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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: 1070632-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Elisa Montgomery elisa.montgomery@state.mn.us Suspected Maltreatment Reported: It was reported that a staff person (SP) was witnessed yelling at and laughing at a vulnerable adult (VA) causing the VA to become upset. Date of Incident(s): October 18, 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 November 5, 2025; from documentation at the facility; and through six interviews conducted with facility staff persons (P1-P3), the VA’s guardian (G), the VA, and the SP. The VA enjoyed going listening to music, going on walks with staff persons, and making meaningful connections with his/her staff persons. The VA was diagnosed with intellectual disabilities, episodic mood disorder, and impulse control disorder. Due to the VA’s diagnoses, the VA was not able to provide information related to the incident and declined to share details with this investigator. The facility was one level and had an entry way that accessed the common area which was set up like a living room and included a dining area and kitchen. To the left of the common area, was an apartment style living area and laundry room. A separate wing that was locked, and was accessible by staff who had a key, had an office area, a meeting room, and various storage rooms. To the right of the common area was three apartment style living areas. In each apartment was a kitchenette, a bedroom, a bathroom, and a living room. Each person served at the facility had his/her own apartment. The VA’s apartment was to the right off of the common area. The VA’s Individual Abuse Prevention Plan provided the following information: The VA was susceptible to emotional abuse and was not able to deal with verbally aggressive peers and others and could place his/herself in situations where there was a potential for others to target him/her verbally. The VA was able to spend time without supervision in his/her apartment and was encouraged to spend time in his/her apartment if the social environment in the common areas were disrupting him/her. P1 provided the following information: · On October 18, 2025, P1 was working at the facility. P1 was in the common area of the facility. The SP was on a couch and the VA was sitting at a dining room table. The SP was using a laptop. The VA was making “funny faces” at P1 and the SP assumed that the VA was making faces at the SP. The SP asked the VA to not look at him/her. · The VA became upset and was redirected to go to his/her apartment. The VA went to his/her apartment, slamming the door behind him/her. The VA, who was alone in his/her apartment, was heard yelling “shut up [SP],” and “you’re not the boss of me [SP].” The SP began laughing at the VA’s reaction to being redirected. P1 told the SP that his/her reaction was “not funny”. · The SP became upset and walked into the office area of the facility and remained in the office area of the facility. P1 heard the SP talking on the phone and crying with an unknown person and was discussing the incident. The SP was in the office area from either 6:30 to 8:00 p.m. or 7:00 to 8:30 p.m. · After some time, P1 went to the office area where the SP was and talked to the SP regarding the incident and no further incidents or issues occurred after and the SP returned to the common area of the facility. · P1 did not believe that the SP handled the situation “professionally” and there were other times when P1 believed that the SP acted in an unprofessional manner toward the VA while working at the facility by staring at the VA, prompting a reaction from the VA, and then telling the VA to stop staring at him/her. P2 provided the following information: · On October 18, 2025, P2 was working at the facility in the afternoon. The VA was sitting on the couch in the common area and moved to sit at the dining room table. The SP was sitting on the couch in the common area facing the dining room table. · P2 observed the VA’s behavior that day was “edgy” and when the SP told the VA to quit staring at him/her. The VA responded, “I’m not.” The SP responded, “Yes, you are.” A few minutes later, the SP told the VA, “Stop making faces at me,” and the VA responded, “I’m not.” The VA became upset and went to his/her room. P2 watched the interaction and did not observe the VA staring at or making faces at the SP. · P1 told the SP that s/he should not be laughing at the VA. The SP left the area to the office and began talking on the phone. At some point, the SP texted P1 to come to the office to talk to him/her about the incident. P2 could hear the SP crying in the office. · Approximately ten minutes later, the SP approached P2 and acknowledged that s/he was laughing at the VA because s/he was “nervous” and that it was not appropriate and would work on controlling his/her reactions. · P2 expressed that s/he believed the SP was “immature” in his/her interactions with the VA and that the SP “antagonized” the VA for an unknown reason. P2 had witnessed other occasions where the SP would stare at the VA, prompting a response from the VA but the SP had not laughed at the VA on previous occasions. P3 provided the following information: · On October 18, 2025, P3 observed the SP sitting on the couch in the common area. The VA was sitting at the dining room table. The SP was staring at the VA and appeared to be waiting for the VA to look at him/her. When the VA did look at the SP because s/he was staring at the VA, the SP would tell the VA to stop staring at him/her. · The VA became upset and went to his/her apartment. While in his/her apartment, the SP began to laugh at the VA, but the VA had not seen the SP laughing. P1 told the SP, s/he should not be laughing at the VA and that it was not appropriate. The SP went to the office area for approximately 30 minutes. P1 and P2 talked with the SP regarding his/her reactions and how they were not appropriate. · P3 witnessed the SP tell the VA, “Stop looking at me, that’s disgusting,” and staring at the VA until s/he looked at the SP, telling the VA, “Stop staring at me,” on multiple occasions. P3 was not able to recall additional dates or times since the SP only occasionally worked at the facility. · The VA would typically react to the SP’s actions by putting his/her head down and “looking defeated” and talked about missing his/her friends or would go to his/her apartment, shut the door, and yell at the staff without the staff being in the room. The SP provided the following information: · On October 18, 2025, the SP was in the common area of the facility with other staff persons and the VA and his/her staff person (P1). The SP was using a laptop and was completing charting. Around 5:30 p.m., while charting, the SP began laughing at him/herself because s/he was feeling “overwhelmed.” · P1 was “discipling” the VA and assumed that the SP was laughing at the VA. P1 told the SP that s/he was “always trying to irritate and agitate” the VA. The SP went to the office area and talked with P1. The SP felt that the incident was “resolved” without further issue. · The SP was uncomfortable when the VA would stare at him/her or make faces at him/her due to a past incident when the VA masturbated in front of the SP. · The SP yelled at the VA “maybe once” and told the VA that it was “disgusting” that the VA stared at him/her on one occasion but did not recall when or in what context. The SP denied laughing at, staring at, or antagonizing the VA. The G provided the following information: The G was not aware that the incident had occurred and did not have concerns regarding the facility, staff persons or care that the VA received. Please add training info here. Conclusion: P1- P3 provided consistent information that on October 18, 2025, while working at the facility, the SP and the VA were in the common area of the facility. The VA was sitting at the dining room table. The SP was staring at the VA and when the VA looked at him/her, the SP told the VA, “Stop staring at me,” and when the VA left the common area to go to his/her apartment, the SP laughed at the VA. P1-P3 provided consistent information that on other occasions when the SP worked at the facility, the SP would stare are the VA until the VA looked at him/her and would tell the VA to stop staring at him/her. P1- P3 believed that the SP’s actions toward the VA were “unprofessional” and “inappropriate”. The SP stated that on October 18, 2025, the SP was at the facility and was using a laptop and was completing charting. Around 5:30 p.m., while charting, the SP began laughing at him/herself because s/he was feeling “overwhelmed.” P1 was “discipling” the VA and assumed that the SP was laughing at the VA. P1 told the SP that s/he was “always trying to irritate and agitate” the VA. Although consistent information was provided by P1-P3 that on October 18, 2025, the SP had stared at the VA and told the VA to stop staring at him/her and the SP stared at the VA on other occasions, given that there was no other information that the SP yelled at the VA more than once, that the SP stated that on October 18, 2025, s/he laughed to him/herself and not at the VA, and that the SP denied laughing at or antagonizing the VA, there was not a preponderance of the evidence whether the SP’s actions rose to the level of emotional abuse. 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 and internal review and determined that their policies and procedures were adequate but were not followed by the SP. The SP received retraining regarding the facilities policies and procedures on November 18, 2025. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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