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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: 1110168-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery 651-431-6474 Suspected Maltreatment Reported: It was reported that a staff person (SP1) threw a cup of juice at a vulnerable adult (VA) and called the VA a “fat fuck.” Another staff person (SP2) was asleep during the altercation and was not providing adequate supervision to the VA. Date of Incident(s): August 10, 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); 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 August 22, 2025; from documentation at the facility; and through seven interviews conducted with facility staff persons (SP1, SP2, and P1), supervisory staff person’s (P2 and P3), the VA’s guardian (G), and the VA. The VA liked to go for walks and be outdoors, watch movies, and go out into the community. The VA was diagnosed with schizoaffective disorder. The VA did not have housemates and required two staff persons present 17 hours per day and one awake staff present overnight. The VA’s Individual Abuse Prevention Plan stated that the VA was “very impulsive” and would not “think about possible consequences” of his/her actions. The VA “may engage in behaviors that provoke others to aggress toward him/her and would be susceptible to physical and emotional/verbal abuse”. The VA’s Crisis Plan identified that the VA was not to have access to excessive amounts of fluids and would “steal beverages, drinking utensils, and drink fluids including out of the toilet.” The VA provided the following information: · On August 10, 2025, the VA took and drank SP1’s espresso coffee drink that was in a can that SP1 left in the kitchen. · SP1 threw juice in the VA’s face then pushed the VA against the wall in the hallway and told the VA that s/he would “fuck his/her life up” if the VA continued to “steal” SP1’s coffee. · SP2 was “dozing off” in a recliner in the living room when SP1 threw juice at the VA and pushed the VA. · SP1 worked on and off with the VA for eight years. During a period of time when SP1 was not working with the VA, the VA told staff persons that SP1 had done meth with the VA, but the VA was “joking” and wanted to be “funny.” · The VA was not hurt by SP1’s actions but was “disappointed” with how SP1 handled the situation. To the VA’s knowledge, SP2 should not have been sleeping in the recliner in the living room. The VA did not know and was not able to guess how long SP2 was sleeping. SP1 provided the following information: · On August 9, 2025, SP1 was working at the facility with SP2. At some point between 8:30 and 9:30 a.m., SP1 put his/her can of espresso coffee drink by the stove in the kitchen and told SP2 that s/he was going to go outside to smoke a cigarette, and that the VA was getting ready to take a shower. SP1 went outside with an 8-ounce cup of juice. · When SP1 came back inside a few minutes later, as they were coming up the stairs, s/he tripped and spilled his/her juice which landed on the VA who was walking down the hallway near the top of the stairs. SP1 then noticed that his/her can of espresso coffee drink was not by the stove. SP1 asked the VA if s/he drank it, and the VA said that s/he had drank SP1’s can of espresso coffee drink. · SP1 told the VA, “You’re lucky you are in here because if you were normal, it wouldn’t have come out great,” and told the VA to stop “stealing” his/her drinks. SP1 acknowledged that s/he was upset with the VA as the VA had a history of drinking beverages left out by staff people. · SP1 observed that during this incident, SP2 was sitting in a recliner in the living room and was on his/her cellphone and was not paying attention to what had occurred and was not asleep. It was not uncommon for SP2 to have minimal engagement with the VA. · SP1 denied that s/he had smoked meth with the VA on an unknown date. · SP1 denied that s/he pushed the VA, called the VA a “fat fuck,” and had purposefully thrown juice on the VA. SP2 provided the following information: · On August 10, 2025, SP2 was working at the facility with SP1. Around 10:00 a.m., SP1 was in the bathroom getting the VA’s toothbrush and grooming stuff ready and the VA was in his/her bedroom getting clean clothes. SP2 went outside onto the patio off the living room to smoke. · When SP2 came back inside and sat back down in the recliner, SP1 was in the hallway. SP1 was yelling “that fat fuck took my coffee” and had a smashed can in his/her hand. The VA was in the bathroom showering. SP2 observed SP1 cleaning up the spilled juice. SP2 did not see if the juice was thrown at the VA or if SP1 had tripped up the stairs and spilled the juice. · The VA finished his/her shower and sat down on the couch in the living room. SP1 was standing at the top of the stairs next to the living room and telling the VA that s/he was “lucky to be in a group home because if they weren’t [SP1] would beat the shit out if him/her.” SP1 did not get in the VA’s face but was talking loud enough for the VA to hear and was calling the VA “lazy” and “fat.” · SP2 observed that the VA was smiling at SP1 while SP1 was talking about the VA. · SP1 said that s/he needed time to “cool down” and went out to his/her car for about 20 minutes and came back inside. · SP2 was concerned with SP1’s boundaries toward the VA and was concerned that SP1 used to give the VA e-cigarettes, candy, and caffeine. SP2 became further concerned when s/he was told by other staff that the SP1 had smoked meth with the VA. P1 provided the following information: · On August 11, 2025, P1 worked at the facility in the morning. P2 and P3 were also at the facility. P1 observed a red colored juice on the wall. P1 asked the VA how the juice got on the wall. The VA described to P1 that SP1 had thrown juice at the VA because the VA had taken and drank SP1’s coffee. The VA also told P1 that SP1 had called the VA “fat” and “lazy.” · P1 cleaned up the juice on the wall and while doing so, the VA continued to talk about the incident and talked about how SP2 was asleep during that time. P1 assisted the VA with doing laundry and observed that the VA had a t-shirt with red colored “sprayed drops” covering the t-shirt. · The VA did not appear to have been affected by the incident with SP1 and SP2 and that SP1 had just “went cuckoo” on the VA. · P1 did not have concerns with how SP2 worked with the VA. · P1 had some concerns with SP1 due to the VA telling P1 that s/he had smoked meth with SP1 previously. P1 did not know if that was true. P2 provided the following information: · P2 received a call from SP2 in the evening on August 10, 2025. SP2 explained that SP1 had “never seen [SP1] so mad before.” P2 did not assume that further incidents occurred because SP2 did not elaborate further. · P2 worked at the facility on August 11, 2025. The VA had explained to P2 and P1 that s/he had taken SP1’s coffee and drank it. When SP1 noticed the VA drank his/her coffee, SP1 threw a gallon of juice at the VA, pushed the VA into the wall and called the VA a “fat fuck” and told the VA that s/he “better be glad that s/he was living in a group home otherwise [SP1] would beat his/her fucking ass”. · P2 observed that red juice was on the walls in the hallway. P2 was not sure if a cup of juice would have created the same volume of spills on the walls and on the VA’s t-shirt. · The VA would not have a reason to not be truthful. In the past, P2 observed when the VA would be saying something untruthful, the VA would smile and rub under his/her lip. When the VA was discussing the incident, the VA did not smile or touch his/her lip. · P2 had some concerns with SP2. SP2 had previously received job performance related disciplinary actions due to lack of interaction and sleeping while working. · P2 had some concerns with SP1 and SP1 would likely have a reason to be untruthful in fear of losing his/her position with the facility. P2 was told by the VA had s/he had smoked meth with SP1 but P2 did not have proof that this had occurred. P3 provided the following information: · P3 was informed by P2 that an incident between the VA and SP1 occurred. SP1 texted P3 on August 12, 2025, explaining that s/he had fallen while coming up the stairs and spilled juice on the walls and on the VA. P3 was not working during this time and informed SP1 that s/he would talk to him/her when s/he returned to work. · P3 worked at the facility and with SP1 for several years. P3 was aware that SP1 had worked with the VA off and on for years. P3 did not have concerns with SP1 and was aware that the VA had told staff persons that s/he had smoked meth with SP1, but no proof was ever found regarding the allegation. · P3 had concerns with SP2’s work ethic and lack of engagement with the VA along with concerns that SP2 spent a lot of time on his/her cellphone during their shift. The G provided the following information: The G did not have concerns with the facility or the care that the VA received. The G was aware that the VA could be “manipulative” at times to get what s/he wanted and may not always be truthful. The facility’s Investigative Summary stated that SP1 was outside while the VA was getting ready to shower. The VA drank SP1’s drink. SP1 was coming up the stairs and fell, spilling his/her juice that was in a cup. The juice went all over the floor and the VA. The VA took a shower and SP1 cleaned up the juice that was spilled. When SP2 came inside, SP1 was swearing at the VA but SP2 did not intervene. Documentation from facility showed that SP2 had previously received a Plan of Action on July 31, 2025, regarding job related performance due to SP2 watching TV on his/her cellphone, not following shift duties and not following the VA’s program. All staff persons interviewed were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plan of care including the VA’s Individual Abuse Prevention Plan and Crisis Plan. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6) stated that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: The VA stated that on August 10, 2025, s/he took and drank SP1’s espresso coffee drink that SP1 had left in the kitchen. SP1 came back inside and observed that the VA drank his/her espresso coffee drink. SP1 became upset and threw a cup of juice at the VA and pushed the VA against the wall and told the VA that s/he would “fuck his/her life up” if the VA continued to steal SP1’s coffee. During this time, the VA observed that SP2 was “dozing off” in a chair in the living room. The VA had also mentioned to other staff person’s that s/he had smoked meth with SP1 but had only said that to be “funny,” but this had not occurred. SP1 denied that s/he pushed the VA against a wall and threw juice in the VA’s face. SP1 stated that s/he was coming up the stairs and tripped causing him/her to spill a cup of juice on the floor and on the VA. SP1 observed that the VA drank his/her espresso coffee drink and became upset and told the VA, “You’re lucky you are in here because if you were normal, it wouldn’t have come out great,” and told the VA to stop stealing his/her drinks. SP1 denied that s/he had smoked meth with the VA at any point. SP1 did not observe SP2 sleeping in the recliner in the living room. SP2 stated that s/he was sitting in a chair in the living room and had gotten up to go outside. SP1 was in the bathroom preparing the VA’s things to shower and the VA was in his/her bedroom getting clean clothes. When SP2 came back inside, the VA was in the shower and SP1 was yelling “that fat fuck took my coffee” and had a smashed can in his/her hand. SP2 observed SP1 cleaning up spilled juice. SP2 did not see if the juice was thrown at the VA or if SP1 had tripped up the stairs and spilled the juice. The VA finished showering and sat down on the couch in the living room. SP1 was standing at the top of the stairs next to the living room SP1 told the VA that s/he was “lucky to be in a group home because if they weren’t [SP1] would beat the shit out if him/her.” SP1 did not get in the VA’s face but was talking loud enough for the VA to hear and was calling the VA “lazy” and “fat.” SP2 denied sleeping in the recliner in the living room. Information varied in what SP1 said and what the VA heard or what was directed at the VA but information was consistent that SP1 called the VA names and threatened the VA which was behavior that was inconsistent with the standard 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). Information was conflicting regarding whether SP1 threw juice at the VA or tripped and spilled juice on the VA. There was no information that SP1 engaged in this behavior on other occasions. Therefore, there was not a preponderance of the evidence whether SP1’s conduct rose to the level of emotional abuse. 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). Although the VA stated that SP2 was “dozing off” in the recliner in the living room, given that SP1 did not see SP2 asleep and SP2 denied sleeping, and that SP1 was also supervising the VA, there was not a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was not 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). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate and were followed. SP2 no longer worked at the facility. SP1 received re-training regarding de-escalation techniques and respectful language. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because they took immediate corrective action.
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