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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: 1073647-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt 651-431-6556 Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP1) screamed at a vulnerable adult (VA1), “grounded” VA1 to his/her bedroom, took VA1’s personal possessions away; kicked a vulnerable adult (VA2) behind his/her knee and had a “stash” of medications in a bag that s/he told staff persons to administer to VA2 when VA2 had “obsessive behaviors;” and sprayed cold water on VA2 when VA2 had behavioral incidents. Allegation Two: It was reported that a staff person (SP2) fell asleep during an awake overnight shift and that VA2 fell during the overnight shift and broke his/her nose. It was also reported that SP2 sprayed VA2 with cold water in the shower and forced him/her to stand in the corner of the shower. Allegation Three: During the investigation, it was reported that a staff person (SP3) put dish soap on a vulnerable adult’s (VA3) food. Date of Incident(s): Prior to July 18, 2024 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), clauses (1) and (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: · 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. 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 scheduled site visit conducted on August 7, 2024, and an unscheduled site visit conducted on August 15, 2024; from documentation at the facility, from VA2’s medical records; and through seven interviews conducted with SP1, SP2, SP3 (former staff person), a facility staff person (P1), a former staff person (P2), VA3, and VA1’s guardian (G). VA1 and VA2 were unable to provide information due to their respective disabilities. VA2 and VA3 were not subject to guardianship. VA1 was diagnosed with anxiety, depression, seizure disorder, dementia, and traumatic brain injury. VA1’s Self-Management Assessment showed that s/he enjoyed going into the community and talking to people. VA1 had a history of making inaccurate “allegations” and “embellishing stories.” VA1 engaged in verbal and physical aggression toward others. When VA1 engaged in behavioral incidents, staff persons were trained to “talk through episodes” and allow VA1 “quiet time.” VA2 was diagnosed with anxiety, bipolar disorder, and attention deficit hyperactivity disorder. VA2’s plans showed that s/he enjoyed watching television, attending “car shows,” and visiting the zoo. VA2’s plans stated that “dementia interventions should be used when [VA2] is agitated or confused.” VA2 needed assistance with completing bathing/showering tasks and medication administration. VA2 used a walker. VA3’s plans showed that s/he enjoyed going into the community and attending parades. Some of VA3’s diagnosis included post-traumatic stress disorder, anxiety, and “reactive attachment disorder.” Information from personnel records showed that all staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the clients care plans prior to August 2024. Allegation One: It was reported that SP1 screamed at VA1, “grounded” VA1 to his/her bedroom, took VA1’s personal possessions away; kicked VA2 behind his/her knee and had a “stash” of medications in a bag that s/he told staff persons to administer to VA2 when VA2 had “obsessive behaviors;” and that SP1 sprayed cold water on VA2 when VA2 had behavioral incidents. SP3 provided the following information: · When VA1 engaged in behavioral incidents, SP1 instructed staff persons to seclude VA1 to his/her bedroom, sometimes up to nine days but VA1 was allowed to leave the room for meals. VA1’s personal possessions, such as puzzles and bed linens, were removed. SP1 told SP3 that the G agreed that VA1 should be “punished.” On an unspecified date, SP3 talked to the G and the G told SP3 that VA1 could be told to go to his/her bedroom for up to 15 minutes when s/he had behavioral incidents, but that the G had not agreed to more time than that. · There were times that SP1 found out that staff persons allowed VA1 out of his/her bedroom when SP1 was not at the facility and when that happened, “all hell would break loose,” and SP1 “would scream” at staff persons. · When VA1 did not eat all his/her meal, SP1 instructed staff persons to put the remaining food in the refrigerator without a covering and the next time that VA1 ate a meal, staff persons were told to give the “cold” and “crusty” food to VA1. (Investigator’s note: on the day of the unannounced site visit, August 15, 2024, the investigator looked inside the refrigerator, and all foods were covered and labeled.) When SP1 talked to VA1, SP1’s tone of voice was “loud and quite demeaning.” SP3 gave an example in which SP1 yelled at VA1 when VA1 was incontinent on his/her pants, which “crushed” VA1’s “spirit.” · On two unspecified dates, SP3 saw SP1 take a water bottle from the refrigerator and “squirt” water on VA2’s upper body when VA2 was being “really bad.” One of those incidents, SP1 did this when VA2 was not eating slowly enough. · On an unspecified date, SP3 saw SP1 kick the back side of VA2’s knees. SP3 did not know why SP1 did that and did not remember how VA2 reacted. · SP1 maintained a box of VA2’s unlabeled medications in a “baggie.” The box, which was stored below scheduled medications, had SP1’s name on it. On several occasions, SP3 saw SP1 take the medications out and give them to VA2 when VA2 had a “really bad day with [his/her] behaviors.” (Investigator’s note: on the day of the unannounced site visit, the investigator observed the box, which contained snacks, but there was no medication stored in the box.) · SP3 stated that SP1 had a written document that outlined specific staff person actions for the clients. SP3 emailed the document to this investigator. The document did not have a date or SP1’s name or signature on it and stated the following regarding VA1: o VA1 “should receive no rewards for 3 days when grounded for bad behavior. This means no dessert, no snacks, no cards, no outings, no walks, no TV.” o If VA1 had leftovers, they “must be served.” “Do not throw them away and give [VA1] what new food was cooked.” “If [VA1] refuses to eat the leftovers, they are kept until the following meal.” On the day of the unannounced site visit, this investigator and the facility’s adult foster care licensor reviewed all the clients’ files, and the document provided by SP3 was not found. SP1 denied being the author of this document and did not have knowledge of its existence. The G stated that SP3 told him/her about some concerns that SP3 observed related to VA1, such as giving VA1 the same food over and over, secluding VA1 to his/her room, and taking VA1’s possessions away. The G was fine with VA1 going to his/her bedroom for 15-20 minutes for behavioral incidents, but that s/he had not agreed to anything more. On an unspecified date, the G visited VA1 and during the visit, VA1 told the G that SP1 told VA1 that s/he needed to stay in his/her bedroom for one day and when the G told SP1 that VA1 should be allowed out of his/her bedroom, SP1 told the G that VA1 was “grounded.” VA3 stated that s/he had not witnessed VA1 being told to go to his/her bedroom, but that there were some instances in which VA1’s belongings, such as blocks, were taken for one day by staff persons, but VA3 did not remember who did that. VA3 also said that s/he did not see staff persons take VA1’s bed linens. VA3 did not have knowledge of clients having to eat cold and improperly stored foods from the refrigerator. VA3 stated that s/he was not secluded to his/her bedroom. P1 did not have any concerns related to how staff persons treated VA1-VA3. P1 described SP1’s tone of voice as being “nothing out of [the] ordinary.” P1 did not have any concerns with how medications were administered and said that they were done in accordance with training. P1 stated that s/he had not observed any staff person being physically abusive to any of the clients. P1 said that some of VA1’s belongings, such as clothes hangers, were removed for short periods of time when VA1 used them as weapons. P1 did not see SP1, or any staff person, spray water on any of the clients and did not see food being improperly stored, or food being given to clients that was improperly stored. P2 stated that s/he did not remember the date but came to work one day and found VA1 “crying” in his/her room because SP1 “grounded” VA1. On another occasion, SP1 told P2 that VA1 needed to remain in his/her bedroom for “three straight days,” and sometimes up to “two weeks,” but that VA1 could leave the room to use the bathroom or to eat meals in the dining room. When VA1 was secluded to his/her bedroom, his/her bed linens and personal possessions were removed. P2 said that s/he did not follow SP1’s rules and that SP1 directed staff persons to put VA1’s leftover food in the refrigerator uncovered and that staff persons were told to have VA1 eat the “cold” and “crusty” food. Sometimes, VA1 was served the same food for up to three days and that it was “absolutely disgusting.” P2 stated that SP1 had cameras installed in the common areas of the home and watched the cameras when SP1 was off duty. (Investigator’s note: when investigator toured the facility, there were no cameras.) When SP1 saw that VA1, who was supposed to be in his/her bedroom, was out of the room, SP1 went to the facility and yelled at staff persons. When VA1 saw SP1 come to the facility, VA1 would “book it” to his/her bedroom. P2 also said that while VA2 was ambulating one time, VA2 was not moving his/her knees and when that happened, SP1 kicked the back of VA2’s knees. P2 did not know if VA2 sustained an injury. P2 did not see SP1 spray water on the clients. P2 also said that SP1 had a “stash of drugs” s/he administered to VA2 and that SP1 administered the medications to VA2 when VA2 asked to use the bathroom. SP2 stated s/he did not hear staff yell at the clients, did not see any physical aggression from staff persons to clients, and that medications were not administered without following doctors’ orders. SP2 stated that clients were not told to remain in their rooms even though some occasions it did occur for short periods of time during shift change so staff persons could exchange information without the clients hearing the information. SP2 said that there were times that VA1’s personal belongings, such as clothes hangers, were removed when VA1 threw them at staff persons. SP1 denied yelling at the clients, denied telling any of the clients they needed to remain in their rooms, denied serving the same food repeatedly, denied administering medications incorrectly, and denied spraying the clients with cold water. SP1 said that there were times that clients were told to go to their bedrooms to calm down, but that the door was kept open at the time. In addition, SP1 denied using any type of physical aggression toward any of the clients and denied kicking VA2. SP1 stated that when clients had behavioral incidents, SP1 talked to the clients and provided verbal redirection. SP1 also stated that the box contained snacks, but never contained medications. SP1 believed that P2 and SP3 were upset with SP1 because SP1 was their supervisor and SP1 had discussions with P2 and SP3 regarding their work performance, such as not doing household chores and incomplete documentation. There was no information that SP3 or P2 brought up any of their concerns regarding SP1 while they worked for the facility. Relevant Minnesota Rules and or Statutes Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) requires the license holder to ensure that a client was treated with courtesy and respect. Conclusion for Allegation One: Regarding physical abuse: Although P2 and SP3 each stated that SP1 kicked VA2 being the knee, given that SP1 denied kicking VA2, that P2 and SP3 could not provide details such as when this occurred or if VA2 was injured, there was not a preponderance of the evidence whether SP1 kicked VA2 or engaged in conduct that would reasonable be expected to produce pain or injury. It was not determined whether physical 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). Regarding emotional abuse: SP3 stated that s/he saw SP1 squirt water on VA2 and that SP1 screamed at VA1. SP3 stated s/he did not see SP1 squirt water on VA3. SP3 and P2 each stated that SP1 secluded VA1 in his/her bedroom. P1 and P2 did not see any of those things occur. The G stated that when s/he visited the facility, VA1 told the G that s/he had to stay in his/her room and SP1 told the G that the VA was “grounded.” P2 had concerns that SP1 removed VA1’s personal belongings. VA3 stated that s/he did not see VA1 being secluded to his/her bedroom, did not see staff persons take VA1’s bed linens, and one occasion a staff person took VA1’s blocks. Sometimes staff persons removed objects from VA1’s bedroom if VA1 could use them to harm him/herself and or others. Although it was concerning that it was alleged that SP1 “grounded” VA1, squirted water at VA2, and screamed at VA1 all of which was behavior 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 there was no information that VA1 was not able to physically leave his/her room, that SP1 denied all the allegations, and that there was not enough information regarding specific occurrences or the effects these things had on VA1 and or VA2, there was not a preponderance of the evidence whether SP1’s conduct rose to the level of emotional abuse and or would be reasonably considered 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). Regarding neglect: Although P2 and SP3 each said that SP1 administered unlabeled medications to VA2 and that SP1 made clients eat “crusty” food that was not properly stored, given that SP1 denied the allegations, that during the site visits, food was properly stored, that no one else had information that either of these occurred, and that there were no medications located in SP1’s box, there was not a preponderance of the evidence whether SP1 failed to provide reasonable and necessary care and services. 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 SP2 fell asleep during an awake overnight shift and VA2 fell during the overnight shift and broke his/her nose. It was also reported that SP2 sprayed VA2 with cold water in the shower and forced him/her to stand in the corner of the shower. SP3 said that s/he did not remember the date but remembered an incident when SP2 worked the overnight shift, which was supposed to be an awake shift, but SP2 slept and VA2 fell and broke his/her nose and needed to go the hospital. SP3 said that s/he was not working when the incident occurred and received that information from SP2. SP3 also said that on one occasion, SP2 told SP3 that while SP2 assisted VA2 with showering, VA2 was not listening. As a result, SP2 turned the shower water to “cold” and sprayed VA2, who was still clothed, and when the shower was done, told VA2 to stay in the shower for one hour. P2, who was working at the time, did not remember the date but said that SP2 told P2 that s/he sprayed VA2 with cold water because VA2 did not wash his/her ears “properly” and told VA2 to stay in the shower for one hour. P1 stated that VA2 did not need physical assistance with ambulating but might need verbal reminders to keep his/her walker close to him/her, as VA2 tended to keep the walker “out too far.” P1 also stated that although VA2 fell and sustained a nose injury, the incident did not happen during the overnight shift. SP2, who worked the overnight shift periodically, denied sleeping during the overnight shift and did not recall the date or time but said that s/he was in front of VA2, who had just used the bathroom, and that SP2 stepped out of VA2’s way. VA2 pushed the walker, but his/her feet remained in place and when that happened, SP2 verbally told VA2 to “pull” the walker back toward VA2, but VA2 “lost [his/her] balance” and fell before SP2 could intervene. SP2 did not remember exactly what happened to VA2 but remembered that s/he assisted VA2 up and that medical attention was sought. SP2 denied spraying anyone with cold water in the shower. The facility’s Consumer Incident Report, written by SP2, showed that at 8:15 a.m. on May 6, 2024, VA2 pushed his/her walker “too far” ahead of VA2 and while “staff stayed” with VA2, VA2 fell forward and ended up “hitting the ground face first and breaking [his/her] nose.” The report noted that 9-1-1 was called and VA2 returned to the facility at about 3 p.m. with a “broken nose glued.” VA2’s medical records, dated May 6, 2024, showed that VA2 was seen in the emergency room (ER) due to a “fall” and a “facial laceration” and that VA2 was diagnosed with a “closed fracture of nasal bone.” Conclusion for Allegation Two: Information showed that VA2 fell resulting in a fractured nose. SP3 stated this occurred on an overnight shift when SP2 worked but was sleeping. SP2 denied sleeping and stated that VA2 fell in the morning while SP2 prompted VA2 to use his/her walker. SP2 called 9-1-1 and VA2’s injury was treated. SP3 and P2 each stated that SP2 told them that s/he sprayed VA2 with cold water in the shower, but SP2 denied doing so. Although VA2 fell and sustained a broken nose and SP3 and P2 said SP2 told them s/he sprayed VA2 with cold water, given that SP2 provided information consistent with documentation and denied spraying VA2, that SP3 and P2 did not witness either event, that SP2 called 9-1-1 and medical care was immediately sought, and that there was no further information regarding SP2 spraying VA2, there was not a preponderance of the evidence whether SP2 failed to provide VA2 with reasonable and necessary care and services. 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 Three: During the investigation, it was reported that SP3 put dish soap on VA3’s food. P1 did not remember the date but saw a “large” amount of dish soap on VA3’s sandwich. When P1 saw that, s/he asked SP3 about it and SP3 thought it was “funny.” P1 did not know if VA3 ate any of the sandwich. P1 also stated that SP3 and VA3 took turns spraying water, from the kitchen sink, on one another. Both incidents occurred on the same day. SP3 said that because VA3 asked for a snack just before a meal was served, SP3 made a sandwich for VA3, but put dish soap on the sandwich because SP3 believed that if VA3 ate the sandwich, VA3 would not eat his/her dinner. SP3 did not remember how much soap s/he put on the sandwich but stated that VA3 did not eat the sandwich. SP3 also stated, “I did not handle that situation correctly, which is why I got out of there, because I didn’t want to continue to do stuff like that.” VA3 said that s/he had “two bites” of the sandwich that contained the dish soap, but that s/he did not see SP3 put the soap on it. VA3 said that s/he was “very upset.” SP2 said that SP3 told him/her that s/he put soap on VA3’s sandwich because VA3 wanted a sandwich “close to mealtime,” but that VA3 did not eat the sandwich. P2 said that s/he did not see anyone put soap on VA3’s sandwich. The facility had a policy and procedure which stated that “employees will interact with clients in a professional and respectful manner at all times.” Conclusion for Allegation Three: A. Maltreatment: SP3 stated that s/he put dish soap on VA3’s sandwich, but that VA3 did not eat the sandwich. However, VA3 told this investigator that s/he had a couple bites of the sandwich and was “very upset” when s/he learned what SP3 did. According to P1, SP3 thought that the incident was “funny.” SP3’s behavior was inconsistent with the standards of a professional caregiver in a facility licensed by the Minnesota Department of Human Services. Given that SP3 stated s/he put a non-edible substance used for cleaning on VA3’s sandwich and that VA3 stated s/he took two bites of the sandwich, likely ingesting the soap, there was a preponderance of the evidence that SP3 failed to provide VA3 with reasonable and necessary care and services to maintain VA3’s health and safety. It was determined that 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). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Given that SP3 was trained on the Reporting of Maltreatment of Vulnerable Adults Act, SP3 was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which SP3 was responsible did not meet statutory criteria to be determined as recurring or serious because this was a single incident and VA3 did not have an injury requiring the care of a physician. Action Taken by Facility: The facility’s Internal Investigation Report stated that policies and procedures were adequate, followed, and that additional training was not needed Action Taken by Department of Human Services, Office of Inspector General: SP3 was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, SP3 was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of SP3. The determination that SP3 was responsible for maltreatment is subject to appeal. The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action. On October 27, 2025, the facility was issued a $200 fine for a background study violation. The Order to Forfeit a Fine is subject to appeal.
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