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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: 1120791-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Beth Virden Christine.Cavanaugh@state.mn.us Suspected Maltreatment Reported: Allegation One: It was reported that staff persons (SP1 and SP2) “overmedicated” a vulnerable adult (VA1) to “restrain” him/her and prevent “behaviors.” Allegation Two: It was reported that SP2 “berated” and “despised” a vulnerable adult (VA2). Date of Incident(s): August 9, 2025; other dates unknown 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 site visits conducted on August 27 and September 10, 2025; from documentation at the facility and medical records; and through 18 interviews conducted with VA2, VA1’s and VA2’s respective guardians (G1 and G2), VA1’s case manager (CM), facility staff persons (SP1, SP2, and P1-P11), and a supervisory staff person (P12). The DHS investigator met VA1 at the site visit but VA1 declined to be interviewed. Attempts were made by telephone to contact and interview additional staff persons (P13 and P14), but P13 did not respond by the completion of this investigation and P14 declined to be interviewed. The facility was a two-level house with VA1 living downstairs and VA2 living upstairs. The facility provided separate staffing for VA1 and VA2. Facility documentation stated that SP1, SP2, and P1-P12 were trained on VA1’s and/or VA2’s support plans and the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that SP1 and SP2 “overmedicated” VA1 to “restrain” him/her and prevent “behaviors.” VA1’s support plans, including Support Plan and Behavior Support Plan, provided the following information: · In 2023, VA1 moved into the facility seeking support and services relating to his/her diagnoses, which included schizophrenia. · VA1 liked dancing and going on rides at Valley Fair and Mall of America. VA1 typically woke up each morning between 7 and 9 a.m., went to bed around 7:30 or 8 p.m., and liked to nap during the day. · VA1 had a history of aggressing toward others and throwing fecal matter. Staff encouraged VA1 to look at his/her pictures, play bean bags, or watch/listen to his/her favorite shows/music. If VA1’s aggression increased, staff remained calm and neutral and encouraged VA1’s coping skills. · Staff prepared and administered VA1’s medications as prescribed. · VA1’s prescriptions included Olanzapine (antipsychotic) 10 milligrams (mg) tablets – Take one tablet by mouth every day as needed (PRN) for agitation. [Note: VA1’s Support Plan stated that when VA1 experienced increasing agitation, staff followed his/her Behavior Support Plan. There was no mention in VA1’s Behavior Support Plan, or support plan addendum, regarding how the facility administered VA1’s psychotropic medication and/or the target symptoms to be alleviated by each psychotropic medication. These were violations of Minnesota Statutes 245D.05, subdivision 1, paragraph (b); and 245D.051, subdivision 1, paragraph (b).] VA1’s Psychiatry Consultation Form stated that on August 5, 2025, VA1 received a new prescription for Olanzapine 2.5 mg tablet – take one tablet by mouth every morning daily. This did not change VA1’s preexisting PRN prescription for Olanzapine 10 mg, meaning s/he was now prescribed a scheduled Olanzapine dose every morning and a PRN Olanzapine dose for agitation. G1, the CM, P4, P5, P7, and P9 each expressed concerns that SP1 and/or SP2 were overusing VA1’s PRN, which might be an attempt to “overmedicate” so that VA1 was tired and/or engaged in “fewer behaviors.” P4, P5, P7, and P9 each said that staff were supposed to redirect and deescalate VA1’s behaviors before administering his/her PRN, but SP1 and SP2 seemed to administer VA1’s PRN more frequently than other staff. P4 and P5 each said that SP2 told them if VA1 was “misbehaving give [him/her] a PRN.” P9 said that on August 9, 2025, s/he arrived at work and VA1 appeared “extremely drowsy” and “high” and that SP2 administered VA1’s PRN that day. SP1 and SP2 each denied overusing VA1’s PRN and/or administering the PRN when it should not be used or without first attempting other behavior support strategies. P1, P2, P3, P6, P8, P10, P11, and P12 each had no concerns or limited direct knowledge of the concerns. Facility documentation included the following: · VA1’s Medication Administration Record (MAR) stated that during July 2025, SP1 administered VA1’s PRN on July 4 and 23. [Note: VA1’s MAR did not document a notation for each PRN administration, which was a violation of Minnesota Statutes 245D.05, subdivision 2, paragraph (c), clause (6).] · VA1’s MAR stated that during August 2025; P14, SP1, or P6 administered VA1’s PRN on August 6, 7, 9, and 11. The Incident Report for August 9 stated that SP1 administered VA1’s PRN because VA1 was “very agitated” and “No amount of redirection was able to help.” · At the time of the site visit on September 10, 2025, the DHS investigator photographed VA1’s medications. VA1’s PRN Olanzapine was last filled August 11, 2025, with a 30-day supply. All 30 tablets were present, indicating that no PRNs were administered between August 11 and September 10.
Conclusion for Allegation One: Information was provided that on August 9, 2025, VA1 appeared “extremely drowsy” and “high”; and more than one staff person expressed concern that VA1’s PRN Olanzapine was being overused by SP1 and SP2. However, VA1’s MARs showed that his/her PRN was administered twice in July 2025 and four times in August 2025, and zero times in September 2025 as of September 10. The documentation for August 9 showed that VA1 was experiencing increasing agitation and not responding to attempts to redirect or deescalate, which supported the administration of his/her PRN; and without additional information to state otherwise, there was not a preponderance of the evidence whether there was a failure to supply VA1 with care or services, which were reasonable and necessary for his/her 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 SP2 “berated” and “despised” VA2. VA2’s support plans, including Self-Management Assessment, provided the following information: · In 2024, VA2 moved into the facility seeking support and services relating to his/her diagnoses, which included schizoaffective disorder. · VA2 liked going out for coffee and shopping at thrift stores and was “polite” and “easy-going.” · VA2 had a history of property destruction and self-harming behaviors. Staff monitored VA2’s mood daily and encouraged him/her to engage in his/her chosen activities, such as coloring, playing games, and listening to meditation music. P9 said that more than once, SP2 called VA2, “bitch” and “fat,” and was “very critical about [VA2’s] weight” when speaking to other staff. P9 did not know if SP2 ever said these things directly to or within earshot of VA2. P9 heard SP2 argue with VA2 “a lot,” “almost every day,” about unspecified topics. VA2 told P9 that s/he felt “anxious” around SP2. P4 said that about “a week and a half ago,” s/he was standing outside and heard SP2 through an open window tell VA2, “You’re lazy. All you want to do is sleep, eat, and be fat.” VA2 responded to SP2 by “screaming.” VA2 said that SP2 told him/her, “You need to start losing weight and go for walks,” which made VA2 feel “bad.” VA2 had back pain and difficulty walking. One time, SP2 told VA2, “You’ve been crabby all day.” SP2 was “very stern” and made VA2 “anxious” and “really nervous.” SP2 never swore at VA2. SP2 said that s/he did not call VA2 names and believed the allegations were made because there was “drama” among staff.
P1, P2, P3, P5, P6, P7, and P10 provided information that at times, when SP2 spoke to other staff, s/he was “unprofessional” and called VA2, “fat” and “lazy,” but this was never done within earshot of VA2. VA2 told various staff that SP2 made him/her feel “anxious” but did not go into details and never told anyone that SP2 called him/her “fat” or “lazy.” G2 said that VA2 was “pretty open” and would tell G2 of any concerns. VA2 never told G2 concerns about SP2’s conduct. VA2 had a history of not always providing accurate information depending on his/her mood and feelings toward specific staff. Conclusion for Allegation Two: Information was provided that SP2 called VA2, “bitch” and “fat,” when speaking to other staff. VA2 did not tell anyone that s/he ever heard SP2 calling him/her names and information was provided that VA2 would say something if s/he heard this. P1, P2, P3, P5, P6, P7, and P10 provided information that SP2’s statements were never directed at or within earshot of VA2. Although calling VA2 names was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, there was not a preponderance of the evidence whether VA2 heard SP2’s statements and/or whether SP2’s statements produced or could reasonably be expected to produce emotional distress and included the use of repeated or malicious oral language or the treatment, which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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). Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate and followed and that there was not a need for additional training or corrective action. The incidents were not like past events involving VA1, VA2, SP1, and/or SP2. Action Taken by Department of Human Services, Office of Inspector General: On November 12, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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