or would “binge eat” his/her favorite foods before the next week’s grocery budget was available. Given that there was conflicting information regarding what food was available to the VA and whether it was a lack of food or rather food the VA did not like, a licensing violation was not determined. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. More than one staff person was informed of, or suspected, SP1 was drinking alcohol while working with the VA; however, no staff reported this as required. The facility provided additional training to staff regarding the Reporting of Maltreatment of Vulnerable Adults Act. In response to the allegations of drinking on the job, SP1 was no longer working in a supervisory role or with the VA. Action Taken by Department of Human Services, Office of Inspector General: On September 26, 2024, the facility was issued a Correction Order for the violations outlined in this report and for two additional violations relating to background studies. It was determined the facility failed to submit a new background study or notify the commissioner of a staff person’s legal name change, which was in violation of Minnesota Statutes section 245C.04, subdivision 7. It was also determined the facility failed to affiliate a staff person on their active roster in NetStudy 2.0, which was in violation of Minnesota Statutes section 245C.07, paragraph (f).
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