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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: 1116927-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Christine Cavanaugh/Alice Percy Minnesota Department of Human Services 651-431-3444 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) called a vulnerable adult (VA) a bitch and encouraged the other clients to harass the VA by making up false accusations about the VA stealing items from the other clients. The SP took the VA’s personal items and hid them. It was also reported that the SP drank alcohol and smoked marijuana at the facility. Date of Incident(s): Ongoing, prior to July 15, 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 two site visits conducted on August 13 and 19, 2025; from documentation at the facility; and through fifteen interviews conducted with four facility staff persons (P1 – P4), three administrative staff persons (P5 – P7), the SP, a community person (CP), three clients (C1 – C3) who also lived at the facility, the VA, the VA’s case manager (CM), and the VA’s guardian (G). Information obtained showed that there were interpersonal conflicts between P1 and the SP. There was initial information provided that there were concerns that the SP drank alcohol and smoked marijuana at the facility and may have driven clients in the facility van while under the influence of either alcohol or marijuana and that s/he allowed the VA to eat cat food. Through interviews and documentation there was no information that corroborated these concerns. Therefore, this investigation memorandum will only address the other allegations as listed above. The VA enjoyed listening to music, using his/her iPad, caring for his/her pet, going on community outings, and spending time with family members and friends. The VA’s diagnoses included mild to moderate developmental disability, mutism, obsessive-compulsive disorder, oppositional defiant disorder, diabetes, and anxiety. The VA went to a day training and habilitation program each weekday. The VA’s Assessment stated that because the VA sometimes ate excessive amounts of food at night, a rights restriction was implemented to address this. An alarm was placed on the staircase so that the staff persons could redirect the VA if s/he walked up the stairs to the kitchen. In the past, the VA took personal items and food from the other clients in the facility and the VA was working on changing his/her behavior. The VA might not recognize potential risk or danger posed by others and was at risk for exploitation and maltreatment. The VA had difficulty advocating for his/her own needs. The staff persons were trained to keep the VA safe and free from neglect or abuse. The VA’s Individual Abuse Prevention Plan stated that the VA was not always an accurate reporter of events. The VA might admit to things that may not be accurate just because a staff person asked him/her. The VA was easily influenced and could be taken advantage of. The VA stated that the SP “wasn’t very nice to me” and that the SP took the VA’s dolls and hid them in the garage. The SP also told others that the VA was a thief and called the VA “trash” and “bossy.” The SP told the VA that s/he would “get kicked out” of the facility. C1 stated that the SP “yelled” at the VA every day and the SP called the VA a “bitch” and a “trash thief,” which caused the VA to cry. The SP took the VA’s cell phone and his/her dolls. C2 stated that in the past, the SP told C2 that s/he was going to take some of the VA’s personal items and hide them. C2 was not certain that all of the items were returned to the VA. C3 believed that the SP took personal items from the VA and put them in the garage. The SP also took the VA’s iPad from the VA and kept it until the VA’s behavior improved. P1 provided the following information: · The SP frequently “berated” the VA and told the VA that s/he “didn’t like [his/her] ass.” The SP did not yell or swear at the other clients. In June 2025, the SP yelled at the VA for taking a cookie and told the VA that s/he was going to “get your ass kicked out” of the facility. The SP swore at the VA “almost every time” s/he talked to the VA, which caused the VA to hold his/her face in his/her hands and cry. The SP sometimes encouraged the other clients to verbally abuse the VA. The SP took items from the VA, including his/her dolls, radio, and coloring books and told the VA that s/he would not get the items back until the VA returned a key that the SP believed the VA took from a staff person. C3 once told P1 that s/he found a box of the VA’s personal items in the garage. Although P1 told P5 about the incidents, P5 “chose to not do anything.” · C1 told P1 that in June 2025, the SP went into C2’s bedroom and broke C2’s cell phone so that the VA would be blamed for breaking the cell phone. On July 2, 2025, P1 was working at the facility when the SP arrived in his/her car and smelled of marijuana. The SP “interrogated” the VA about breaking C2’s cell phone and tried to get the VA to admit to breaking the cell phone. The SP told the VA to get into his/her car so P1 telephoned P6 and told him/her that the SP was intoxicated and was trying to force the VA to get into his/her car. P6 then called P5, who arrived at the facility and talked to the SP before sending the SP for a blood alcohol test. The SP then left the facility. · P1 was unable to provide additional details of the SP’s interactions with the VA, including dates, times, circumstances, and/or individuals present at the time. P2 stated that on two occasions, the SP raised his/her voice when speaking to the VA about taking items from C1’s and C2’s bedrooms. The VA became upset and began to cry. P2 believed C1 “might exaggerate” events. P3 stated that s/he did not work with the SP often and had no concerns regarding the SP’s interactions with the clients. P3 stated that the SP sometimes raised his/her voice when speaking to the VA, but s/he did not believe the SP behaved in an abusive manner. P3 never heard the SP swear at the VA. P3 believed all of the clients sometimes exaggerated when talking about events. P4 stated that s/he did not work with the SP often and had no concerns about the SP’s interactions with the clients. The VA told P4 that the SP was “always rude,” but did not provide additional information to P4. P4 believed that C1 was an accurate reporter of events. P5 stated that s/he had no previous concerns about the SP’s interactions with the VA or other clients. P5 believed that C1 was not always an accurate reporter of events. P6 stated that s/he had no previous concerns about the SP’s interactions with the VA or other clients. P6 believed that the SP was sometimes “frustrated” and sometimes “stirred the pot” when talking about their actions. P6 believed that C3 was probably the client who would provide the most accurate account of events. The VA had a rights restriction on accessing food, so the refrigerator was locked at night, but the VA still had access to fruit. P6 believed that the VA was sometimes blamed for taking the other clients’ possessions, but P6 was uncertain if the VA was actually responsible in every case. P7 stated that prior to July 2, 2025, s/he was unaware of any concerns about the SP’s interactions with the clients. P7 did not believe that P1 was always an accurate reporter of events because P1 had conflicts with supervisory staff persons. P7 believed that P5 would address any concerns brought up about any of the staff persons behaving unprofessionally. P7 did not believe that C2 or C3 were always accurate reporters of events. The CP stated that in the past, s/he worked at the facility, but did not have concerns with the SP’s interactions with the clients. The SP provided the following information: · If the VA did not go to the gym or do his/her daily tasks, the G allowed the staff persons to take the VA’s iPad from him/her and keep it in the staff office, where the VA did not have access to it. [Note: Not allowing the VA access to his/her personal items was a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (b), clause (16) which states that a person’s protection related rights include the right to access to the person’s personal possessions at any time.] There was also a box of prizes, stored in the staff office, that the VA could choose from once a week if s/he did not steal any items from the other clients or staff persons. On one occasion, the facility purchased a doll for the VA’s birthday, but P2 mistakenly gave the doll to the VA prior to the VA’s birthday, so the SP took the doll from the VA and placed it in the prize box. The SP stated that s/he never took the VA’s dolls from the VA on any other occasion. The SP believed that the VA told “stories” to the G and did not always look for his/her lost items. · The VA sometimes went into the other clients’ bedrooms and took food and beverages from them. The VA also took keys from the staff persons so that s/he could unlock the bedroom doors of the other clients. The SP “paid more attention” to what the clients were doing than the other staff persons did, so the SP was aware that the VA “was stealing a lot.” Whenever the SP found out that the VA took something belonging to one of the clients, s/he told the other staff persons and P6. · The SP stated that s/he was very soft-spoken and never yelled at any of the clients. The SP did not swear at the VA or called the VA a bitch. The other clients sometimes “cussed out” the VA. At those times, the SP intervened and had all the clients take time to calm in their bedrooms. The SP never drank alcoholic beverages at the facility and was never under the influence of alcohol while working. The SP believed some of the other staff persons did not like the SP because s/he made them accountable for working their scheduled work shifts. The G stated that the SP took the VA’s iPad and other items away when the VA “snuck” food at the facility or took items from the other clients. The facility then put locks on the cupboards. The G told the staff persons that it was “okay” to do so if it kept the VA from sneaking food at night, but did not believe s/he signed a form allowing locks on the cupboards. The SP told the G that the VA broke another client’s cell phone. P1 told the G that on one occasion the SP “yelled” at the VA for going to the kitchen during the night to get water. The G did not recall hearing any staff person yell at the VA. The CM stated that in May 2025, s/he began working with the VA. At that time, s/he talked to the SP, who told him/her that the VA was stealing items from the other clients. The CM was concerned because the incidents were not reported to him/her at the time they occurred. The SP also told the CM that they locked the facility refrigerator and cabinets so that the VA did not take food. The CM did not have a current rights restriction document for doing that. When the CM talked to the G, the G told the CM that when s/he called the VA, s/he sometimes heard the SP yelling in the background, which upset the VA. P1 told the G that the VA was not stealing items from the other clients, but the SP was “making it up” in order to “get [the VA] kicked out of the facility.” The G also told the CM that the SP took the VA’s iPad from the VA even though there was no rights restriction in place regarding the iPad. On July 9, 2025, the VA’s interdisciplinary team met and updated the VA’s rights restriction for locking the refrigerator and cabinets. Facility documentation showed that the SP and P1 – P7 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incidents. Conclusion: The VA stated that the SP “wasn’t very nice to me” and that the SP took the VA’s dolls and hid them in the garage. The SP also told others that the VA was a thief and called the VA “trash” and “bossy” and told the VA that s/he would “get kicked out” of the facility. C1 stated that the SP “yelled” at the VA every day and called the VA a “bitch” and a “trash thief,” which caused the VA to cry. The SP also took the VA’s cell phone and his/her dolls. C2 stated that in the past, the SP told C2 that s/he was going to take some of the VA’s personal items and hide them. C3 believed that the SP took personal items from the VA and put them in the garage. The SP also took the VA’s iPad from the VA and kept it until the VA’s behavior improved. However, information regarding their respective history of providing accurate information varied. P1 stated that the SP frequently “berated” the VA and told the VA that s/he “didn’t like [his/her] ass.” On one occasion, the SP yelled at the VA for taking a cookie and told the VA that s/he was going to “get your ass kicked out” of the facility. The SP swore at the VA “almost every time” s/he talked to the VA, which caused the VA to hold his/her face in his/her hands and cry. The SP sometimes encouraged the other clients to verbally abuse the VA. The SP took items from the VA, including his/her dolls, radio, and coloring books. However, P1 was unable to provide additional details of the SP’s interactions with the VA, including dates, times, circumstances, and/or individuals present at the time. The SP stated that s/he never swore at the VA or called him/her names, never took the VA’s toys away, and never took items from the other clients’ bedrooms and placed them in the VA’s bedroom so s/he could blame the VA for taking them. Although P1 stated that the SP yelled and berated the VA, given that P1 had conflicts with supervisory staff persons including the SP; that the VA’s, C1’s, C2’s, and C3’s history of providing accurate information varied and could not be determined; that the SP denied the allegations; and that P2-P7 each had no concerns with the SP’s interactions with the VA, there was not a preponderance of the evidence whether the SP used repeated oral language toward the VA 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 to the VA. 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 the facility’s policies were adequate but were not followed by the staff persons. The staff persons were retrained on the VA’s plans and on the facility’s policies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: On December 30, 2025, the facility was issued a Correction Order for the violation outlined in this report. During the course of the investigation it was determined that two background study violations occurred. On December 30,2025, the facility was issued a $400 fine for the background study violations. The Order to Forfeit a Fine is subject to appeal.
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