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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: 1068292-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler/Beth Virden jason.pehler@state.mn.us Suspected Maltreatment Reported: Allegation One: It was reported that a staff person (SP) “forced” a vulnerable adult (VA1) to independently complete tasks that VA1 was physically unable to do, including: 1) complete his/her morning bathroom routine, 2) use his/her walker, and 3) clean incontinence from the floor; and that if VA1 declined, the SP used loud stimuli or “threatened” to take away VA1’s phone calls and outings. It was also reported that the SP called VA1 a “bitch.” Allegation Two: It was reported that the SP frequently ignored or walked away from a vulnerable adult (VA2). Date of Incident(s): Fall 2022 and ongoing between September and December 2023; The Department of Human Services did not receive the report until March 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): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on March 25, 2025; from documentation at the facility; and through ten interviews conducted with facility staff persons (P1-P3) and supervisory staff persons (P4-P10). Attempts were made by telephone and mail to contact and interview a staff person (SP), but the SP did not respond by the completion of this investigation. VA1’s and VA2’s respective guardians were contacted but did not have additional information or related concerns. The DHS investigator met VA1 and VA2 at the site visit. However, given the amount of time that passed since the incidents (occurring in 2022/2023), the DHS investigator did not interview VA1 or VA2. The facility was a single-family home where VA1 and VA2 lived with two housemates. Facility documentation stated that the SP and P1-P10 received training on VA1’s and VA2’s coordinated services and support plan-addendums and the Reporting of Maltreatment of Vulnerable Adults Act. Allegation One: It was reported that the SP “forced” VA1 to independently complete tasks that VA1 was physically unable to do, including: 1) complete his/her morning bathroom routine, 2) use his/her walker, and 3) clean incontinence from the floor; and that if VA1 declined, the SP used loud stimuli or “threatened” to take away VA1’s phone calls and outings. It was also reported that the SP called VA1 a “bitch.” VA1’s coordinated services and support plan-addendum, including Self-Care Plan, stated that s/he moved into the facility in 2014 seeking support relating to his/her diagnoses, which included moderate intellectual disability. The facility provided VA1 with at least one staff person 24-hours a day. Staff were responsible for VA1’s care and supervision, including ensuring VA1’s safety, intervening in potentially dangerous situations, and reporting abuse on VA1’s behalf. P1-P10 provided the following information: · P1-P10 each said that it was “very important” for VA1 to remain independent. G1 told staff that s/he wanted VA1 to be as independent as possible, and previously, VA1 could complete most tasks independently. However, during 2022 and 2023, VA1’s abilities “gradually” declined and s/he was losing strength and struggling more. · P9 and P10 each said that in 2022 and 2023, they were having ongoing discussions with G1 about figuring out the appropriate level of staff assistance while also maintaining VA1’s independence. They wanted VA1 to have a fulfilled life but also not spend hours in the bathroom, for instance, independently completing his/her bathroom routine. Staff handled VA1’s decline in abilities differently. New or more recently employed staff adjusted without issue but veteran staff, like the SP, struggled to accept that VA1’s abilities were changing. · Consistent information was provided that during September through December 2023, there was staff turnover, and several “new staff” (e.g., P1, P4, P5, P7, and P8) were employed during that time. The SP was a “veteran staff” and the “main trainer” for new staff. In December 2023, the SP no longer worked at the facility. In February 2025, the SP visited the facility for a housemate’s birthday party, which prompted P1, P4, P5, P7, and P8, who were no longer “new staff,” to recall and tell P9 and P10 about the SP’s prior conduct. Regarding the SP “forcing” VA1 to independently complete his/her morning bathroom routine: VA1’s coordinated services and support plan-addendum, including Self-Care Plan (dated August 2023), stated: Staff encourage [VA1] to be as independent as possible with daily needs while still assisting wherever necessary … Staff will be present to observe specified cares to ensure [s/he] is thorough in [his/her] tasks. If [VA1] does not complete cares by a specified time staff will complete all [activities of daily living skills] for [him/her] … in a reasonable amount of time. P1-P10 provided the following information: · Before 2022 and 2023, VA1 wheeled his/her wheelchair into the bathroom, transferred him/herself into and out of the bathtub, showered and dressed him/herself, and brushed his/her teeth – all independently. This might take VA1 a few hours to complete with staff checking-in periodically. Starting in August 2023, the facility started making adjustments and increasing their level of assistance for VA1. · P1-P10 provided consistent information that around August 2023, the facility (or P9) created procedures called the “rule of 15” and “absolute time” in response to VA1’s increasing need for assistance. The “rule of 15” meant that if VA1 was working on a task, like pulling up his/her pants, for 15 minutes and did not make progress, staff offered minimal assistance, and once that task was complete, the rule of 15 then applied to the next task, like putting on his/her socks. “Absolute time” meant that if VA1 needed to complete tasks to make his/her bus or an appointment, staff provided the level of assistance needed to complete the task on time. · P1, P2, P4-P7, and P9 each said that when implementing the “rule of 15” or “absolute time,” VA1’s morning bathroom routine took between one and two, or maybe three hours. · P1 said that around October 2023, s/he was trained by the SP and immediately had concerns with the SP’s conduct but did not tell anyone at the time. The SP had worked at the facility for many years and P1 was “new” and did not feel as though s/he should immediately question the SP’s conduct. However, P1 saw that the SP did not honor the “rule of 15” and there were “no absolute times” when it came to VA’s morning bathroom routine. “There comes a point where [VA1] simply cannot do something, and [the SP] would never recognize that point, and [the SP] would often leave [VA1] stuck in a task for hours on end, which is not how we work with [VA1], or should work with [VA1].” In September, October, and November 2023, P1 saw more than once when the SP was working and VA1’s bathroom routine took from 7 a.m. to 2 p.m., which “is an obscene amount of time to be in the bathroom.” · P7 said that in September or October 2023, more than once, s/he arrived at work at 2 p.m. and VA1 was in the shower or just finishing in the shower. The SP told P7 that VA1 typically started his/her morning routine at 7 a.m. P7 said that the SP made VA1 redo his/her bathroom cares when they were not done “to [the SP’s] standards.” P7 heard the SP, sounding “upset and frustrated,” and telling VA1, “I’m going to stay in here (bathroom) all day.” The SP was “very strict” with VA1 completing tasks independently and “adamant” about VA1 maintaining his/her independence. The SP made VA1 rewash his/her hair “several times” if VA1 missed shampoo when rinsing. P7 did not tell anyone about his/her concerns because the SP trained P7 and once told P7 that s/he was going to “report” a staff person who the SP believed had “reported” him/her. P7 was “scared of retaliation” from the SP. · P6 said that the SP was “unwilling” to make changes like using the “rule of 15” or “absolute time.” Instead, the SP made VA1 complete his/her tasks independently even if it took hours. The SP instructed VA1 to rewash his/her hair three or four times and “then all of a sudden, it’s 2 p.m.,” and VA1 was not dressed yet and had not had breakfast or lunch. · P4 said that in the summer of 2023, the SP trained him/her and told P4 to “not help” VA1 in the bathroom. However, despite this, if it got to be 9 a.m. and VA1 had not eaten breakfast yet, P4 stepped-in and helped VA1 in the bathroom. If VA1’s bathroom routine took too long, s/he was “upset” and “crying,” and his/her day was “ruined” because s/he was “sad and upset” the rest of the day. P7 said that VA1 was “upset” for at least an hour afterward if the SP was the one who helped with his/her morning bathroom routine. · P1 said that one morning, date unknown, s/he heard VA1 “sobbing uncontrollably” in the bathroom. P1 stepped-in and asked to switch out with the SP to complete VA1’s morning routine that day. After the SP left the bathroom, P1 told VA1, “It’s okay. [The SP is] not here anymore. I’m going to help you.” VA1 was then able to complete his/her task, which was putting on his/her own brief, in five minutes. · P9 said that more than once in 2023, s/he noticed the SP was not following the “rule of 15” or “absolute time” and more than once, P9 intervened asking the SP why VA1 was not dressed or still in the bathroom. The SP typically gave a “slew of excuses.” P9 told the SP to follow the procedures and reminded the SP that G1 “signed off” on the “rule of 15” or “absolute time” and every staff person, including the SP, “signed off” as well. P9 said that it seemed like the SP was “trying to prove” VA1 could still do tasks independently. P9 provided more than one verbal re-training (undocumented) to the SP but in hindsight believed that something more should have been done to ensure the SP followed the procedures. Regarding the SP “forcing” VA1 to independently use his/her walker: VA1’s coordinated services and support plan-addendum, including Self-Care Plan, stated that VA1 was formerly more ambulatory; however, “in recent years” (as of August 2023), preferred to “solely” use his/her wheelchair. P1-P10 provided the following information: · P7 said that during September through December 2023, VA1 was “barely” able to stand for “a minute.” One time, on an unknown date, P7 heard VA1 “yelling” from another room and asked the SP was what going on. The SP told P7, “Oh, [VA1] has to complete [his/her] five minutes of walker time.” P7 heard VA1 screaming and asking to stop, but the SP redirected VA1 saying, “We have to do your five minutes of walker time.” P7 said that VA1 was “unable to consistently walk for five minutes.” P7 did not tell anyone about his/her concerns because in the fall of 2023, the facility did not have a direct supervisor and P7 did not feel comfortable talking to an administrator at that time. · P4 and P8 each said that VA1 formerly had a goal to use his/her walker five minutes a day; however, as of at least October 2023 that was no longer a goal. P1, P4, P5, and P8 never saw VA1 use his/her walker. · P6 said that s/he heard from unidentified staff that the SP “thought very highly” of VA1’s use of his/her walker and “really pushed” VA1 to use his/her walker every day. P6 did not witness the SP’s conduct firsthand. · P2 and P3 each said that they saw VA1 using his/her walker a couple of times but did not see anyone “forcing” him/her. · P9 said that VA1’s walker was always available, and staff should offer it to VA1 but not force it. · P1-P10 were not aware of any injuries to VA1. Regarding the SP “forcing” VA1 to independently clean incontinence from the floor: P1-P10 provided the following information: · P5 said that around mid-September 2023, s/he saw the SP make VA1 clean up his/her own bladder incontinence from the floor. P5 walked upon the incident and saw VA1 in the hallway holding a mop and there was urine on the floor and the SP was instructing VA1 to clean up “the mess.” VA2 and another housemate were watching and VA1 looked “anxious” and “embarrassed.” P5 saw that there was urine on VA1’s clothing but the SP wanted VA1 to mop up the floor before going into the bathroom or changing his/her clothing. P5 was “shocked” by what was happening. P5 added that VA1 could not stand or walk, his/her hands were “really shaky,” and s/he did not have arm strength. P5 believed the process of pushing a mop back and forth would “not be easy” for VA1. The SP told P5 that VA1 had been trying to mop the floor for 30 minutes. At that time, the SP’s shift was ending but before leaving, the SP told P5, “Make sure [VA1] cleans it up before going to the bathroom.” P5 said that as soon as the SP left, P5 wheeled VA1 into the bathroom and said, “I’m so sorry. Let’s get you cleaned up.” P5 then mopped the urine from the floor and did not ask VA1 to do so. P5 never saw any other staff ask a housemate to clean up incontinence. P5 did not tell anyone about his/her concerns because the SP had been working at the facility for five years. “It almost felt out of place for me, for someone who'd only been working there for like a month” to say something about the SP’s conduct. · P3 said that one time, date unknown, VA1 vomited on the floor and the SP asked VA1 to clean it up and VA1 said, “No.” P3 was initially “surprised” but then the SP explained that cleaning up after him/herself was something VA1 did. P3 then left to help another housemate and when s/he returned, the vomit was cleaned. P3 did not know who cleaned it. Later that day, P3 heard VA1 tell G1 on the phone about the incident and G1 said something like, “Well, we got to clean up after ourselves.” G1’s response made P3 not concerned about what happened. · P4 said, “[It was] like a power trip of like, actually making [VA1] do it.” The SP seemed to believe VA1’s incontinence or vomit was “behavioral.” P4 believed VA1 “could barely” clean up something like incontinence or vomit independently. P4 did not believe the SP’s conduct was consistent with VA1’s care plans. “Not at all.” P4 added that at the time, s/he was one of the newest staff at the facility and “trusted” the SP knew what s/he was doing. · P6 did not witness the SP making a housemate clean up their own incontinence or vomit and believed it would be “embarrassing” for the housemate if that occurred. · P8-P10 each said that VA1 should not be cleaning up incontinence or vomit on the floor. P9 said, “At no point should [VA1] have been cleaning up any mess that [s/he] made.” P9 was aware that VA1 sometimes offered to help clean up and in those cases, P9 would reassure him/her but continue to clean it up without VA1’s help. Regarding the SP using loud stimuli and “threatening” to take away VA1’s phone calls and/or community outings: P1-P10 provided the following information: · P2 said that in 2022, VA1 had a goal to help with the evening dishes. VA1 would wheel his/her wheelchair up to the sink and then staff mechanically lifted the chair so VA1 could reach into the sink. VA1 rinsed the dishes and put them in the dishwasher, which staff opened for him/her. One night, in the fall of 2022, P2 saw a towel fall from the sink to the floor. The SP unclipped VA1’s shoulder straps and told him/her to pick the towel up from the floor. P2 could not recall if VA1 fell to the floor or intentionally sat down but somehow VA1 ended up sitting on the floor in front of the sink next to his/her wheelchair. VA1 was “frustrated” and “upset,” and asked the SP to help him/her stand. The SP declined to help and instead told VA1 to get off the floor on his/her own. When VA1 declined, the SP used his/her cellphone to continuously play a YouTube video of a sponge bob alarm clock with “a big blow horn” and held it “a few inches” from VA1’s ear. VA1 swatted at the phone but the SP moved out of reach and continued playing the sound “until [VA1] was willing to get up.” P2 believed the video was played for one to five minutes or until VA1 stood up from the floor. P2 believed the SP intended to “annoy” VA1 with the noise and P2 considered the noise “really bothering.” P2 did not remember what VA1 was doing while the noise played, but said, “It wasn’t a positive experience for [VA1].” P2 said that the incident was “nerve wracking;” however, s/he did not believe s/he could say anything to the SP or tell anyone at the time because the SP was “a veteran staff.” “[The SP] seemed very confident in [his/her] job” and P2 was new to the direct care field. P2 added, “The more [I] work with [the SP], the more [I] recognized how [the SP] acted compared to other staff.” · P4 said that one morning, between September and December 2023, s/he saw VA1 looking tired in bed and told VA1 that s/he could sleep-in. However, the SP overheard from elsewhere in the facility and entered VA1’s bedroom stating, “No, [VA1] has to get up.” The SP then used his/her cellphone to continuously play a “loud … foghorn” and held it next to VA1. VA1 got “really upset,” threw off his/her blankets, and rushed to get out of bed. The SP played the foghorn for about one minute and turned it off once VA1 was out of bed. · P1, P3, P7, and P8 each said that they did not observe the SP using an alarm with VA1. However, P1 said that there was an instance, date unknown, when s/he heard the SP tell VA1, “You’re not going to be allowed to call [G1] today if you don’t do this business.” In response, VA1 started “screaming and crying.” P1 did not know what “business” VA1 was supposed to do but assumed the SP was “attempting [to] motivate” VA1. P1 was not aware of any times the SP prevented VA1 from calling G1. · P4 said that one time, date known, VA1 was having a “rough day” and the SP said something like, “If you don’t do this, or if you don’t stay calm, then you can’t make phone calls,” which “upset” VA1. P4 said that s/he never saw a phone call withheld from VA1. · P5 said that one time, date unknown, s/he heard the SP saying something about the SP’s family friend wanting to give some stuffed animals to VA1, but “implying” that if VA1’s behavior remained “poor,” “then [the family friend] would no longer give [VA1] these stuffed animals.” VA1 reacted by “being sorry for [his/her] behavior.” · P7 said that s/he heard the SP tell VA1 that if s/he did not go to the gym, which was not something VA1 did often, then s/he would not get to go on his/her outing. P7 and P8 each said that staff should never threaten to withhold outings from the housemates. · P9 said, “Those things shouldn’t have been threatened.” VA1 had a right to make phone calls and go on outings. “I am upset to hear about [this] … but, knowing [the SP] as a person, the escalation is not something that is surprising to me.” P9 felt “sad for” VA1. Regarding the SP calling VA1, “bitch”: P1-P10 provided the following information: · P1 said that on an unknown date, s/he heard VA1 call the SP, “Bitch,” and the SP respond, “Well, you’re acting like a bitch.” Another time, P1 heard the SP tell VA1, “You’re the reason staff quit.” The SP then looked at P1 and said, “I'm not lying like [s/he's] the reason they quit.” P1 did not notice a reaction from VA1 during either of these incidents but added that the SP’s statement did not improve the situation. P1 said that s/he did not tell anyone about the SP’s conduct because s/he “was told” the interaction and language were “normal” for VA1 and the SP. P1 said that the SP once “threatened to report” a staff person, who the SP believed “reported” the SP’s conduct. P1 was “afraid” of the SP and “feared retaliation.” · P6 said that there were times when s/he heard the SP making comments to VA1 like, “You've done it before. You can do it again. I don't know why you can't do that. You should just be able to do it … Oh, that’s stupid. I know you can do that. You’re being purposefully difficult.” In response, P6 observed VA1 “immediately shutdown” or state “insults and curse words back” at the SP. · P10 said that around October 2023, an unidentified staff told him/her that the SP made “rude (unspecified) comments” to the housemates. P10 reviewed the allegations at that time but did not find anything “substantiated.” · P1, P2, P5, P7, P8, and P10 said that they did not witness “name-calling” by the SP towards a housemate. Relevant Minnesota Statutes and Rules: Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6); paragraph (b), clause (1) states; in relevant part, that a person's protection-related rights include: · the right to be treated with courtesy and respect; and · the right to have daily, private access to and use of a non-coin-operated telephone. Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a), states the license holder must provide services in response to the person's identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan and the coordinated service and support plan addendum, and in compliance with the requirements of this chapter. License holders providing intensive support services must also provide outcome-based services according to the requirements in section 245D.071. Minnesota Rules, part 9544.0060, subpart 2, item N, states in part that presenting intense sounds, lights, or other sensory stimuli is prohibited from use for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. Conclusion for Allegation One: A. Maltreatment: P1-P7 provided multiple examples of the SP’s conduct, which included: · declining to follow the “rule of 15” or “absolute time” procedures despite VA1’s limited mobility and strength and causing VA1 to spend seven hours in the bathroom preparing for the day, missing breakfast and sometimes lunch; · making VA1 use his/her walker despite his/her screams and requests to stop; · telling VA1 to clean up his/her own incontinence or vomit, or to pick up a towel despite VA1’s limited mobility and strength; · continuously playing a loud alarm, “blow horn,” or “foghorn” sound until VA1 completed a task; · telling VA1 that s/he could not call G1 or go on an outing until VA1 completed a task; and · making comments to VA1, like, “You’re acting like a bitch,” “You’re the reason staff quit,” and “You’re purposefully being difficult.” The SP did not provide information for this investigation and although the SP might have been able to explain or give context to some of the situations, the volume of examples and consistency within the examples, from multiple staff, provided an account of the SP’s conduct, which was credible. The SP’s conduct, as described by multiple staff, was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and violations of Minnesota Statutes section 245D.04, subdivision 3, paragraph (a), clause (6); paragraph (b), clause (1); Minnesota Statutes section 245D.07, subdivision 1a, paragraph (a); and Minnesota Rules, part 9544.0060, subpart 2, item N. VA1 was living at the facility for support and services and care and supervision and was gradually declining in his/her abilities and strength. More than once a staff person intervened with the SP’s conduct towards VA1 or reminded the SP of VA1’s declining abilities but the SP’s conduct continued. Multiple staff saw VA1’s reaction to the SP’s conduct, which included screaming, yelling, crying, asking to stop, and remaining upset following the interaction; and multiple staff said the SP’s conduct made them feel “shocked,” “surprised,” “embarrassed,” “really bothered,” and “sad.” Therefore, there was a preponderance of the evidence that the SP’s conduct was not an accident or therapeutic, included the use of repeated or malicious oral language and treatment which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and produced or could reasonably be expected to produce emotional distress. It was determined that 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). 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. The SP was responsible for VA1’s care and supervision and received training on VA1’s coordinated services and support plan-addendum and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of VA1. 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 emotional abuse for which the SP was responsible was “recurring” maltreatment. The SP’s conduct included a pattern of behavior, which is considered a single incident of maltreatment; however, it also included specific, significant incidents (e.g., continuously playing a blow horn or foghorn next to VA1’s ear on at least two separate occasions) that stand-alone as separate incidents of emotional abuse. Allegation Two: It was reported that the SP frequently ignored or walked away from VA2. VA2’s coordinated services and support plan-addendum, including Individual Abuse Prevention Plan, provided the following information: · VA2 was unable to reliably interpret social cues and might not be able to identify dangerous situations. Staff instructed VA2 on how to be “socially appropriate” and reported abuse on VA2’s behalf. · · VA2’s diagnoses included intellectual disability and cerebral palsy. Staff assisted with all VA2’s activities of daily living skills. P1-P10 provided the following information: · P1 said that VA2 was a “talkative” person, asked questions, and frequently sought attention which “can be quite overwhelming at times.” P1 saw the SP “ignoring [VA2] a lot … for [VA2’s] commonplace conversation.” P1 did not see a reaction from VA2 and did not believe VA2 noticed the SP’s conduct. In instances when VA2 was talking and P1 needed to focus, P1 told VA2 that s/he was busy and would circle back to VA2 when P1 was finished and VA2 typically handled that response without issue. · P2 said that the SP “didn’t seem fond of” VA2 and saw the SP ignoring or walking away when VA2 tried to talk to him/her. · P4 said that the SP “always” told VA2 that s/he could not talk to him/her until VA2 watched “calming videos.” The SP was “short and closed off” to VA2. However, VA2 did not have a reaction or seem to notice. Once on an unknown date, P4emailed P10 about his/her concerns but did not know what happened with the information and did not see any changes in the SP’s conduct. · P7 said that the SP and VA2 “had tension often” and “argued frequently.” The SP was “frustrated” with VA2. P7 heard VA2 call his/her ride to his/her day program, “a bus,” and the SP corrected him/her saying it was called “a van.” The SP “talked back” to VA2 in a “more aggressive kind of manner.” “It was definitely more aggressive in tone.” VA2 responded to the SP by shutting down and sitting alone. · P5 said that VA2 was “excited” at which staff were working on a given day and wanted to start chatting at the start of the staff’s shift. At least one time, P5 saw the SP “cut off” VA2 in a “slightly demeaning or bossy” way. “It wasn’t super snappy but it also, I don’t think it would feel good to be spoken to in that way.” It seemed like the SP was “annoyed” by VA2. · P8 said that VA2 liked chatting with staff but sometimes struggled with understanding personal space. If P8 needed time to focus on a specific task, s/he redirected VA2 to a different activity. Staff should not ignore or argue with VA2. · P10 said that G2 wanted staff to ignore VA2 if s/he was having “behaviors” like throwing things or yelling, but from what staff told P10 about their concerns, VA2 was not having behaviors when the SP ignored him/her. Staff should not be ignoring him/her or walking away when VA2 talked to them. · P1, P2, P5, P7, P8, and P10 said that they did not witness “name-calling” by the SP towards a housemate. · P3 believed the SP and VA2 had a “good relationship” and did not witness the SP ignoring or walking away from VA2. Conclusion for Allegation Two: P1, P2, P4, P5, and P7 each provided information about the SP ignoring or walking away when VA2 talked or asked a question. The SP did not provide information for this investigation. Although the conduct of ignoring or walking away was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, there was no information the SP called VA2 inappropriate names and there was inconsistent information whether VA2 experienced emotional distress or even noticed the conduct. In addition, it was unclear whether the SP followed up with VA2 afterward or whether VA2 talked to a different staff instead of the SP. Therefore, there was not a preponderance of the evidence whether the SP’s conduct included the use of repeated or malicious oral, written or gestured language toward VA2 or the treatment of VA2, 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 but not followed. The facility provided additional training on the Reporting of Maltreatment of Vulnerable Adults Act. The SP was no longer employed. Action Taken by Department of Human Services, Office of Inspector General: The SP was notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that the SP was responsible for maltreatment is subject to appeal. On November 17, 2025, the facility was issued a Correction Order for the violations outlined in this report. Minnesota Statutes, section 626.557, subdivision 3, requires mandated reporters at a facility to immediately report suspected maltreatment. The investigation determined that seven staff failed to report suspected maltreatment as required. A letter from DHS was sent to each of these individuals regarding their failure to report the suspected maltreatment and potential consequences for future such failures. On November 17, 2025, the facility was issued a $200 fine for failing to report maltreatment as required.
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