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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: 1124257-H_CRS (Home and Community-Based Services-Community Residential Setting) 1103884-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) displayed behaviors towards three staff persons (SP1, P1, and P5), SP1 and an additional staff person (SP2) responded by “pulling” the VA out of his/her wheelchair and placing the VA in “a hold” that was not consistent with the facility’s policies or the VA’s care plans which resulted in the VA’s finger being broken. Date of Incident(s): April 14, 2025; received by the Department of Human Services on June 4, 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 subdivision2, paragraph (b), clause (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on June 13, 2025; from documentation at the facility, law enforcement (LE) records, and medical records; and through eight interviews conducted with two facility staff persons (SP1 and P1), two supervisory staff persons (SP2 and P2), an administrative staff person (P9), the VA’s family member (FM), the VA’s case manager (CM), and the VA’s probation officer (PO). Multiple attempts were made via phone to contact and interview seven additional staff persons (P3, P4, P5, P6, P7, P8, and P10), but the attempts were not successful. Additionally, due to ongoing concerns with the VA’s mental health and behaviors after DHS received this report, the VA was unable to meet with this investigator and/or provide information for this investigation. However, the VA provided information to law enforcement officers, medical health professionals, and emergency medical service personnel which was included below. Multiple attempts were also made via phone and email to administrative facility staff persons to request additional documentation but the attempts were not responded to by the completion of this investigation. This was a violation of Minnesota Statutes, section 245A.04, subdivision 5, paragraph (a), clauses (2) and (4) which states in part that when the commissioner is exercising the powers confined by this chapter and 626.557, the commissioner must be given access to documents and records and staff and personnel records of current and former staff. The VA enjoyed reading, building with Legos, being outdoors, fishing, and going to the zoo. The VA’s diagnoses included autism spectrum disorder, fetal alcohol syndrome, unspecified anxiety disorder, attention deficit hyperactivity disorder, moderate intellectual disabilities, reactive attachment disorder, depressive disorder, disruptive impulse-control and conduct disorder, autosomal dominant hereditary paraplegia (disorder that caused slow progression of weakness and muscle tightness in a person’s legs), Charcot-Marie-Tooth disease (disorder that caused progressive weakness and sensory loss in a person’s hands, feet, and lower legs), and spinocerebellar ataxia disease (disorder that affects the part of the brain that controls a person’s coordination and balance). Additionally, the VA was semi-ambulatory and used an electric wheelchair, a manual wheelchair, a walker, a shower chair, and an Ezy Stand for assistance with standing and/or mobility. The facility was a rambler style home in a rural area, where the VA lived with one housemate (H). The facility had an accessible and open floor plan with a living room directly in front of the main door that connected to a dining and kitchen area, with a hallway to the left of the kitchen. Along the left side of the hallway was a laundry room and the H’s bedroom. On the right side of the hallway was a shared bathroom, the VA’s bedroom that included a private bathroom, and a third bedroom which was converted into a staff office and was to be locked when not in use. Due to the VA’s “complex” medical/behavioral needs and the VA’s history of self-abuse and abuse towards others, the facility provided home modifications to maintain the safety of the VA and the safety of others which included installing surveillance cameras around the outside of the home and to the main living areas of the home, plexiglass to the windows, and alarms on all exterior exits. Additionally, “all” medications and “sharp” or “hazardous” items were to be secured in a manner that was “double locked” and only accessible by staff persons. According to the VA’s RMS Worksheet, the VA had 2:1 staffing 24 hours a day and no unsupervised time in the facility or the community. Additionally, the H’s care plans showed that the H also received 2:1 staffing 24 hours a day. Therefore, the facility had at least four staff persons onsite 24 hours a day to maintain the level of care and supervision that was to be provided to each client. The VA’s Support Plan, Support Plan Addendum- Intensive Services, Self- Management Assessment, and Individual Abuse Prevention Plan, provided the following information: · On September 11, 2024, the VA moved into the facility seeking supports and services relating to his/her diagnoses that included health and behavior management, medication administration, community integration, transportation, supervision, and assistance to complete activities of daily living. Upon admission into the facility’s care, the FM was the VA’s legal guardian until the VA was no longer subject to guardianship in March 2025. In August 2025, the CM helped the VA complete assessments that determined the need to reestablish guardianship to the VA but the paperwork to appoint guardianship to the VA was still in-progress by the completion of this investigation. · The VA had a history of physical and sexual abuse; self-injurious behaviors (SIB); suicidal ideations; emotional dysregulation; behavioral “dyscontrol;” verbal aggression that included “yelling, swearing, and threatening” others; using “intimidation” or “scaring” others to get what the VA wanted; and physical aggression that included “hitting, biting, striking, slapping, and spitting” at others and property destruction that included “punching holes into walls […] and [breaking] glass windows.” The VA also had a history of “inappropriate” sexual behaviors and language, sexually assaulting opposite gendered persons, and was currently serving a probationary sentence for criminal sexual misconduct. Furthermore, the VA became “easily annoyed, irritated” and/or “upset” which the VA then communicated through maladaptive behaviors and “fits of rage” without “caring for [his/her] safety” or “understanding the consequences” that resulted from his/her behaviors. · Due to the VA’s history and behaviors, the VA was on “continual observation status” and remained within sight of staff persons at “all times.” Staff persons were trained to recognize “signs” of when the VA was becoming “agitated” or aggressive and to use “person-centered” and “early intervention” strategies when responding to and redirecting the VA’s behaviors “whenever needed.” During situations when the VA was “dysregulated” and had “escalating” behaviors that were sexually assaultive and/or physically aggressive, staff persons were to provide the VA with verbal prompts, coping strategies, and redirection to “calm” the VA and “de-escalate” the situation. Additionally, staff persons were “permitted” to respond to the VA’s behaviors with “blocking” techniques, “holds,” and/or to “physically remove” the VA “when necessary” to maintain the safety of the VA and/or others, while using whichever response was the least restrictive intervention. SP1, SP2, P1, P2, and P9; the facility’s Incident Report completed by P2; the facility’s documentation of staff time sheets for April 13 to 15, 2025; and the VA’s T-Logs dated April 14, 2025, completed by P1, P5, SP1, and an unknown staff person (U) provided the following information: · On April 14, 2025, P1 worked at the facility with the VA from 7 a.m. to 3 p.m., the U worked with the VA from 9 a.m. to 12:45 p.m., SP1 worked with the VA from 3 to 6:30 p.m., and P5 worked with the VA from 3:30 to 5:55 p.m. Additionally, P4 was also working at the facility with the H from 7 a.m. to 5:52 p.m. SP2 did not work on April 14 or 15, 2025. · At approximately 7:15 a.m., the VA woke up “refusing” to go to school and “threatened” to “have behaviors” if the VA was “forced” to attend. P1 contacted and notified SP2 and SP2 told P1 that the VA could remain at the facility since the VA was “recently struggling” with his/her behaviors. At approximately 8 a.m., the VA got out of his/her bed, walked to the living room using his/her walker, sat on the living room couch, and P1 administered the VA’s morning medications. Shortly thereafter, the VA began to “cuss” and “yell slurs” at P1 and P4. The VA also told P1 that the VA was going to “rape” and “kill” facility staff persons and “kill the [United States] President.” At some point after this, P1 assisted the VA to transfer into his/her wheelchair while the VA continued to “yell” at P1. The VA then started making “sexual remarks” to P1 that the VA was going to “fuck” and “rape” P1 and “smack [P1’s] ass.” When the U arrived at the facility, the VA was in the living room with P1 and the VA was saying “inappropriate” comments about P1. The VA also told P1 and the U that the VA “wanted to wrap the T.V. cord around [P1 and the U’s] necks until [they] stopped breathing.” · At approximately 11:30 a.m., the VA started to “punch” P1’s legs, chest, and back while P1 attempted to “put distance” between him/herself and the VA but then the VA started to “throw” the couch pillows at P1 and the U while “yelling vulgar and inappropriate things.” The U told the VA that his/her behaviors were “not okay” and that the VA could not “put [his/her] hands” on staff persons. The VA then “stopped” these behaviors for approximately five minutes but then began to call the staff persons names that included “bitch” and racial slurs. · At an unknown time after this and due to the VA’s “dangerous and extremely inappropriate” behaviors, P1 walked away from the VA to the staff office and locked the office door while the VA “unplugged all” of the surveillance cameras, broke a kitchen cabinet door, took items out of the kitchen cabinets and drawers, and attempted to “break into” the staff office to get to P1. When the VA could not get into the staff office, the VA became “more angry” and told P1, “Bitch, if I’m talking to you, you fucking answer me, you slut.” The VA also told P1 that s/he would “hurt” P1 “the second” that P1 left the staff office. · When SP1 arrived at the facility, the VA was in the living room “yelling inappropriate sexual slurs” towards P1, “threatened” to “kill” staff persons, and then made “racist” comments towards SP1. SP1 responded to the VA with attempts to “redirect” the VA’s behaviors but this made the VA “more agitated” and so the VA used his/her wheelchair to “rush at” SP1 trying to hurt SP1 but SP1 “avoided” being hit by the VA’s wheelchair and continued to try to redirect the VA’s behaviors. Shortly thereafter, P5 arrived at the facility and then P1 left the facility. · Upon P5’s arrival to the facility, the VA was “agitated” and tried using his/her wheelchair “to ram into” staff persons. SP1 and P5 attempted to “redirect” the VA’s behaviors but the VA continued to be aggressive towards staff. At approximately 3:50 p.m., SP1 and P5 responded to the VA’s behaviors with emergency use of manual restraint (EUMR) techniques by physically removing the VA from his/her wheelchair to the living room floor while the VA continued to try and “hurt” the staff. The VA then began to “roll around” the living room floor while “hitting” and “swinging” at the staff persons and saying that s/he wanted to “kill” SP1 and P5. At some point, the VA “grabbed” a “plastic” object that was lying on the floor and attempted to use the object “as a weapon” to “stab” SP1 and P5 but staff were able to use couch cushions “to block” the VA’s behaviors. The VA then “acted like [s/he] wanted to hurt [him/herself” using the object but when SP1 and/or P5 tried to take the object from the VA, the VA would “hit” or attempt to “hurt” them. Sometime later, staff were able to successfully “calm” the VA and obtained the “plastic piece” from the VA. SP1 then attempted to contact and notify administrative staff persons about the VA’s behaviors but administrative staff did not answer SP1’s call at that time. · At approximately 4:37 p.m., the VA became “upset again” and started “ripping up” the living room flooring. The VA also made sexual remarks towards P5 that included telling P5 that s/he was going to “grab” P5’s intimate areas “if given the chance.” SP1 then called two supervisory staff persons (P2 and P11) for assistance in responding to the situation, who each told SP1 to call 9-1-1 and SP1 did so. Shortly thereafter, law enforcement officers (LEO) arrived at the facility and talked with the VA and to staff persons. The VA was then transported via ambulance to a local hospital where the VA was admitted for psychological evaluation. The following morning, the VA was discharged from the hospital and returned to the facility. · SP1, SP2, P1, and P2 provided consistent information that at some point after the incident, staff persons were made aware that the VA had fractured his/her finger on or around April 14, 2025, but staff persons were not aware of any additional information about how this injury occurred or the timing of the injury. Furthermore, SP1 and SP2 stated that the VA could have injured his/her finger on April 14, 2025, during times when the VA was engaging in aggressive behaviors and “hitting” the walls, furniture, and/or other items or during similar incidents that occurred the days prior. · A “few months” after the incident, the VA told multiple staff persons and members from his/her care team that SP1 and SP2 “pulled” the VA out of his/her wheelchair and “broke” the VA’s finger while placing the VA in “a hold.” The VA also told additional staff persons that emergency service personnel “broke” the VA’s finger while transporting the VA to the hospital. According to P1, P2, SP2, and P9, the VA did not always say things that were “true” and was not considered an accurate reporter of information. · SP2, P1, P2, and P9 provided consistent information that there were not any prior concerns with SP1’s interactions with the VA or other facility clients. Additionally, SP2 stated that SP1 would “never intentionally hurt” the VA and that SP1 only used EUMR when necessary and in accordance with facility policies and the VA’s plans. LE records provided the following information: · On April 14, 2025, at approximately 5 p.m., the LEOs (LEO1 and LEO2) were dispatched to the facility in response to SP1’s call for assistance in responding to a situation in which a facility client (the VA) was engaging in aggressive behaviors and property destruction. Shortly thereafter, the LEOs arrived at the facility, entered the home into the living room that was noted by the LEOs to be “in disarray.” The VA sitting on a couch “laughing about the incident” and was near a second couch that was “tipped over” and next to the facility’s main entrance. The LEOs also saw that the “plank flooring” in the “middle of the room” near the dining area had “pieces broken off and ripped out,” a table was “tipped over” near the kitchen, a lower kitchen cabinet door was “broken in half and hanging off the hinges,” and two surveillance cameras in the main living area were “ripped out” of the walls. There were two staff persons present (SP1 and P5). · Shortly after the LEOs entered the facility, the VA told SP1 and P5 that s/he needed to use the bathroom so they helped the VA stand and walk to the bathroom and then returned to the living room to talk with the LEOs. SP1 and P5 then provided information to the LEOs that was consistent with the information each later provided in facility documentation and their respective interviews. Additionally, SP1 told the LEOs that the VA had been engaging in similar behaviors for the past two days which was also similar to a prior incident with the VA that LE had responded to in March 2025. · After the VA finished using the bathroom, the VA came back into the living room and sat on the couch where the LEOs were waiting to talk with the VA. At first the VA did not want to speak to the LEOs and “initially blamed” staff persons for tipping over the furniture and breaking the items. Shortly after this while P5 was speaking to LEO2, the VA overheard P5 say that the VA hit P5’s wrist earlier that day. The VA became “excited” and told LEO2 that the VA also “hit” and “scratched” three additional staff persons. After the LEOs finished talking with the VA and staff persons, the LEOs determined that the VA’s current mental health and behaviors were “a risk” to the safety of the VA and/or others at the facility, and they issued a medical hold for the VA. The VA was then transported via ambulance to a local hospital where the VA was admitted into the hospital’s care for evaluation. · On April 15, 2025, at approximately 10:55 a.m., the LEOs (LEO1, LEO3, and LEO4) were dispatched to the facility in response to another call involving the VA who had been discharged from the hospital’s care and returned to the facility earlier that morning. Shortly thereafter, the LEOs arrived at the facility and saw the VA sitting in his/her wheelchair with three staff persons (P2, P3, and P10) standing next to the VA in the facility’s driveway. The LEOs approached the VA and the staff persons to obtain additional information. Staff persons told the LEOs that after the VA was discharged from the hospital and being transported back to the facility by staff persons, the VA told staff that s/he did not want to return to the facility and that s/he was going to start “breaking things again” “the moment” s/he returned. Then shortly after arriving to the facility, the VA entered the home, “immediately” became “irate and uncooperative” towards staff persons, and became physically aggressive including “tipping furniture over” and “ripping out cords” from the walls and the surveillance cameras that “the maintenance crew” had just finished repairing. The VA then started to repeat behaviors that were similar to the day prior including property destruction, threating to “rape” and “kill” staff persons, using “vulgar” and “sexually explicit language” towards staff, “yelling,” using “racial slurs,” using his/her wheelchair to “run into” staff person, and being physically aggressive towards staff persons. Staff persons attempted to “de-escalate” the VA’s behaviors but were not successful. P3 and P10 then tried to use the VA’s wheelchair to move the VA to a “safer” situation but the VA responded by “hitting,” “punching,” and attempting to “bite” P3 and P10. · While LEO1 and LEO3 spoke with staff persons, LEO4 stayed with the VA. During this time, the VA asked LEO4 to “help [the VA] kill the President” and then the VA became verbally aggressive towards P2 using “racial slurs” towards P2 and telling P2 to “shut up, bitch.” Shortly thereafter, the VA was arrested by the LEO and transported to the local county jail. · At the completion of this report, the LE investigation into this matter was pending review for criminal charges against the VA that also included an additional and similar incident that occurred on September 19, 2025. Medical Records provided the following information: · On April 14, 2025, at approximately 6:09 p.m., the VA arrived at a local hospital’s emergency room (ER) via ambulance for psychological evaluation and monitoring after the VA had “episodes” of “violent” and aggressive behaviors towards facility staff persons. Sometime later, the VA told medical health professionals (MHP) that s/he initially made sexual comments and gestures towards staff persons “to be funny” but then the VA’s behaviors became aggressive after staff persons made the VA “mad.” The VA told the MHP that when s/he was “mad” s/he was physically aggressive and “crawled around on the floor.” The VA also said that s/he had “pain” in his/her left index finger due to an unnamed staff person “accidentally stepping on [the VA’s finger]” during an “altercation” that occurred earlier that afternoon. After an initial examination, the VA had an X-ray of his/her left hand which showed a fracture in the VA’s left index finger. The VA’s finger was placed within a splint and the VA was to have a follow up with an orthopedic doctor. · From approximately 7 to 7:20 p.m., the VA’s mental health was assessed using “telehealth services” and the VA said that s/he “attacked” and “hurt” facility staff persons, “broke things,” and made “inappropriate comments.” According to the VA, these incidents resulted after the VA made comments to staff persons that the VA “thought would be funny” but when the staff persons did not “like” the VA’s comments, it made the VA “angry” and so the VA began “attacking” staff. The past two days, the VA was “angry” which made the VA “think about harming” staff persons because even though the VA “knew” that s/he “shouldn’t attack staff,” the VA “liked” to act aggressively towards staff persons and behaved in this manner “most weeks.” The VA said s/he did not want to return to the facility because s/he “still felt like [s/he] wanted to attack staff.” · At approximately 7:57 p.m., P11 was contacted in an attempt to discharge the VA from the hospital but P11 said that the facility did not have adequate staffing for the VA to return that evening and that staff persons would pick up the VA the next morning after 8 a.m. · At approximately 9:49 a.m., as the VA was being driven back to the facility, the VA told Emergency Medical Services (EMS) personnel that when s/he got back to the facility, s/he was going to “assault” facility staff persons because s/he “liked misbehaving.” · According to the VA’s medical records, the VA had four follow up appointments between May 1 and August 27, 2025, and the VA’s finger was healing “without any concerns.” The CM stated that s/he was aware of the incidents and the VA’s fractured finger and did not have any concerns with the care and services that the VA received from the facility. The CM “believed” that the VA may have initially injured his/her finger during an incident of aggression in March 2025 and then the VA re-injured it during the April incident. The VA was a “hit or a miss” when reporting accurate information and that it was a “toss up” that was dependent upon the VA’s “mood that day.” The FM stated that s/he was aware of the incidents but did not have additional information to provide for this investigation. The FM did not have concerns about interactions that s/he observed between the VA and specific staff persons but was concerned with the facility’s ability to provide the level of care that the VA needed and if staff persons were able to “effectively” manage and respond to the VA’s health conditions and behaviors. The PO was contacted regarding this investigation but did not have additional information specific to the incident to provide. According to the facility’s Program Abuse Prevention Plan, staff persons were to use “positive behavioral supports” and follow client care plans when responding to incidents involving “challenging” behaviors including situations in which clients showed aggressive or assaultive behaviors towards him/herself or others. If a client’s behavior posed an imminent risk of harm to him/herself or others, staff persons were to implement an EMUR, if necessary. Facility documentation showed that SP1, SP2, and each staff person interviewed for this investigation received training on the VA’s care plans, the facility’s Program Abuse Prevention Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: According to the VA’s plans, the VA had a history of maladaptive behaviors that included SIB, emotional dysregulation, verbal and physical aggression, and sexual assault towards opposite gendered persons. Additionally, the VA became “easily agitated” and “upset” that was then shown through the VA’s behaviors and included physical, verbal, and sexual aggression towards staff persons. Information from all sources was consistent that on April 14 and 15, 2025, the VA became “upset” with staff persons and engaged in engaged in physically and sexually aggressive behaviors towards staff, significantly damaged property at the facility, and made threats of harm towards staff persons which resulted in LE response, hospitalization, and legal implications. Staff persons responded to the VA’s behaviors with redirection and de-escalation techniques, performed EUMRs in accordance with their training and the VA’s plans, and contacted LE for assistance. Although the VA was unable to provide information to this investigator, the VA provided information to the LEO, the MHP, and EMS personnel that the VA “attacked” multiple staff persons and “liked” to engage in aggressive behaviors that were intended to cause harm to staff persons. The VA also provided inconsistent information about how the VA’s finger was injured and told the MHP that an unnamed staff person “accidentally stepped” on the VA’s finger while the VA was using aggressive behaviors and “crawling around” and the floor. The VA later told staff persons and his/her care team that the VA’s injury was a result of SP1’s and SP2’s actions when removing the VA from his/her wheelchair and placing the VA in “a hold” that was not consistent with the VA’s care plans or facility policies. Information from staff persons, the FM, and the CM was consistent that there were no concerns with the interactions between SP1 and the VA and facility documentation showed that SP2 was not working . Although the VA had a fractured finger, given that during the incident the VA engaged in physically aggressive behaviors including hitting things, that the VA provided different accounts of when/how s/he sustained the injury, and that the VA’s physical aggression required staff persons intervention, there was not a preponderance of the evidence whether all of the staff persons actions were therapeutic conduct or whether the VA sustained the injury by any means other than accidental. 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). Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed. Action Taken by Department of Human Services, Office of Inspector General: On November 4, 2025, the facility was issued a Correction Order for the violation outlined above.
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