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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: 1123926-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scout Peterson Suspected Maltreatment Reported: It was reported that a staff person (SP1) called a vulnerable adult a derogatory term for a gay man. [Note: The use of gay man should not be used as an indicator of the gender of the VA.] It was also reported that a supervisory staff person (SP2) told the VA to “stop sucking dick.” Date of Incident(s): September 11, 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 October 6, 2026; from documentation at the facility; and through five interviews conducted with the VA, SP1, SP2, another supervisory staff person (P1) another staff person (P3), and the VA’s therapist (T). Attempts were made via phone to contact and interview staff person (P2). However, P2 did not respond. The VA’s Individual Abuse Prevention Plan stated that the VA engaged in “inappropriate” interactions and became verbally and physically aggressive with others. The VA was susceptible to verbal abuse. The VA’s diagnoses included borderline personality disorder, bipolar disorder with psychotic features, and autism spectrum disorder. The VA enjoyed hanging out with friends, singing, and going fishing. The VA’s Support Plan stated that the VA was part of the LGBTQIA+ community and that it was important to be affirming and supportive of the VA’s identity; the VA experienced homophobia in the past. The VA stated that s/he lived at the facility for a year and described it as the “year of hell.” The VA stated that all the staff of a certain nationality were “verbally abusive” and that every day for the entire year that s/he lived at the facility, various staff persons called him/her a derogatory term for a gay man and told him/her to “stop sucking dick.” The VA added that for over a year, SP1 called him/her a derogatory term for a gay man each time s/he worked and SP2 told him/her to “stop sucking dick” every time s/he saw the VA. The VA reiterated to this investigator that it was always the staff of a certain nationality that said things about his/her sexuality. On an unknown date the VA “attacked” SP2 and “beat the fuck out of [him/her]” because s/he told the VA to “stop sucking dick.” The VA did not remember anything else about the incident other than that his/her shirt got ripped. The T provided the following information: · On September 24, 2025, the VA went to the T’s office with P2 for an appointment. During the appointment, the VA stated that on an unknown date SP1 called him/her a derogatory term for a gay man and SP2 told him/her to “stop sucking dick.” The VA stated that SP1 and SP2 repeated those things until the VA “attacked” them and called them the N word. · The T stated that s/he first thought there might have been a “mental health component” to what the VA disclosed due to his/her history of psychosis and delusions. The T added that the details the VA provided about the incident were more concrete than someone experiencing psychosis was typically able to provide, but the VA could not provide specific dates and times. P1 provided the following information: · On September 14, 2025, the VA called P1 and was “very agitated,” so P1 went to the facility to meet the VA and discuss his/her concerns over lunch. During lunch, the VA remained “agitated” and was talking about the staff of a certain nationality; the VA called them “cunts,” said they should go back to their country, and stated s/he wanted them all fired. The VA later stated that “a while ago” SP2 told him/her to “stop sucking dick” and that SP1 picked up a chair and threatened the VA with it. P1 attempted to obtain a better timeframe from the VA but the VA repeatedly stated, “a while ago.” · On September 24, 2025, P2 took the VA to an appointment with the T. The VA told the T and P2 that both SP1 and SP2 told him/her to “stop sucking dick” and that was why s/he attacked SP2 on September 11, 2025. · The VA had a pattern of reporting that all staff, other than whomever s/he was talking to, called him/her a derogatory term for a gay man and “mistreat[ed]” him/her. P1 stated that the VA was inconsistent in reporting who called him/her the derogatory term, but was consistent in his/her statements that s/he wanted all the staff persons of a certain nationality fired. P1 never observed any staff persons call the VA a derogatory term for a gay man or tell him/her to “stop sucking dick.” SP2 who spoke to all staff individually, reported no concerns to P1. SP2 provided the following information: · On September 11, 2025, the VA, SP1, SP2, and P3 were sitting at a picnic table outside the facility. The VA was upset and verbally agitated because s/he wanted to get a haircut, but another staff person was using the company van at that time. The VA spit and threw an ashtray at SP2 and then “charged” at SP2, pulled his/her hair, and hit him/her on the head. SP1 immediately removed the VA from SP2, SP2 ran from the VA, and the VA chased SP2. Tthe VA then began hitting cars that were parked near the facility. One of the staff persons [SP2 could not remember who] called 911 for assistance, and police and EMS arrived and transported both SP2 and the VA to the hospital. The VA was later discharged with no injuries and SP2 was discharged with a concussion. · On an unknown date after the incident, the VA reported to P1 that all the staff persons of a certain nationality called him/her a derogatory term for a gay man , and that SP2 told the VA that s/he “shouldn’t suck on dick.” SP2 told this investigator, “I can’t even say the words [that the VA used]; the words themselves make me uncomfortable.” SP2 added that s/he never heard staff or anyone else that worked with the VA call him/her the derogatory term, nor tell the VA to “stop sucking dick.” Moreover, SP2 added that she hadn’t even heard any staff persons talk to the VA in a disrespectful tone. The VAs stories were “inconsistent” and changed depending on who s/he was talking to. SP1 provided the following information: · On September 11, 2025, P3, SP1, and the VA were outside of the facility and SP2 arrived at the facility. The VA cursed at, spit on, and jumped SP2 when s/he got out of the car. SP1 and P3 “rushed” to get the VA off SP2 and the VA pulled SP2’s hair. After they separated, SP1 called 911 and after responders arrived, the VA and SP2 were both taken to the hospital. · SP1 stated s/he had “no issues” with the VA. SP1 never heard any other staff persons call the VA a derogatory term for a gay man, and SP1 never called the VA the derogatory term. SP1 stated that if staff persons said something the VA did not like, s/he became aggressive and had increased behaviors and for that reason, staff persons avoided saying things that the VA did not like. SP1 had no concerns with the way that SP2 interacted with the VA and stated that s/he was never disrespectful to the VA. P3 provided the following information: · On September 11, 2025, at the end of P3’s shift, SP1 arrived at the facility to relieve P3. The VA asked SP1 about getting a haircut, and SP1 explained to the VA why they were unable to do so at that time. The VA started “cussing out” SP2, and P3 told SP2 to go outside, which s/he did. About five minutes later, the VA and P3 went outside so the VA could smoke. · While they were all outside, SP2 arrived at the facility, without money that the VA was expecting. The VA then called SP1 and SP2 the N word and told them to go back to the country they came from. The VA then spit on SP2, threw things at him/her, hit him/her, and pulled his/her hair. SP1 and P3 intervened to stop the VA from attacking SP2, and SP1 called 911. The police and EMS arrived and both the VA and SP2 were taken to the hospital. Later that night when P3 was still working, the VA was discharged and the hospital transported him/her back to the facility. · P3 never heard SP1, SP2 or any other staff persons call the VA names. More specifically, P3 never heard SP1 or SP2 call the VA a derogatory term for a gay man or tell him/her to “stop sucking dick.”
The facility’s Internal Review stated that the VA had a history of “stating [his/her] desire” for all the staff of a certain nationality to be fired. The VA also provided inconsistent information as to what was said, when things were said, and which staff persons were involved. According to the facility’s Service Recipient Rights policy, staff persons were required to speak to clients “respectfully and courteously.” Additionally, clients reserved the right to be free from bias and harassment regarding their sexual orientation. All staff persons interviewed for this investigation and P2 were trained on the VA’s plans, the Reporting of Maltreatment of Vulnerable Adults Policy and the facility’s Service Recipient Rights policy. Conclusion: It was reported that on September 11, 2025, SP1 called the VA a derogatory term for a gay man and SP2 told the VA to “stop sucking dick.” P3 was also working that day. SP1, SP2, and P3 each denied that they heard anyone call the VA a derogatory term or tell him/her to “stop sucking dick;” that day or any other day. The VA stated that SP1 and SP2 each called him/her the derogatory term and told him/her to “stop sucking dick,” every time they worked for the entire time s/he lived at the facility. The VA added that it was always staff persons from a specific nationality that said those things to him/her. The T stated that the VA told him/her that SP1 and SP2 told him/her those things and the T thought that there might be a “mental health component” to what the VA disclosed due to his/her history of psychosis and delusions.” Given that the VA provided inconsistent information about when incidents occurred and which staff were involved, that the VA had a history of stating his/her desire for all the staff of a certain nationality to be fired, , that SP1 and SP2 denied the allegations, and that neither P1, P2, nor P3 heard any other staff person say those things to the VA, there was not a preponderance of the evidence that SP1’s or SP2’s interactions included repeated oral language that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. 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 and followed. Action Taken by Department of Human Services, Office of Inspector General: On December 3, 2025, the facility was issued a Correction Order for failing to report maltreatment as required.
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