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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: 1108015-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Beth Virden Thomas.C.Nixon@state.mn.us Suspected Maltreatment Reported: It was reported that during an altercation, a staff person (SP) spit saliva on a vulnerable adult (VA) and called the VA, “[The N-word]” (a racial slur) and that the VA spit saliva on the SP and “smacked” the SP’s face. Date of Incident(s): September 8, 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); and subdivision 17, paragraph (a): 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. The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 25, 2025; from documentation at the facility; law enforcement records and body worn camera footage; and through eight interviews conducted with the VA, the VA’s case manager (CM), the VA’s housemates (H1 and H2), facility staff persons (the SP and P1), and supervisory staff persons (P2 and P3). The VA’s support plans, including Coordinated Services and Support Plan, stated the following: · In 2021, the VA moved into the facility seeking services and support relating to his/her diagnoses, which included schizophrenia and psychotic disorder with delusions. The facility provided the VA with at least one staff person 24-hours a day. Staff helped the VA with attending medical appointments, managing household responsibilities, solving problems, and providing reminders as needed. · The VA liked playing basketball and interacting with others. S/he was “laidback, funny, and social.” · At times, the VA might become “dysregulated” and use verbal aggression towards others, like name-calling and yelling. Staff deescalated the VA by speaking in a calm-manner and giving him/her space. · The VA was not subject to guardianship. The VA, H1, and H2 lived together at the facility, which was a single-family home where the SP, P1, and P2 worked. A police report and body worn camera footage included the following: · On September 8, 2025, at 3:46 p.m., the SP called 9-1-1 reporting that s/he was “attacked” by the VA. · A law enforcement officer (LEO) arrived at the facility and spoke with the VA outside. The VA said that the SP and the VA were talking when the SP started lying about the VA’s conduct. The VA told the SP to stop lying, which prompted the SP to “come at” the VA. The VA spit in the SP’s face and then put his/her fist in the SP’s face. The VA demonstrated by touching or tapping his/her fist to the LEO’s fist. · The LEO next spoke with the SP inside the facility. The SP said that s/he told P2 that the VA did not clean up after him/herself. The VA overheard this and called the SP, “Bitch.” The VA then spit on the SP and the SP spit back at the VA. The SP told the LEO, “I was about to hit [him/her], but I stopped myself ‘cause I know I would get in trouble. I think the spit was a quick react.” P2 tried pulling the VA away from the SP but the VA punched the SP’s face “so hard.” The VA had never punched the SP before but had a history of “cussing [the SP] out.” · After speaking with the LEO, the SP left the facility for the day. The LEO then left and closed their case with no further action taken. “[The LEO] believed [the SP] to be the primary aggressor in the incident.” Information was consistent that the incident, on September 8, 2025, occurred in the facility’s living room. The living room was a large space with multiple recliners and couches around the perimeter. The VA, the SP, H1, H2, and P1 were sitting on the various furniture and P2 was standing in the living room because s/he was leaving for the day. The VA said that the SP frequently “blamed” him/her for things that happened in the facility, like leaving messes behind, and told the VA, “Clean up your shit … Hurry up.” The VA typically responded by telling the SP to not talk to him/her like that. However, on September 8, 2025, their interaction “escalated real fast” and the VA spit in the SP’s face. The SP responded by spitting in the VA’s face, which made the VA “angry,” and the VA used his/her hand and “smacked” the SP’s face. P2 stepped between them and directed the VA outside. As the VA was walking out, the SP stated, “I am going to have my [family member] beat your ass. I hope you rot in prison.” Someone then called 9-1-1 and the LEO arrived. The VA said that s/he felt “sorry for the whole situation.” The VA also said s/he did not hear the SP say anything to him/her that was insulting or name-calling. H1 said that one day in September 2025, in the afternoon, s/he was in the living room and heard the SP and the VA get into “a cat fight.” The VA called the SP, “Bitch,” and spit in the SP’s face. The SP told the VA, “You need to back off,” and then the SP spit in the VA’s face. H1 explained further that s/he did not know if s/he saw the SP spit in the VA’s face or heard about it from someone else. H1 did not have concerns with the SP’s conduct prior to this incident. H2 said that s/he was in the living room and heard the SP and the VA talking about picking up a mess. “Then, it escalated.” The SP called the VA, “[The N-word],” and the VA called the SP, “Bitch.” The SP and the VA spit on each other and the VA punched the SP’s left eye. The SP then called the VA, “Fucker. [The N-word].” P1, P2, and P3 provided the following information: · P2 said that on September 8, 2025, around 4 p.m., s/he was getting ready to leave work for the day and reminded the VA to pick up his/her wrappers before going downstairs. The VA was sitting on a couch, and the SP was sitting on a different couch. The SP told P2 that s/he already told the VA to clean up but that the VA did not listen. The VA and the SP then started yelling at one another. This was the first time P2 heard the SP yell at a client. P2 told the SP, “Stop,” and to leave the room, but the SP did not move. The VA then called the SP, “Bitch,” stood up and walked over to the SP’s spot on the couch, and spit in the SP’s face. P2 immediately grabbed the VA’s hand and tried moving him/her away from the SP; however, the VA did not move, and the SP stood up facing the VA. P2 placed his/her outstretched arms between them and told them, “Stop.” The SP called the VA, “Bitch ass [N-word],” and said, “Stop spitting at me.” The VA, now standing face to face with the SP, made a noise in his/her throat like s/he might spit again, but the SP spit on the VA. P2 did not see where the SP’s saliva landed on the VA. The VA then reached out and “smacked” the SP’s face. P2 led the VA outside while the SP stayed in the living room and called 9-1-1. From outside, P2 heard the SP yell that the VA was “going to rot in jail” and that the SP’s family member was going to come over and “beat [the VA’s] ass.” · P1 said that s/he was in the living room and saw the VA and the SP start arguing. P1 could not clearly hear what they were saying because they were talking over each other and P2 was trying to separate them. At some point, the VA stood up from the couch and spit on the SP’s face and then stepped away from the SP. P1 said that s/he would have expected the SP to move away or leave at that point. The SP could have walked away because no one was blocking the SP from leaving. However, instead, the SP stood up, walked up to the VA, and spit on the VA’s neck. The VA told the SP, “I’m going to hit you,” and the SP said, “I dare you. Do it.” The VA then struck the SP’s face with the VA’s hand. P2 moved between them and directed the VA outside. After the VA left, the SP called a family member on his/her cellphone and told the family member, “This [N-word] is insulting me … This [N-word] just hit me. I’m going to call the cops.” P1 said that the VA was no longer in the living room when the SP said, “[The N-word].” · P1 said that the SP and the VA had a history of going “back and forth” (arguing), during which, the SP might say things to the VA, like “Fuck you,” but the SP always appeared to be joking, and the VA typically laughed. P2 said that the SP did not always think before s/he spoke and sometimes spoke to the VA like a peer instead of a client. The SP’s tone and attitude sometimes came across as “disrespectful.” · P1, P2, and P3 each said that the VA had a history of “cussing out” staff and getting more escalated if staff responded (said something back) to him/her. Staff were trained to not respond to the VA, to give him/her space, suggest s/he go outside or to another room, and try to calm him/her down. P1 and P2 each said that the VA did not have a history of physically aggressing towards a staff person and that the incident on September 8, 2025, was the first such instance they were aware of. A day or two after the incident, the SP was at the facility and interacted with the VA without incident. The SP’s documentation, immediately following the incident on September 8, 2025, stated: I was sitting on the couch in the living room so was [the VA]. [P2] was talking to [the VA] about cleaning up [the VA’s] mess while [P2] was talking to [the VA] I interrupted [him/her] and said this is the reason why [the VA] disrespected me and my background the other day as soon as [the VA] heard me say it [s/he] got agitated & got really angry with me [the VA] started calling me names & cussing me out [s/he] then came up to my face try to hurt me but [P2] held [him/her] back. somehow [s/he] got to me was all up in my face, [the VA] spit on me then I told [him/her] to not spit at me but [s/he] did it again, so I did it back. As soon as I did [the VA] slapped/punched me in the face, [s/he] was all up in my face again and when [s/he] was about to hurt me again [P2] held [him/her] back, while [s/he] was doing that I called the cops…. The SP provided the following information: · The SP said that on September 8, 2025, “I was scared for my life … I was afraid.” The VA was walking towards the SP, who was sitting on a couch, and the VA was “400 pounds,” “a big [person].” [Note: The VA’s support plans stated that as of January 2025 the VA was 6’1” and 386 pounds.] The SP said that five minutes prior to the incident, the VA had been “okay.” “[The VA] went from zero to 100 in two seconds.”
· This was not the first time the VA aggressed toward the SP; it had happened before and during those instances, the SP left the area. However, on September 8, 2025, the VA was more escalated than the SP had ever seen, and the SP felt “more safe” in the living room surrounded by other people. · When the VA spit at the SP, the VA’s saliva landed in the SP’s mouth. The SP said that s/he spit back to remove the VA’s saliva from his/her mouth. “I think it was an honest mistake. I am disappointed in myself.” The SP said that s/he did not yell or call the VA names. The SP did not remember if s/he called the VA, “[The N-word]” and might have told the VA that his/her family member would beat the VA up. “I was very emotional, crying, very angry.” The CM said that the VA was a reliable reporter of information. Facility documentation stated that the SP, P1, and P2 received training on the VA’s support plans, including Coordinated Services and Support Plan; and that the SP, P1, P2, and P3 received training on the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: A. Maltreatment: Consistent information was provided by the VA, H1, H2, the SP, and P1-P3 that on September 8, 2025, the SP and the VA got into a verbal altercation and spit on each other and the VA struck the SP’s face with the VA’s hand. Information was also provided that the VA called the SP, “Bitch,” and the SP said that the SP’s family member was going to “beat [the VA] up” and that the SP hoped the VA “rotted in jail.” H2 and P2 each said that they heard the SP call the VA, “[The N-word];” P1 said that the SP said, “[The N-word]” after the VA went outside; and the SP did not remember if s/he called the VA, “[The N-word].” The VA said that s/he did not hear the SP say anything insulting or name-calling. Regarding emotional abuse: Although the VA said that s/he did not hear the SP say the N-word and P1 said that the SP said the N-word after the VA went outside, the SP and the VA were actively arguing during that time and so it was possible the VA did not hear it because s/he was distracted by the arguing. P2 and H2 each said that they heard the SP call the VA the N-word in the VA’s presence and there was no information P2 and H2 had any reason to provide inaccurate information about what happened. Given the nature of the N-word (a racial slur), and that the word was directed at the VA as a means to likely insult the VA, there was a preponderance of the evidence that the SP called the VA the N-word, which was a highly derogatory and untherapeutic word and while it was not repeated it was consider malicious. In addition to calling the VA the N-word, the SP’s actions of spitting on the VA would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, and/or threatening and 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). Regarding neglect: P1-P3 each said that the VA had a history of “cussing out” staff and staff were trained to not respond to the VA, to give the VA space, suggest s/he go outside or to another room, and try to calm him/her. On September 8, 2025, the SP’s conduct of continuing to engage with and spitting on the VA, despite P2’s multiple attempts to intervene and redirect, was inconsistent with the VA’s support plans, staff training, and the standards of a professional caregiver in a facility licensed by the Department of Human Services. Although it was understandable that someone might have an immediate reaction to being spit on, the SP was a staff person and had experience with similar situations with the VA, in which s/he left and did not continue to engage. On September 8, 2025, P2 repeatedly told the SP to disengage and leave but the SP chose to stay subsequently spitting on the VA. Therefore, there was a preponderance of the evidence that the SP failed to supply the VA with care or services, which were reasonable and necessary to obtain or maintain the VA's physical or mental health or safety. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). 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 the VA’s care and supervision. The SP received training on the VA’s support plans, including Coordinated Services and Support Plan, and the Reporting of Maltreatment of Vulnerable Adults Act. The SP was responsible for maltreatment of the VA. 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 and neglect for which the SP was responsible was not “recurring” or “serious” maltreatment. The single incident of maltreatment met two definitions, which did not result in a serious injury to the VA that reasonably required the care of a physician. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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