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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: 1117977-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns Suspected Maltreatment Reported: It was reported that after a vulnerable adult (VA) would not wake up, a staff person (SP1) poured water on the VA and another staff person (SP2) played a foghorn sound on a phone application near the VA. Date of Incident(s): August 12, 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 (3): 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544. Summary of Findings: Pertinent information was obtained during a site visit conducted on August 26, 2025, from documentation at the facility, law enforcement records, and through ten interviews conducted with two administrative facility staff persons (P1 and P2), three facility staff persons (P3, P4, and P5), a client (C), the VA’s guardian (G), the VA, and two staff persons (SP1 and SP2). The VA was diagnosed with oppositional defiant disorder, diabetes, an intellectual disability, and an impulse disorder. The VA enjoyed fishing, meal planning, cooking, and spending time with his/her fiancé. The VA’s plans stated that s/he had a history of showing physical and verbal aggression when s/he did not get what s/he wanted “immediately.” At times, the VA “refused” medications, would not get out of bed, or would not wake in time to take medications. Staff persons were to “cue” the VA around medication time and give verbal prompts. In the VA’s past, s/he “over-consumed” caffeinated beverages which caused irregular sleep. When the VA did not get adequate sleep, s/he had an increase in “interfering behaviors,” and emergency room visits, and “an overall decline in [his/her] physical and mental health.” The facility’s Internal Review stated that the VA had frequent history of sleeping in the common areas, “snoring loudly, ignoring staff [person] redirection, and disrupting [his/her] housemates.” The VA “pushed boundaries, [went] against [his/her] programming,” and made many calls to the G and law enforcement. Other facility documentation stated that the VA often fell asleep in areas in the house other than his/her bedroom, such as common areas, while riding in vehicles, and in the bathtub. The VA was at times, incontinent, and had accidents on shared furniture. Improving this was one of the VA’s goals. The main level of the facility consisted of a living room, a dining room, and a kitchen which was one large room. The VA stated that s/he accidentally fell asleep on the couch for “a couple hours” and SP1 “dumped water” on the VA. It was the first time it had happened, and the water temperature was not burning nor freezing, but was “nuke” warm. The water went into the VA’s ear and then the VA called law enforcement. The VA could not remember more details. The VA was a hard sleeper and did not recall anyone talking to the VA during that time. The VA did not recall anyone playing “loud noises” to wake the VA and stated that staff persons did not use alarms. The VA did not know what staff were supposed to do to get the VA up. Facility documentation stated that on August 12, 2025, the VA was sleeping on a living room couch, “taking up the whole space,” when SP2 redirected the VA to sleep in his/her own bedroom so that other clients in the facility could use the couch. Video of the incident, which started at 6:09 p.m. on August 12, 2025, showed the VA sleeping on the couch when SP2 asked the VA to get up so that others could use the couch. SP2 put his/her phone near the VA’s ear and played a “foghorn” sound, which lasted approximately four seconds. The VA said that s/he was “up” but continued to lay on the couch. SP2 continued to ask the VA to get up, stating, “If you don’t get up, we’re gonna throw water on [you].” Several seconds later, SP1 placed a cup under the kitchen faucet while P3 washed dishes at the kitchen sink with his/her back to the rest of the room. SP1 said s/he would “take the blame,” and walked to the couch. SP1 stood near the VA’s head and appeared to pour water on the VA’s head for approximately two seconds, with his/her left hand before stepping away. SP1’s back was to the camera and blocking the camera’s line of sight to the VA’s face. The VA was lying with his/her left side of his/her face down and right side of his/her face up, facing the living room. The video’s angle only showed the top of the VA’s forehead, so it did not record where on the VA’s head the water was poured. SP1 said, “Time to get up. If you’re tired, you need to go to bed.” Several seconds later, the VA said, “I’m calling the fuckin’ cops.” SP1 told the VA that they tried to wake the VA or get him/her to move to his/her bedroom and then asked, “How else are we supposed to wake you up?” SP1 then went to the kitchen sink and appeared to dump the remaining water prior to putting the cup down on the counter. Facility documentation consistent with the video, stated that prior to the water being poured, the VA “did not comply,” to staff persons requests to wake up and continued to sleep. SP2 attempted to wake the VA by using a noise application on his/her cell phone. SP1 and SP2 stated that they used verbal and other methods to “redirect” the VA from sleeping and possibly urinating on the couch before SP2 told the VA that they would use water to wake the VA. SP1 filled a cup with water and poured a “small amount” on the side of the VA’s head. The VA “jumped up” and was “angry,” and called law enforcement. Staff persons called the on-call management team and another staff person from another facility traded locations with SP1 for the remainder of the shift. Additional facility documentation stated that on the day after the incident, August 13, 2025, the G, the VA, and administrative staff persons from the facility met to discuss the incident. Although staff persons had been told that “this wasn’t allowed,” the G reminded the VA that previously, s/he told staff persons to “use whatever means necessary to wake [the VA] up, including water.” During the meeting the VA said that s/he did not think the incident was “assault” but was not going to “drop the charges” because SP1 had “pissed off” the VA about other things. The VA was reminded that part of living with other clients was “recognizing” that they had the same rights that the VA had and that “internationally urinating” on common area furniture “disrupted” their health or safety. SP1 provided information consistent with the video and added the following information: · When SP1 arrived on shift on August 12, 2025, it was “stressful” and SP1 was the only one holding the VA accountable to his/her protocol, set by administrative staff persons, that s/he could not sleep for more than thirty minutes in the day area. Things “escalated” throughout the day with the VA being “aggressive” toward SP1. At times, SP1 disengaged from the VA or walked away. · Prior to the VA’s nap, they reminded the VA that s/he could only sleep in the living room for 30 minutes and then they would try to wake the VA. At about 5 p.m., the VA arrived home and fell asleep on the couch in the living room. After 30 minutes, staff persons, especially SP1 and SP2, had “tried everything,” including “almost screaming” the VA’s name. SP1 did not hear SP2 use the “air horn” application on his/her phone. The VA’s socks and shoes were off and his/her feet “stunk up” the facility. Reminding the VA to shower or wash his/her feet made the VA “mad.” · Previously, the VA said do “anything” to wake him/her. When the VA did not wake, SP1 filled a cup of water with room-temperature water and poured a “teaspoon to a tablespoon” on the VA’s neck. The water also got on the VA’s cheek and chin. SP1 said that it was not done “maliciously,” and that the VA woke up and called law enforcement at 6:32 p.m. SP1 dumped out the rest of the water and called an on-call supervisor to tell the supervisor about the incident. SP1 also stated that s/he would take the responsibility. SP1 regretted using water to wake the VA. SP2 provided information consistent with the video and added the following information: · On August 12, 2025, the VA was sleeping for about an hour and SP2 attempted to wake the VA by touching his/her feet, which were exposed, by tapping his/her ears, and using a louder speaking voice but nothing was working. At some point, all staff persons attempted to wake the VA. SP2 used a phone application to play a noise while holding the phone approximately four feet from the VA’s head on a volume of a two on a scale of ten being the loudest. SP2 said that s/he tried the alarm a “couple of times” for no more than two minutes. The VA did not get up but covered his/her ears. Cuing the VA to go downstairs and sleep in his/her bed did not work. SP2 also stated that if the VA did not get up, they were “gonna throw water” on the VA. (Investigator’s note: SP2 appeared to be standing several feet from the VA when s/he played the application, but stepped toward the VA, within possibly a foot of the VA’s head when s/he played the sound on the application). · The C was complaining about the noise and tried to wake the VA by saying the VA’s name. The VA previously asked staff persons to wake him/her with loud noises. The VA’s bare feet “really stunk.” Staff persons cued the VA to wash his/her feet or shower, and the VA did not do anything. · SP1 told SP2 and P4 that s/he was going to use water on the VA, and they said s/he should probably “think about that” before actually doing it. P3 and P4 provided the following information: · On August 12, 2025, between 5:30 or 6 p.m., P3 was washing dishes while the VA slept on the couch and P4 went outside and sat with a client and SP1 while they were discussing the VA’s sleeping. · The VA was not wearing socks and the VA’s feet had an odor which according to P3, “everyone in the room” could smell, so everyone went to eat outside. According to P4, a blister on the VA’s foot popped and staff persons were trying to wake the VA to clean the wound, and a client was “irritable” about the VA sleeping on the couch. P3 said there was a rule throughout the various facility locations that there was no sleeping in the living room which was why staff persons were trying to wake the VA and because s/he was difficult to wake. All staff persons were trying to get the VA up to join them for dinner. · According to P3, while they were eating outside, SP1 mentioned trying to use water to wake the VA, P4 and SP2 said that they did not think SP1 should do that. According to P4, P4 told SP1 that on a previous date, s/he “teased” the VA that s/he would pour water on the VA if s/he did not get up, but never actually did so and knew that it was not allowed. · SP2 next played a foghorn noise on his/her cell phone. P3 said that SP2 stood approximately three to four feet from the VA to wake the VA but it did not work so SP2 gave up. P4 said that the VA “stirred” but did not get up. P4 said that the volume was half-way between a zero and the phone’s loudest setting. SP1 went back inside. · According to P3, while s/he washed dishes, SP1 came in and “filled” a cup with room temperature water, but P3 did not know what for. The next thing P3 heard was the VA say, “What the fuck? You’re not supposed to do that to a client,” and then the VA wiped his/her face. SP1 returned to the sink to dump out the remaining water into the sink. The cup was “most of the way full” when SP1 returned to dump it out. · According to P4, after SP1 went inside, the VA next went outside and was upset, stating that SP1 poured water on him/her. P4 later heard that it was a teaspoon or tablespoon of water poured on the VA’s face and was unsure of the water temperature. · P3 said that afterward, SP1 went outside to make a phone call and P3 asked SP2 what staff persons were supposed to do next. SP2 stated that they would talk to the VA and try to “calm” the VA, which staff persons did. · P3 and P4 stated that SP1 and another staff person from another facility locations swapped locations for the rest of the shift and then law enforcement arrived. According to P3, the rest of the evening was “pretty normal” and P4 stated that there was “not much more” to the incident. · According to P3, staff persons were trained to “cue” the VA every few minutes or when it was mediation time to make sure that the VA knew s/he needed medications. · According to P4, there was no protocol as to how to wake the VA. Ideally, not allowing the VA to sleep on the couch was the best option, because the VA sometimes had “incontinence episodes,” and snored “very, very loudly,” snoring louder, the harder s/he slept, which disrupted the clients. Some alternatives were tickling the VA’s feet or ear, which “sometimes worked” or placing an arm on the VA’s upper shoulder to “shake” the VA, but this could be risky because the VA sometimes “startled awake.” Staff persons tried “whatever worked” to get the VA up and P4 sometimes offered to the VA that they go outside to smoke. Generally, staff persons “cued” the VA to wear socks and wash his/her feet, but wearing socks was the VA’s choice. · SP1 did not “target” the VA but was not “lenient” with him/her either. P3 could not recall any other staff persons being involved as the others were outside during the incident. SP1 discussed using water to wake the VA prior to using water, and was going to call an on-call staff person to ask but P3 did not hear any conversations that SP1 made. The C provided the following information: · The VA sometimes fell asleep in common areas of the facility. The C recalled an incident where a staff person “dumped” water on the VA but could not recall who. Staff persons tried to wake up the VA “every which way,” and the VA continued to make “sleeping sounds.” Staff persons did not know what else to do to wake the VA up. It was close to supper time when staff persons were trying to wake up the VA. · Clients were supposed to sleep in their bedrooms and not in the shared areas. Staff persons would try to decide to let the VA sleep in the common area or to wake the VA. Staff persons would tap the VA on the shoulder and wiggle his/her toes or legs, but the VA was a “hard one” to wake up and “never” would wake up. If the VA did not get up for medications, s/he blamed staff persons. The G provided the following information: · On August 12, 2025, the VA called the G “highly upset” and instead got a hold of an on-call guardian. The next day, the G spoke with the VA when they met and discussed the incident. The G understood that the VA wasn’t getting up and SP1 poured a “whole glass of water” straight into the VA’s ear. After talking further and with P1, it was determined that it was maybe a teaspoon or two that “dribbled down” to the VA’s ear. The VA typically got upset and want to get a staff person fired. · The G previously heard the VA tell staff persons to pour water on him/her, tickle his/her feet, put ice packs on him/her, shake him/her to wake him/her, or put a fan on the VA to make him/her cold so that s/he would wake up. The G told the VA that staff persons should not be pouring water or using ice packs, even though the VA suggested it. The G was not told anything else and said that this was the only time the VA said they have used water. P1 and P2 who were not present for the incident, provided information similar to what was already provided, and added the following: · According to P2, the VA told staff persons to do what they could to wake him/her. Staff persons could not force anyone to not sleep on the shared furniture, but the VA should not have been “impacting the rights” of the other clients. The VA wore a watch with an alarm for medications but would not wake to that. · P2 stated that sleeping on the couch and chairs were a “health issue” for the VA because of neck and back pain, missing seizure medications or other medications that put the VA “off baseline” and missed outings. The VA had sleep apnea but refused to sleep with a continuous positive airway pressure (CPAP) device. The VA stayed on his/her baseline when s/he got sleep. When the VA did not, s/he would be “threatening” to staff persons. Incontinence issues impacted the condition of the VA’s skin, who was diabetic. · According to P1, SP2 suggested using water to wake the VA, which the VA had suggested, previously. P1 told staff persons that was not an okay option. P1 stated the SP1 and SP2 both provided information consistent with what the video showed during the internal investigation. P5 provided the following information: · P5, who was not present during the incident stated that on August 12, 2025, s/he arrived for his/her shift at about 9 p.m. A staff person told P5 what happened earlier. P5 provided information consistent with what was observed on the video footage. Pouring water on the VA was not allowed and P5 had not heard of it happening before. · During the overnight shift, the VA woke up and wanted to talk about the incident with P5 and another staff person. P5 told the VA that s/he was not comfortable talking to the VA about it in case anything else came up regarding the incident. · Staff persons were supposed to use verbal and physical redirection, as well as incentives to get the VA to do things, but that depended on the VA’s behaviors and outcomes as to how well that worked. All staff persons were trained on the Reporting of Maltreatment of Vulnerable Adults Act, and the VA’s plans. Relevant Rules and or Statutes: Minnesota Rules, part 9544.0060, subpart 2, items N and O stated that actions or procedures prohibited from use as a substitute for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience included presenting intense sounds, lights, or other sensory stimuli and using a noxious smell, taste, substance, or spray, including water mist. Conclusion: Information was consistent that on August 12, 2025, the VA fell asleep on the couch in the living room and that staff persons attempted to wake the VA including tickling the VA’s ear or foot and speaking loudly. Video surveillance showed that SP2 played an “air horn” sound from his/her phone while standing over the VA and threatened that if the VA did not get up they were “gonna throw water” on the VA. The video showed SP1 standing by the sink and then bringing a cup of water over to the couch that the VA was sleeping on. Although SP1 was standing in the way of the camera, preventing the viewer from seeing exactly where and how much water was poured, SP1 stated that s/he filled a cup of water with room-temperature water and poured a “teaspoon to a tablespoon” on the VA’s neck. Although SP1 poured water on the VA and SP2 used an air horn sound to wake the VA both which were in violation of Minnesota Rules, part 9544.0060, subpart 2, items N and O, given that there was no information that either of these had been used to wake the VA on other occasions and that the VA was not injured, there was not a preponderance of the evidence whether SP1’s or SP2’s conduct could reasonably be expected to produce physical pain or emotional distress. It was not determined whether 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: Use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable adult from other persons against the will of the vulnerable adult or the legal representative of the vulnerable adult unless authorized under applicable licensing requirements or Minnesota Rules, chapter 9544).
Action Taken by Facility: The facility’s Internal Review stated that the facility’s policies and procedures were adequate but not followed. There was a need for additional staff training and both SP1 and SP2 completed additional training, in addition to all staff persons being trained on “alternate approaches.” SP1 was transferred to another facility within the company and there was not a need for additional corrective action. Action Taken by Department of Human Services, Office of Inspector General: On November 25, 2025, the facility was issued a Correction Order for the violations outlined in this report.
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