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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: 1125525-HCBS (Home and Community-Based Services) Investigator(s): Thomas Nixon/Alice Percy Minnesota Department of Human Services 651-431-2155 Suspected Maltreatment Reported: It was reported that a staff person (SP) punched a vulnerable adult (VA) in the face, causing a bruise. It was also reported that the SP choked the VA, “slammed” the VA onto his/her bed, called the VA “retarded” (r-word) and a “(n-word)”, and threatened the VA. [Note: At the time of the incident, the SP used the actual words, but throughout the remainder of the report they will be referred to as the r-word and n-word.] Date of Incident(s): Ongoing, prior to July 25, 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), clauses (1) and (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: · 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 1, 2025; from documentation at the facility and law enforcement records; and through seven interviews conducted with three facility staff persons (P1 – P3), an administrative staff person (P4), the VA, and the VA’s family members (FM1 and FM2). FM2 was also a staff person. Attempts were made by telephone, text, and letter to contact the SP, but the SP declined an interview. The VA enjoyed watching sporting events on his/her television, gardening, playing cards, going to concerts, doing arts and crafts projects, going to the casino, and spending time with his/her family members and friends. The VA’s diagnoses included hypoxic ischemic encephalopathy (a brain injury caused by a lack of oxygen and blood flow to the brain), dysphagia (difficulty swallowing), anoxic brain damage, and Hirschsprung’s disease (a congenital condition leading to severe constipation and bowel obstruction). The VA lived in his/her own home and was not subject to guardianship. The VA went to work one day a week and used a wheelchair for mobility. The VA received Individualized Home Supports Without Training Services from the facility and throughout the report “facility” will be used to describe the services the VA received in his/her home. The VA’s Support Plan stated that the VA required assistance with all of his/her personal activities of daily living, household management tasks, meal preparation, and personal paperwork. The VA’s Support Plan Addendum – Basic Services stated that the staff persons were to assist the VA with activities of daily living such as dressing, grooming, bathing, transfers, mobility, positioning, toileting, and eating. Other duties included monitoring for safety, community integration, and opportunities for socialization. The staff persons could offer a hug or handholding to calm the VA, but once comfort was provided the staff persons were to release the VA. The VA’s Individual Abuse Prevention Plan stated that the VA was susceptible to physical abuse and lacked the ability to deal with aggression from others. A video camera was located in the VA’s bedroom and provided a view of the area around the VA’s bed. A large mat was placed on the floor next to the VA’s bed which allowed a soft spot in the event the VA fell from his/her bed. The SP typically worked the overnight shift with the VA. The VA stated that the SP was not always polite to the VA and recently called the VA a “dumb fucking piece of shit,” the “n-word,” and the “r-word.” The SP had used the words when speaking to the VA on multiple occasions. The SP also told the VA that s/he would hurt the VA’s fingers and handled the VA roughly by “tossing” the VA onto his/her bed. On two occasions, the SP grabbed the VA by his/her neck, which “scared” the VA. The SP also tied the VA’s oxygen tube around the VA’s neck for “like two seconds” and the VA believed s/he passed out as a result. On one occasion, the SP hit the VA on his/her face. At times, the SP blocked the video camera in the VA’s bedroom and punched and choked the VA. FM1 stated that the VA had never accused any staff person of hitting him/her. Recently, after the VA’s family member (FM2) saw a bruise on the VA’s face, the VA told FM2 that the SP had hit the VA on the face. The bruise was on the left side of the VA’s chin and was “very dark and slightly larger than a dime.” FM1 then watched video footage from the facility and saw that on July 17, 2025, the SP was “being very aggressive” with the VA and “throwing” the VA onto his/her bed. The SP called the VA “a stupid n-word” and the “r-word.” The SP also spoke to the VA in a “mocking” manner and talked to the VA like s/he was stupid. The SP also told the VA, “I can say whatever the fuck I want.” The SP blew into a medical glove “like a balloon” and placed it in the VA’s mouth. At one point, the SP used a large floor mat to block the view of the video camera. FM1 talked to the SP, who told FM1 that s/he choked the VA with the oxygen tube and his/her hand, but s/he always made sure that the VA was “okay” afterwards. The SP also told FM1 that s/he “tipped” the VA while the VA was in his/her wheelchair. FM1 did not notice any injury to the VA except for the bruise on his/her chin. FM2 stated that s/he frequently worked with the VA. The VA recently had a “small oval” mark on the left side of his/her chin, which looked like a “knuckle punch.” The VA told P1 and FM2 that the SP punched him/her. FM2 then told FM1 to review the video recordings to see what happened. FM2 believed the VA told the truth about the cause of the bruise and did not believe the VA could have hit him/herself in the face because of his/her physical limitations. In the past, the SP posted in a messaging app used by the staff persons that the VA was an “asshole.” FM2 believed that at that time, FM1 talked to the SP about using “mean and unprofessional language” when writing about the VA. P1 stated that s/he usually began his/her work shift in the mornings, only seeing the SP in passing. On one unknown occasion, the VA told P1 that the SP did not feed the VA. On July 21, 2025, P1 started his/her work shift and noticed a mark on the VA’s chin. P1 was not certain if the mark was a bruise and described it as a quarter-sized “spotty purple mark” below the VA’s mouth. When s/he asked the VA about the mark, the VA told him/her that the previous Friday the SP punched him/her. The VA also told P1 that the SP covered the video camera with something. P1 then told FM2 about the incident. P2 stated that s/he had not typically seen unusual marks or bruises on the VA. On one occasion P2 saw a quarter-sized bruise on the left side of the VA’s chin. When P2 asked the VA about the bruise, the VA told him/her that the SP “punched” the VA in the face and that the SP had choked the VA. The VA did not provide additional information about the incidents. P3 stated that s/he had not seen unexplained marks on the VA except for one occasion when s/he had a “big bruise” on his/her face that was the size of a half-dollar coin. P3 did not believe the VA could have caused the mark on his/her face and s/he believed that the mark was a knuckle mark. When P3 asked about the mark, the VA told P3 that the SP punched him/her. Two days prior to seeing the mark on the VA’s face, P3 took photographs of the VA while at the beach. There were no bruises on the VA’s face at that time. P4 stated that on July 25, 2025, FM1 told P4 that s/he had viewed video footage that showed concerning interactions between the SP and the VA. The SP also sent text messages to FM1 acknowledging that s/he punched the VA, choked the VA with his/her hands and oxygen tubes, and “slammed” the VA into his/her bed. A photograph of the VA taken by P1 on July 21, 2025, showed a dark red mark on the left side of the VA’s face. Text messages between the SP and FM1 on an unknown date showed the following: · FM1: “The fact u knuckle punched [him/her] near [his/her] chin and that was picked up on the hidden camera was even worse.” · The SP: “That’s what I really was talking about that I wanted to tell you I felt so bad. . . .” · FM1: “How many times did u hit [the VA]?” · The SP: “I don’t know. I choked [the VA] but not enough to hurt [him/her] but I did that too there’s probable more I can’t think of because I’m freaking out. Please let me come talk to you and [the VA] before you watch the videos. It was only after the hospital stay. Nothing before. I don’t know when exactly.” · FM1: “When [the VA] was even more fragile. You could have killed [him/her].” · The SP: “Yes I know I’m so sorry. It doesn’t make it better but I always made sure [s/he] was ok after.” · FM1: “I want all the details before I watch them now please [referring to the video recordings].” · The SP: “I used [his/her] oxygen tube to choke [him/her] before putting it back in I used my hand to choke [him/her] I’ve hit [him/her] I slammed [him/her] on [his/her] bed I’ve tipped [him/her[ on [his/her] back in the wheelchair and been rough when moving [him/her] or giving [him/her] things” · FM1: “And most of this fairly recent?” · The SP: “Yes it is” A review of seven video recordings from July 17, 2025, showed the following: · Video #1, starting time stamp 20:54: The VA was in his/her wheelchair when the SP grabbed the VA by the biceps, lifted and turned the VA, roughly placed the VA on the bed, lifted the VA’s legs, adjusted the VA’s position, and dropped the VA’s legs toward the foot of the bed. · Video #2, starting time stamp 21:09: The VA was in bed and the SP appeared to reposition the VA higher on the bed a few inches by holding the VA’s neck or head and pulling the VA to the head of the bed. The SP appeared to give the VA a pill and said, “I will break your goddamn fingers if when I come back you have a fucking [unclear] tonight, do you understand me?” At time stamp 21:10:20, based on the SP’s arm motion, it appeared that s/he might have slapped the VA. · Video #3, starting time stamp 21:14: The SP said, “I can say whatever the fuck I want you ‘stupid n-word. . .’ and in the United States of America and I can say whatever the fuck I want, you dumb piece of shit.” The SP spoke loudly and leaned over close to the VA’s face as s/he spoke. The SP then blew into a latex glove, inflating it, then placed a finger of the inflated glove against the VA’s nose and mouth area. The SP’s body blocked the view, but it appeared that the SP placed the inflated finger into the VA’s mouth for approximately eight seconds before removing it. · Video #4, starting time stamp 21:17: The SP said, “You done fucked up.” The SP leaned over the VA’s bed and adjusted something. · Video #5, starting time stamp 21:26: The floor mat was placed in an upright position, blocking the camera’s view. The VA asked for a pillow and the SP went to the head of the bed and leaned over the VA before moving out of the camera’s view. · Video #6, starting time stamp 21:29: The floor mat was out of view. The SP leaned over the VA’s upper torso and head, blocking the view of the camera. The SP said, “Probably nothing. Are you a r-word?” The SP appeared to grab the VA by his/her neck or head and pulled the VA toward the head of the bed by several inches. · Video #7, starting time stamp 21:31: The VA was in bed and the SP was off camera. The SP said, “You didn’t see what the fuck [unclear]. [The VA] you probably, you think that was bad, if you think that was bad, it gets worse. Don’t fuck with me.” The SP leaned over the VA’s upper chest and face, blocking the camera’s view. According to a law-enforcement officer’s Supplemental Report, the SP refused to talk to the LEO without an attorney present. The SP was charged with criminal neglect of a vulnerable adult, criminal abuse of a vulnerable adult, and 4th and 5th degree assault of a vulnerable adult. At the time of this report, the criminal proceedings were still pending. The facility’s Person-Centered Planning and Service Delivery Requirements stated that the expectation for all staff persons was to treat the individuals they supported in a person-centered manner. The staff persons were to support each client’s preferences, daily needs, activities, and accomplishments of the clients’ personal goals. The staff persons were to respect each client’s history, dignity, and cultural background. Facility documentation showed that P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. While facility documentation showed that the SP and P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the facility’s policies, there was no documentation that they received training on the VA’s plans prior to the incidents which was a violation of Minnesota Statutes 245D.09, subdivision 4, paragraph (a), state that prior to having unsupervised direct contact with a person served, a staff person must have received instruction on the person’s support plan or support plan addendum. However, P4 stated that the SP had received training on the VA’s plans and the facility’s policies, including information on permitted physical interactions. Conclusion: A. Maltreatment: Information obtained during interviews and in video footage showed that the SP choked the VA with his/her hands and the VA’s oxygen tube, hit the VA including on the chin causing a bruise, “slammed” the VA onto his/her bed, and tipped the VA back in his/her wheelchair. The SP also handled the VA roughly and threatened the VA by pulling the VA by his/her neck or head toward the head of the bed; threatening to break the VA’s fingers; calling the VA “a stupid n-word,” the “r-word,” and “a dumb piece of shit;” swearing at the VA; and putting the fingers of an inflated medical glove over and/or in the VA’s nose/mouth area. The SP’s actions and comments to the VA were not accidental or therapeutic conduct. In addition, the VA stated that the SP made the comments on multiple occasions and when FM1 asked the SP, “And most of this fairly recent?” the SP responded, “Yes, it is,” which likely implied it had happened on more than the single shift as viewed on the video. Given the SP’s physical and verbal interactions with the VA as seen on video and that the VA sustained a bruise on his/her chin as a result of the SP’s actions, there was a preponderance of the evidence that the SP’s actions produced and could reasonably be expected to produce physical pain or injury and was treatment which could be considered by a reasonable person to be disparaging, derogatory, humiliating or threatening and could reasonably be expected to produce emotional distress to the VA. It was determined that physical and 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: Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult and/or 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). 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. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the facility’s policies, and P4 stated that the SP was trained on the VA’s plans. The SP 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 physical and emotional abuse for which the SP was responsible was “recurring and serious” maltreatment because it occurred on multiple occasions and on at least one occasion resulted in a bruise on the VA’s chin which was visible for several days. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. On November 7, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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