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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: 1117210-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Deb Neubauer-Hoffman 651-431-6567 Suspected Maltreatment Reported: It was reported that a staff person (SP) called a vulnerable adult (VA) “fat,” threatened to take away the VA’s vacation due to his/her behaviors and called the VA a “fat fucking [R-word].” The SP also threatened the VA’s housing, told the VA that the VA was the reason a particular staff person (P1) left, and threatened to take away the clients’ (the VA and C1-C3) “one-to-one” outings. Date of Incident(s): Prior to June 2025 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): 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. Summary of Findings: Pertinent information was obtained during site visits conducted on June 13 and July 11, 2025; from documentation at the facility; and through nine interviews conducted with the VA, two clients (C1 and C2), five facility staff persons (the SP and P1-P4), and the VA’s guardian (G). Another client (C3) was not interviewed due to his/her dementia diagnoses. The VA enjoyed cooking, going out to eat, and drinking soda pop. The VA also enjoyed visiting with his/her family, traveling, and participating in Special Olympics. The VA’s diagnoses included moderate intellectual disabilities. The VA’s plans stated that his/her “target behaviors” included using derogatory or insulting terms or swearing, and that staff persons were supposed to respond by remaining calm and respectful. The VA followed a “heart healthy” doctor’s ordered diet. The VA resided at a townhome referred to as “Hugo A” with C1-C3. The organization also provided services to additional clients in an adjoining townhome referred to as “Hugo B.” P2 provided the following information: · P2 said on one occasion, the SP and P1 were in the facility office talking when P2 heard the SP “screaming” at P1 for “over an hour” and the VA and either C1 or C2 were present. · On multiple other occasions, the SP told P2 about how the VA “used to call [the SP] the N-word.” After the VA used derogatory terms toward staff persons, the SP told P2 that the G told the SP to call the VA “a fat fucking [R-word]” if the VA continued to use derogatory slurs. The SP told P2 that s/he “did say it” to the VA and later talked to the VA about how it “didn’t feel good” to have others say “demeaning things” about them. · “Multiple times” P2 heard the SP call the VA “fat” or said, “look at you, you are fat.” On one of those occasions the VA said to P2, “I am not fat, this is muscle.” After the SP said that to the VA, “did not feel good” about it and said that s/he wanted to exercise. This discussion was centered around the VA wanting soda pop. · If the VA or C1-C3 did not follow the rules or had “behaviors,” the SP said that s/he was going to take away their one-to-one outings. (One-to-ones were described as a monthly outing between one client and one staff person. The client chose a restaurant for dinner and went shopping for personal needs items during those outings.) · On May 22, 2025, the VA and C2 attempted to go outside with C2’s soda pop. P2 believed the VA wanted C2 to share his/her soda with the VA and when P2 attempted to follow the VA and C2 outside, the VA tried to pull the door shut to prevent P1 from going outside with them. P1 called the SP who was at Hugo B. The SP came to the facility and told the VA if the VA hit the SP, and the SP hit the VA back, it would be “the [VA’s] problem, not the guardian’s.” The SP flexed his/her muscles and had the VA feel the SP’s bicep. During that same conversation, the SP called the VA fat “multiple times.” That same day the SP told the VA that s/he was going to talk to the G about the VA not going on a vacation to Florida because the VA was “acting up.” The SP told the VA that s/he was going to ask P4 (a supervisory person) and another person from the “office” come to the facility and “evict” the VA and also told the VA that s/he was going to take away the VA’s one-to-one. When the VA said that s/he missed P1, the SP told the VA that the reason P1 no longer worked at the facility was because P1 did not take good care of the VA, did not clean the VA or the facility, did not love the VA, and that P1 left the facility because of the VA’s behaviors. The VA was crying because of this conversation with the SP. · P2 said that s/he believed “all the clients had some fear of [the SP] for some reason” and after P2 brought his/her concerns forward, the SP talked to P2 and P2 felt “retaliation” because the SP said s/he would treat P2 different now. · P3 told P2 that s/he did not like “how [the SP] treats the clients.” P1 provided the following information: · P1 worked at the facility for several years. When asked if the clients’ one-to-ones were ever withheld, P1 said “once or twice” and that it was due to the client being “aggressive” or not acting safe on the day their one-to-one was scheduled. · When asked if s/he heard a staff person say anything demeaning to a client, P1 said “once or twice” s/he heard the SP tell the VA, “You are fat.” When asked how the VA responded, P1 said that the VA “moved on” but was “probably upset over not getting a pop.” Generally, the VA brought soda to work for lunch and at the facility was offered a substitute drink. · P1 was concerned about how the SP “treated staff” and on one occasion “screamed at” P1 in the office for “two hours.” P1 left the facility because of how s/he was treated by the SP. After P1 was no longer working at the facility, P1 “heard about things” from P2. P3 did not have any concerns about interactions s/he saw or heard between any staff persons and the clients. P3 did not hear about any staff person calling a client fat. When asked about when clients had soda pop, P3 said clients were allowed soda but “not all day long.” P3 was not aware that any clients had their one-to-ones withheld, that anyone had their vacation threatened, or that they were threatened with eviction. When asked what the clients would do if any of those incidents occurred, P3 said, “I would hope they would say something,” and “[the VA] would for sure.” P3 believed the VA would “come to staff” or tell his/her guardian. P4, a supervisory person, provided the following information: · P4 heard about the allegations from a supervisory staff person (P5) who worked at a different facility within the organization. P5 heard about allegations from a staff person (P6) who worked with P5, and who was related to P2. · When P4 asked the SP about the allegations, the SP said, “None of those things happened.” P4 was aware that the VA “was complaining” about P2 “not talking to [the VA] nicely,” however, according to the VA, “saying no, or not right now” meant that staff persons were not being nice to the VA. · P4 had no information about any client’s one-to-ones being withheld. · P4 was aware that the VA and C1 called some staff persons “the [N-word].” As a result, about a year and half ago, P4 and a human resource (HR) person came to the facility to talk to them about respect. In addition, the G talked to the VA about his/her derogatory remarks. P4 heard that the G asked the VA how s/he would feel if staff persons called the VA a “fat [R-word]” and the G told the VA that s/he would not go on vacations if the VA called others derogatory names. P4 was aware that the SP shared these conversations with P2. · When asked about the VA being told s/he would be evicted, P4 said that if the VA was told such a thing, s/he would be “very upset” and would call the G, P4, or talk to someone at his/her day program. The VA “advocated” for him/herself and when s/he was “upset, everyone knows about it.” · P4 was “blown away” by the allegations about the SP and said that P2 and the SP “were great with these [clients]” and P4 believed they “worked great together.” The VA provided the following information. P2 said “mean things” to the VA like the VA was not allowed to date, hug, or kiss. When asked about anyone calling the VA the “[R-word],” or fat, the VA identified other people by name and said they called him/her those names, but the people who said those things were clients, not staff persons. The VA said his/her favorite thing to drink was soda pop and the SP told the VA if s/he had “too much [s/he] will gain weight.” The VA admitted that sometimes s/he called staff persons the “[N-word].” When the VA was asked if s/he was ever told s/he could not attend his/her one-to-one outing, or was told that s/he may need to move out of the facility, the VA said the SP told him/her that the VA might miss his/her one-to-one if the VA got “three strikes” for engaging in “behaviors” like “calling names” and “hitting” him/herself, but that the VA was the one who said s/he would like to live at different house. The VA said that s/he “heard” the SP “say mean things” to P1 when P1 and the SP were in the office and said that the SP told the VA that P1 was “a bad person and did not know how to cook.” The VA denied that any staff persons showed him/her their bicep muscles; however, the VA said that s/he showed staff persons his/her muscles “all the time.” C1 and C2 each said that they did not hear any staff persons call any clients derogatory names. When asked if a staff person called anyone “fat,” C1 said that a van “driver” called P2 “fat.” C1 and C2 each said their one-to-one outings were not withheld. The G said that “a long time ago” the VA “could have” told him/her about not going on his/her one-to-one due to the VA’s behaviors. The G also said that s/he was the one who told the VA that the VA would not be able to go on vacation due to his/her behaviors and when the G heard that the VA called staff persons the “[N-word],” s/he told staff persons “to use the [R-word] toward [the VA] because that is what [the VA] can equate it to.” The G did not hear anything about anyone threating to evict the VA and said if the VA was told that, the VA would “give me a call and complain.” The G said that “staff changes” were difficult for the VA and s/he was “horrible” to new staff persons when it occurred. The G did not believe the VA was an accurate reporter of events. On July 11, 2025, this investigator returned to the facility to interview the SP. While in the office with the SP, the VA, C1, and C2 each returned to the facility from their day programs. The clients knocked on the office door and wanted to see, talk to, and hug the SP. The SP provided the following information: · P2 and the VA “never got along” and the SP told the VA that s/he needed to treat staff respectfully. · The SP said it was as “lie” that s/he called the VA “fat.” The SP said things to the VA such as if s/he ate certain things it would make the VA fat or make the VA gain weight. · On May 22, 2025, the SP was asked to come from Hugo B to Hugo A to address a “misunderstanding” between the VA and P2. The VA was saying s/he did not want P2 working at the facility and wanted P1 working there instead. The SP told the VA that s/he needed to “get along” with P2 and told the VA that P2 “cooks better,” bathes the VA better, and the VA needed to give P2 a chance because P1 no longer worked at the facility. The VA walked away and said, “Don’t make me say [the N-word] again.” P2 told the SP that the VA called the SP “[the N-word].” (Prior to this date, the SP told P2 about the G confronting the VA for using the N-word and the G asked the VA how s/he would feel if the SP called the VA “fat.”) · The SP denied telling the VA if the VA hit the SP, it would be the VA’s problem if the SP responded by hitting the VA. · Regarding the VA going on vacation, the SP said the conversation centered on incontinence issues that would make it difficult for the VA to comfortably fly. The SP denied telling the VA s/he would not be allowed to go on vacation. · The SP denied telling the VA that s/he would be evicted from the facility. On an unknown date, the SP told P2 about P4 and the HR coming to the facility to talk about respecting staff persons and not using derogatory names. · The SP did not tell clients that they could not have their one-to-one outings because that would “create behaviors.” · When asked why someone would say the SP did all these things, the SP said while some or part of the conversations occurred, the allegations were “twisted,” and things were “added on” that did not occur. Facility information showed that staff persons were trained regarding individual rights, person-centered thinking, client program plans, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: It was reported that the SP called the VA “fat,” the “[R-word],” threatened to have the VA evicted, and threatened to take away the VA’s vacation. It was also reported that the SP threatened to take away the clients’ (the VA and C1-C3) one-to-one outings. P2 said on multiple occasions s/he heard the SP call the VA “fat” or said, “look at you, you are fat,” and on one occasion admitted to using the “R-word” with the VA; however, the VA said the only persons who called him/her those names were other clients and that the SP told the VA if s/he drank too much soda pop the VA would gain weight. Although P1 also said that “once or twice” s/he heard the SP tell the VA, “You are fat,” information also showed there was some interpersonal conflict between the SP and P1. In addition, P1 said that after the SP said the VA was fat, the VA “moved on” but was probably “upset over not getting a pop.” Although P2 said that the SP threatened to have the VA evicted, the VA said s/he was the one to say s/he wanted to live at a different facility. The SP denied the allegations occurred as stated while admitting that some or part of the conversations took place but were taken out of context or were “twisted.” Although the SP had reason to minimize his/her interactions with the VA, information also showed P3 did not have any concerns about interactions s/he saw or heard between any staff persons and the clients, it was evident that P1 and P2 each had some interpersonal conflict with the SP. Regarding the SP withholding the clients’ one-to-one outings, the VA described incidents that possible withholding was related to his/her behaviors (name calling and self-injurious behaviors) and C1 and C2 stated their one-to-one outings were not withheld. Given that the VA provided credible information regarding the disagreement in the office between the SP and P1, and admitted that s/he sometimes called staff persons derogatory names, the VA’s credibility seemed intact and there was no reason to question the VA regarding the credibility of his/her other statements. Given the interpersonal conflict between P1 and P2 and the SP, even if some of the SP’s interactions occurred as told by P1 and P2, there was not a preponderance of the evidence whether the SP’s actions rose to the level of conduct that could reasonably be expected to produce physical pain or injury or emotional distress to the VA or the other clients. It was not determined whether 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but were not followed when a maltreatment report was not made, but not within 24 hours as required and staff persons were retrained regarding that issue. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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