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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: 1072232-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Brandt Suspected Maltreatment Reported: It was reported that while a staff person (SP) assisted a vulnerable adult (VA1) with showering, the SP told VA1, “Poor you getting showered” and that a bruise was discovered the following day on VA1’s genital area. It was also reported that the SP yelled at another vulnerable adult (VA2) to eat his/her food, go back to his/her “man cave” and that the SP leaned up against the bathroom door so VA2 could not leave the bathroom. Date of Incident(s): Prior to November 20, 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), clauses (1) and (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: · Hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. · 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 December 1, 2025, from documentation at the facility, from law enforcement records, and from VA1’s medical records; and through five interviews conducted with a facility management person (P1), two facility staff persons (P2 and P3), the SP, and a law enforcement officer (LEO). Although this investigator met VA1 and VA2, they were unable to provide information due to their abilities. VA1’s support plan showed that VA1 was diagnosed with a severe developmental disability, autism, and pervasive developmental disorder. The plan showed that VA1 “loves baths and showers” and “this also has been identified as a calming technique.” VA1’s documentation showed that VA1, who ambulated independently, needed physical assistance from staff when bathing or showering. VA2’s support plan showed that VA2 was diagnosed with a severe developmental disability, scoliosis, and intermittent explosive disorder. VA2’s plans showed that s/he was “very social” and “can be outgoing and liked to be silly.” Regarding VA1: P1 stated that on November 19, 2025, P2 told P1 that while P2 assisted VA1 with morning cares that morning, P2 noticed a large bruise on VA1’s genital area that was not present the morning before (November 18, 2025). P1 stated that staff assisted VA1 with bathing/showering every night. VA1 would make some “moaning and groaning noises” in the shower, but VA1 typically did well and enjoyed bathing/showering. P1 also stated that s/he had worked with VA1 for over 15 years and during that time, VA1 had not engaged in self-injurious behavior (SIB) to his/her genital area. VA1’s medical records showed that VA1 was seen at an urgent care on November 19, 2025, for an “abdominal contusion” that was “likely secondary to blunt trauma.” No treatment was provided. P2 and P3 provided the following information: · On the morning of November 18, 2025, P2, who worked from 8 a.m. until 8 p.m. that day, assisted VA1 with getting ready for the day and did not notice any concerns or bruising on VA1’s genital area. That night, around 7 p.m., the SP assisted VA1 with taking a shower and VA1 was “moaning really loud” and it sounded like VA1 was “being tortured.” P2, who was near the bathroom, heard the SP say, “Poor you having to take a shower.” · P3 worked the same hours that day as P2 and provided information consistent with P2’s information. After the shower was done, P2 and P3 each stated that they did not notice anything unusual regarding VA1. · It was somewhat typical for VA1 to make some noises while bathing/showering, but VA1 made more noise during the shower than was typical. After the SP finished assisting VA1, VA1 seemed “normal.” · At about 8 a.m. on November 19, 2025, P2 assisted VA1 with getting dressed for the day and noticed a bruise on VA1’s genital area that was a “few inches” wide and a “few inches” long. The bruise was “dark purple” and “black.” P2 took VA1 to an urgent care facility. P2 did not see VA1 fall or bump into anything that could have caused the bruising. · Although VA2 engaged in SIB, P2 never saw that VA2 engage in physical aggression toward VA1. The SP provided the following information to this investigator and the LEO: · When the SP, who worked from 4-10 p.m. on November 17, 2025, assisted VA1 with taking a shower at about 7 p.m. that night and did not notice any bruising, but the SP “did not stare” at VA1’s genital area. · On November 18, 2025, the SP assisted VA1 with taking a shower and stayed in the bathroom the entire time and did not notice any bruising. The SP did not remember VA1 acting any different than previous times the SP assisted VA1 with taking a shower. The SP did not see VA1 fall in the shower, bathroom, or while walking back to his/her bedroom to get fully dressed. After the shower was done, the SP assisted VA1 with getting dressed and ready for bed. · The SP did not do anything to cause the bruising to VA1 and did not remember if s/he said, “Poor you having to take a shower.” The SP believed that the bruise was caused when VA1 self-stimulated him/herself. Regarding VA2: P2 provided the following information: · P2 did not remember the date but remembered a time when the SP asked VA2 to eat his/her dinner, but VA2 did not do so. A few minutes later, P2 asked VA2 to eat and VA2 ate. After that, the SP said, “Oh okay, you’ll eat for [him/her] but not for me. I’ll remember that.” · After dinner, the SP told VA2 to go wash his/her face. When VA2 did that in the bathroom, P2, who was in the hallway, saw the SP close the bathroom door, which opened outwards, and “stood against it.” P2 was not certain whether VA2 was attempting to leave the bathroom or not while the SP stood against the door. While VA2 was in the bathroom with the door closed, VA2 attempted to open the medicine cabinet and when the SP heard that, the SP opened the door and “yelled” at VA2 to get out of the medicine cabinet. P2 did not remember how VA2 responded to that. P2 also stated that s/he thought that VA2 was “scared” of the SP because VA2 stayed in his/her room more often when the SP worked. P3 did not remember specific dates but stated that s/he heard the SP say, “Go to your fucking room now,” “Nobody wants to see you in the morning,” and “Go back to your cave,” on varying dates. When the SP said those types of things to VA2, VA2 went to his/her bedroom. P2 also thought that VA2 was afraid of the SP because VA2 stayed in his/her bedroom more often when the SP worked. The SP denied yelling, swearing, or making comments to VA2. The SP also denied not allowing VA2 to leave the bathroom. The facility’s training records showed that all staff persons interviewed for this investigation were trained on VA1’s and VA2’s care plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to November 18, 2025. Relevant Rules and Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), state that a person’s protection-related rights include the right to be treated with courtesy and respect. Conclusion: Regarding VA1: On the morning of November 18, 2025, P2 assisted VA1 with dressing and getting ready for the day. At the time, P2 did not notice any bruising on VA1. Later that night, at 7 p.m., the SP assisted VA1 with taking a shower and P2 said that VA1 was moaning loudly, and it sounded like VA1 was “being tortured.” The following morning, November 19, 2025, P2 assisted VA1 with dressing and getting ready for the day and noticed a dark purple and black bruise on VA1’s genital area. Later, P2 took VA1 to urgent care where VA1 was diagnosed with an “abdominal contusion” that was “likely secondary to blunt trauma” according to medical records. Although VA1 had a large bruise, given that the SP denied causing the bruise, that the SP stated VA1 did not fall or hit anything while in the bathroom, and that there was no further information to determine how VA1 sustained the bruise, there was not a preponderance of the evidence whether the bruise was caused by means other than accidental. It was not determined whether physical 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: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Regarding VA2: P2 said that when VA2 was in the bathroom, the SP closed the door and leaned against the door but P2 did not know whether VA2 was attempting to leave the bathroom at that time. P2 also stated that the SP then yelled at VA2 when VA2 went into the medicine cabinet. P3 heard the SP say, “Go to your fucking room now,” “Nobody wants to see you in the morning,” and “Go back to your man cave.” The SP denied The SP denied yelling, swearing, or making comments to VA2. The SP also denied not allowing VA2 to leave the bathroom. Although the SP denied making the comments witnessed by P3 and yelling at VA2 in the bathroom, the SP had reason to minimize his/her actions for fear of consequences so it was more likely than not that the SP made inappropriate comments to VA2 which was behavior inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and a violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6). However, given that there was no information whether the SP’s actions were repeated or rose to the level of emotional abuse therefore there was not a preponderance of the evidence whether the SP’s conduct was repeated or could be reasonable expected to produce emotional distress. It was not determined whether emotional abuse occurred (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 its policies and procedures were adequate and not followed. The SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violation outlined in this report because the facility took corrective action.
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