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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: 1073198-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson Suspected Maltreatment Reported: It was alleged that a vulnerable adult’s (VA’s) mattress was “black,” “soaked through,” and “sunken in” because of urine. In addition, there was trash in the VA’s bedroom and in the common areas of the facility. Date of Incident(s): Ongoing prior to August 29, 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 17, paragraph (a): 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 an unannounced site visit conducted on September 10, 2025; from documentation at the facility; and through three interviews conducted with the VA, a facility supervisory staff person (P1), and the VA’s guardian (G). An administrative staff person (P2), a county licensor (L), and the VA’s case manager (CM) each provided additional information via email that was included below. The facility was a single-family home with a main floor, upper level, and basement. There were three bedrooms, including the VA’s, and one bathroom on the upper level, and one bedroom and bathroom on the lower level. There were two common areas, one on the main floor and one in the basement. There were two other residents who lived at the facility with the VA. On September 10, 2025, this investigator conducted an unannounced site visit to the facility. The VA’s room had no trash or clothes on the floor or on furniture. There were two plastic water bottles on a table that the VA put in the recycling in the kitchen during site visit. The facility appeared to have less trash and was tidier than when the G and the L took the photos. The VA’s plan for cleaning posted on the refrigerator in the kitchen and showed that staff assisted the VA with cleaning his/her room on Thursdays and helped all three residents clean the common areas on Mondays and Saturdays. The VA’s diagnoses included pervasive developmental disorder, attention deficit hyperactivity disorder, a neurocognitive deficit, severe anxiety, and autism spectrum disorder. The VA liked to play video games, watch movies, and hang out with his/her housemates. The VA’s Coordinated Services and Support Plan (CSSP) dated August 31, 2024 - August 31, 2025, showed that the VA “struggled” to keep his/her room clean. The CSSP also stated that staff “should” check the VA’s room at the end of their shifts to ensure that there were no dirty dishes or garbage in the VA’s room and that “if [the VA] did not clean [his/her] room staff may clean it for [him/her].” An undated Incident Report provided by the facility showed that the VA’s bedroom “was not maintained to meet sanitary conditions.” The VA left used dishes in his/her room for “too long,” and did not throw away his/her trash. The VA did not “tidy” his/her room which resulted in it becoming very “messy.” The VA had a cleaning schedule with a supporting goal and objective to maintain a clean room which the VA struggled with for “many years.”
· On August 28, 2025, the G visited the VA and saw that his/her bed “soaked in urine,” and did not have a sheet or mattress protector. Prior to this date, the G did not have concerns about the condition of the VA’s bed or of the facility although the VA’s room and clothes were typically “dirty.” · The G stated that the VA did not want to clean his/her room so the VA’s team was going to add a section to the VA’s plans about staff cleaning the VA’s room. Cleaning the VA’s room “needed to be” the staff persons’ responsibility because the VA’s bedroom was “unsanitary” if left up to the VA to clean. · A photograph of the VA’s bedroom taken on August 28, 2025, showed a portion of the VA’s bedroom and half of the VA’s mattress was visible. Approximately 2/3 of the mattress was grey with additional brown spots/marks. There was a small portion of mattress that appeared clean and unstained and the remainder of the mattress was covered in the VA’s property and/or plastic bags. A mini fridge, storage trunk, table, and TV were also in the photo and there was an opened bag of potato chips on the floor and some garbage and packaging from something purchased. [Note: There are no dishes or food in the photograph and the mattress appeared to be dry.] The L via email, photos taken by the L, and a Correction Order dated August 29, 2025, provided the following information: · On August 29, 2025, the L went to the facility and took photos. The L took eight photos of the VA’s bedroom which showed the VA’s personal items scattered throughout the room on the furniture and the floor. Also scattered around the room on the furniture and floor were dirty dishes and silverware and various sized pieces of garbage. In one photo, the VA had a clean white fitted sheet on his/her mattress and a comforter was on top, but in two other photos, the fitted sheet was lifted and showed the mattress with the same grey and brown spots/marks that were in the G’s photo. · The L also took four additional photos of the facility, which showed one bedroom that was clean and tidy; one bedroom that had an unmade bed and a few items of clothing on the floor; a living area with items scattered throughout the room on the furniture and floor; and one that had what appeared to be a garbage bag filled with clothing on the floor next to a garbage can. Another photo showed the inside of the refrigerator, which was clean and had various food items, and another photo was of an August (2025) “Cleaning Calendar.” The cleaning calendar began with items starting on August 10 and the items included whose bedroom was being cleaned each day. · The L talked to P1 who said that staff tried to follow a cleaning schedule, but the VA and his/her housemates refused so staff did not clean. The L issued the facility a Correction Order that stated a violation of Minnesota 245D.21, subdivision 2, “Home is dirty, garbage lying around on the floor and garbage bags full around the house, directly floors, mattress is filthy with stains which might need to be further assessed, staff reportedly not following cleaning schedule, home smells dirty and greasy smells, lines not washed and not on the bed. Dirty dishes in bedrooms.” On September 5, 2025, the facility provided the corrective action that included “deep cleaning” the bedrooms and common areas, implementing a weekly cleaning schedule, and replacing the VA’s mattress. P2 also attached photos of the corrections. The VA stated that the facility got him/her a new mattress one week prior to this investigator’s site visit. The VA and staff had a “new plan” to keep his/her room clean that included taking trash to the kitchen. The VA showed this investigator the trash cans and recycling bins where s/he put his/her garbage and pointed out the cleaning schedule that s/he and staff follow that was posted on the refrigerator in the kitchen. The VA added that s/he knew a report was being made about the condition of his/her room but was “disappointed” that it was reported because his/her team made a cleaning plan, and the facility already got him/her a new mattress. P1 provided the following information: · P1 began supervising the facility on April 1, 2025. At that time P1 met the VA and visited the facility. The VA’s room had trays with “half eaten food,” piles of dirty clothes on the floor, and his/her mattress was “grey.” Staff persons were to clean the VA’s room, but the VA often refused to let staff persons do so, so it did not get cleaned. · P1 then implemented a timer for staff and the VA to use where they would clean the VA’s room together for 5-to-10-minute increments with breaks. The VA still often refused, and staff persons did not always clean the VA’s room because of the VA’s refusal, however, the condition of the VA’s room was had improved since s/he began working at the facility in April. · On August 29, 2025, P1 participated in a meeting with the VA’s team. The team decided to update the VA’s plans to reflect that the VA needed to keep his/her room clean and if s/he did not, staff persons were required to assist him/her in cleaning. P1 then checked the VA’s room four days a week to ensure cleanliness and do any additional cleaning that was necessary. · P1 stated that after the meeting, s/he and P2 ordered the VA a new mattress and on September 4, 2025, it was delivered. P1 stated that s/he did not know of any time that the VA’s mattress was saturated with urine and thought that the discoloration on the mattress was due to body oil, sweat, and food spills. Prior to the change in the VA’s plans, staff persons did not think that they could clean the VA’s room if the VA refused and did not want them to clean it. P2 via email and photos taken by P2 provided the following information: · The VA “struggled” maintaining a clean room for “many years.” Staff persons prompted the VA to clean but the VA made “excuses” why s/he could not clean his/her room. Then when staff persons attempted to clean the VA’s room, the VA got “upset” so staff persons “backed off.” On August 28, 2025, a new protocol and schedule was implemented for assisting the VA in cleaning his/her room and P2 communicated to all staff persons that the VA could not refuse to allow staff to clean his/her room if they saw “unsanitary” conditions. · P2 said that the VA’s mattress was “black on one side” but it was not soaked in urine. The mattress was purchased in February 2025, and the VA used one side of the mattress as a table for drinks and food. The VA’s mattress was replaced again on September 4, 2025. · Five photos of the VA’s room and the facility showed that the VA had a new mattress and new clean linens and there was no visible garbage, dishes, or clothes on the floors or furniture. The CM provided information via email that on August 29, 20205, the CM met with the VA, the G, another family member of the VA’s, a facility nurse, and P1. The G told the CM that the VA’s mattress was “sagging” in the middle, and stained with urine, sweat, and/or food. The CM said it was “pretty usual” for the VA’s room to be messy, but the condition of the mattress was “not normal.” The VA was unable to tell when things were “too dirty” and that s/he needed assistance with keeping things clean. At the end of the meeting, a plan was agreed upon that outlined how staff persons would assist the VA in cleaning his/her room and a new mattress was ordered for the VA. Facility documentation showed that P1 and P2 were involved in the creation of the VA’s plans and therefore did not need to receive training. P1 and P2 were also trained on the Reporting of Maltreatment of Vulnerable Adults Act. Relevant Rule and Statute: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5) stated in part that a person’s protection related rights includes the right to receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site. Minnesota Statutes, section 245D.24, subdivision 3, paragraph (d), clauses (1) and (2) stated in part that each person must be provided with a clean mattress in good repair and clean bedding appropriate for the season.
Conclusion: Information obtained showed that prior to August 29, 2025, the VA’s room was untidy/dirty, contained garbage and dirty dishes/utensils, and his/her mattress was at least 2/3 stained grey with additional brown spots/marks. In addition, other areas of the facility were untidy/dirty and had garbage on the floor and furniture. These were violations of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (5); and section 245D.24, subdivision 3, paragraph (d), clauses (1) and (2). P1 stated that the VA often refused to allow staff persons to clean his/her room. As of September 5, 2025, the facility “deep cleaned” the bedrooms and common areas, implemented a weekly cleaning schedule, and replaced the VA’s mattress. Five photos of the VA’s room and the facility showed that the VA had a new mattress and new clean linens, and there was no visible garbage or dishes on the floor or furniture. On September 10, 2025, at the time of the unannounced site visit, the VA’s room had no trash on the floor or furniture and the facility was tidier than previously seen by the G and the L and documented with pictures. Although there was a period that the VA’s room was dirty and his/her mattress was soiled, the VA was given a new mattress in February 2025 and within a month or two the mattress became soiled again which according to P2 was because the VA used a portion of it as a table for his/her food and beverages. Given this, that the VA was given another new mattress seven months later, and that the VA’s team implemented a plan that allowed staff to clean the VA’s room even if the VA refused, there was not a preponderance of the evidence whether there was a failure or omission to supply the VA with care or services that were reasonable and necessary to maintain the VA’s physical or mental health or 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.) Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed because staff persons did not support the VA in maintaining a clean bedroom. There was a need for additional staff training and all staff persons that worked with the VA were retrained on the VA’s plans for cleaning and the new policy regarding no food in client rooms. P1 monitored the staff to ensure they followed the cleaning schedule and sent pictures of the VA’s room to the G and CM weekly, per their request. Action Taken by Department of Human Services, Office of Inspector General: On August 29, 2025, the L issued a Correction Order for a violation of Minnesota 245D.21, subdivision 2, regarding the cleanliness of the facility. Given this and that the facility took corrective action, the facility was not issued a Correction Order for the additional violations outlined in this report.
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