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 MALTREATMENT INVESTIGATION MEMORANDUM Office of Inspector General, Licensing Division Public Information Minnesota Statutes, section 260E.01, paragraph (a), “The legislature hereby declares that the public policy of this state is to protect children whose health or welfare may be jeopardized through maltreatment.” Report Number: 202406474 Date Issued: August 28, 2025 Name and Address of Facility Investigated: The Links Youth Emergency Shelter Program dba Dignity House
License Number and Program Type: 1104909-CRF (Children’s Residential Facility) Investigator(s): Gessner Rivas/Alice Percy Minnesota Department of Human Services Office of Inspector General Licensing Division PO Box 64242 Saint Paul, Minnesota 55164-0242 Gessner.Rivas@state.mn.us 651-431-3970 Suspected Maltreatment Reported: It was reported that a staff person (SP) called alleged victims (AV1 and AV2) names including calling AV1 “dumb, retarded, and stupid” and using other slurs about AV1’s size and calling AV2 “fat and disgusting.” [Note: Throughout the remainder of the report the word “retarded” will be referred to as the R-word.] The SP also punished AV1 by sending him/her to bed without food and made comments about AV1’s underwear in front of the other children, resulting in AV1 running away from the facility. Date of Incident(s): Ongoing, prior to July 26, 2024 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 260E.03, subdivision 15, paragraph (a), clauses (1) and (2): Failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so. Failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so. Summary of Findings: Pertinent information was obtained during a site visit conducted on September 11, 2024; from documentation at the facility; and through eight interviews conducted with a facility staff person (P1), an administrative staff person (P2), the SP, AV1, AV2, two of AV1’s guardians (G1 and G2), and AV2’s foster parent (FP). AV1 was sixteen years old at the time of the incidents. AV1 diagnoses included autism and asthma. AV1 moved to the facility after refusing to return to his/her foster home. AV2 was fifteen years old at the time of the incidents. AV2’s diagnoses included attention-deficit hyperactivity disorder (ADHD), depression, and post-traumatic stress disorder (PTSD). AV2 was admitted to a hospital after assaulting a family member. The facility provided emergency shelter services to youth ages 10 to 17 who have run away from home, are experiencing homelessness and/or who are involved in the child welfare and juvenile justice systems. AV1 provided the following information: · AV1 lived at the facility on two occasions and living there was “cool for a while” until the SP told AV1 that s/he was a “dumb, [R-word], and stupid individual” on multiple occasions. On some occasions, the SP told AV1 that AV1 “disrespected” the SP, so the SP sent AV1 to bed without food. On one occasion, the SP told AV1 in front of the other residents that s/he had a “wedgie” which caused “shit stains” on AV1’s underwear. The incidents occurred in mid-October 2024. AV1 did not recall the names of the other youth who were present when the SP made the comments. AV1 became upset and ran away from the facility because s/he could not handle the SP calling him/her names. At some point, AV1 told P2 about the comments the SP made about AV1 and the SP did not work at the facility again. · The SP frequently told the youth that the staff persons only worked at the facility for a paycheck and that they did not care about the youth. At times the SP refused to cook food for the youth so another staff person would have to do the cooking. On other occasions, the residents had to cook breakfast or lunch for themselves because there were no other staff persons besides the SP at the facility. Sometimes, the SP made food for him/herself and then not for the youth. AV2 provided the following information: · On numerous occasions, the SP called AV2 fat. On one occasion, AV1 was present when the SP called AV2 fat. The SP was also rude to AV1 and called him/her “[R-word].” The SP was “nice” when AV2 first moved into the facility, but then “got rude” and told AV2 that s/he was not going to be the SP’s “favorite” youth anymore. The SP did not let AV2 do things like watch television and made AV2 sit in his/her bedroom. · The SP told the youth that s/he did not care about any of them and was only working there to make money. The SP also told the youth not to “talk bad” about the SP or the SP would “get kicked out.” · The SP “barely cooked” when s/he was at the facility and sent AV1 to bed without making food for AV1. AV2 “didn’t think [the SP] fed any of us either.” The SP frequently brought food for him/herself to the facility, but did not cook for the youth. If other staff persons were not present to cook, the SP told the youth they were “old enough to cook for yourselves.” P1 provided the following information: · P1 stated that s/he heard the SP call the youth “fat, dumb, and stupid.” The SP would also “snatch” cell phones from the youth and refuse to give them food. Any time AV1 did anything “wrong,” such as vaping, the SP told AV1 that s/he was “[R-word].” P1 believed that the SP made similar comments to the youth “every weekend” that P1 worked with the SP. The SP also threatened staff persons. AV2 told P1 that the SP told the youth that the SP was “only here for the paycheck and did not care about” the youth. · P1 stated that on several occasions, the SP brought food to the facility for him/herself, but did not make food for the youth. At those times, P1 cooked food for the youth. While the staff persons were supposed to work as a team, the SP typically “would do nothing.” On one occasion in June 2024, the SP punished AV1 by sending him/her to bed without food so P1 made food for AV1. · P1 told P2 about the SP’s comments because s/he did not feel comfortable with the way the SP treated the youth and the staff persons. Other staff persons also complained about the SP because s/he “did not treat anyone well.” P2 provided the following information: · P2 stated that AV1 lived at the facility twice, from May to October 2023 and March to August 2024. · P2 stated that another administrative staff person (P3) periodically “checked in” with the youth. AV1 told P3 that the SP made negative comments to AV1 and the other youth. The SP called AV1 “[R-word]” and told AV1 that s/he had “shitty drawers” in front of the other youth. After AV1 left the facility, s/he did not want to return to the facility because of the SP’s comments. P2 and P3 talked to the youth and other staff persons about the SP’s interactions. The facility put the SP on leave while the allegations were investigated. The SP no longer worked at the facility. · AV2 told P2 that the SP sometimes brought food to the facility for him/herself, but did not make food for the youth. P2 stated that the facility’s policies stated that the staff persons could not withhold food from the residents. The SP provided the following information: · The SP stated that s/he never called a youth dumb, the R-word, or stupid and never said those things to AV1. The SP never sent AV1 to bed without food. AV1 “would never eat” and the staff persons “begged” him/her to do so. When AV1 went on community outings with his/her family member, s/he returned to the facility and told the staff persons s/he was not hungry. AV1 then went to his/her bedroom or outside to play basketball. · On one occasion, AV2 told AV1 that s/he had a “wedgie” and “shit stains on [his/her] underwear.” The SP asked AV2 not to swear. The SP did not know why AV1 would say that the SP made the comment. · The SP never told the youth that s/he was only working at the facility for the paycheck and did not care about the youth. The SP and the other staff persons prepared food for the residents. At times, the SP spent his/her own money to buy pizza for the youth. When another staff person prepared food for the youth, the SP completed the paperwork. If s/he was the only staff person at the facility, s/he prepared food for the youth. The SP documented when s/he prepared food for the youth. AV1 “never ate” and told the staff persons that s/he was not hungry even though the staff persons, including the SP, “begged” AV1 to eat. · The SP never told AV2 that s/he looked “fat and disgusting.” P1 and AV2 had “a joke” in which AV2 was referred to as “big back,” but the SP did not refer to AV2 as “big back.” When the SP asked P1 why s/he engaged with the youth that way, P1 told the SP that s/he was having “harmless fun” with the youth. When the SP complained to his/her supervisors about P1’s interactions with the residents, “nothing was done.” The SP did not provide any additional information about who s/he talked to or when s/he talked to them. The SP believed that AV2 “had a big dislike” of the SP. · The SP did not tell the youth that s/he only worked at the facility for the paycheck. G1 stated that s/he was AV1’s previous guardian. At that time, AV1 frequently had complaints about the staff persons, but never told G1 that s/he was sent to bed without food. AV1 “always got extra food” from his/her family member. AV1 “talked down” about him/herself and was very self-deprecating. G2 stated that AV1 lived at the facility from March to August 2024. During that time, AV1 complained about it because s/he felt that s/he was “dumped there” and wanted to move. G2 believed AV1’s complaints were “baseless reasons” to try and transfer out of the facility. The staff persons at the facility were “supportive and communicative.” The FP stated that on one occasion while s/he was on the telephone talking to AV2, s/he overheard P1 questioning AV2 about something. The FP did not hear P1 curse or use derogatory words toward AV2. According to the facility’s Employee Handbook, the staff persons were conduct themselves in a professional manner, to behave and communicate in a businesslike manner, and to be courteous and respectful. According to the facility’s Policies & Procedures Manual, the residents had a right to be free from abuse, neglect, inhumane treatment, and sexual exploitation. The residents had the right to nutritious and sufficient meals as well as the right to courteous and respectful treatment. The residents also had the right to be free from restraint and seclusion used for any purpose other than to protect the residents from imminent danger to themselves or others. All of the residents were to be provided with three meals per day as well as snacks. The staff persons were prohibited from using corporal punishment, name calling, making derogatory statements about the clients, making statements intended to shame, threaten, humiliate, or frighten the residents, or withholding basic needs such as a nutritious diet. Facility documentation showed that the SP, P1, and P2 each received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incidents. Conclusion: A. Maltreatment: Although it was reported that the SP sent AV1 to bed without food, consistent information was provided that although the SP sometimes did not cook food for the residents, other staff persons or the residents themselves would then cook food. AV1 stated that on multiple occasions, the SP called him/her “dumb, [R-word], and stupid” and also told AV1 in front of the other residents that AV1 had a “wedgie,” which caused “shit stains” on AV1’s underwear. AV1 became upset and ran away from the facility because s/he could not handle the SP calling him/her names. AV2 stated that on numerous occasions, the SP called AV2 fat and made other “fat” comments about AV2 and that the SP called AV1 “[R-word].” Although the SP denied calling AV1 and/or AV2 names, given that P1 stated s/he heard the SP call AV1 “[R-word]” and also call youth “fat, dumb, and stupid,” which was consistent with the information provided by AV1 and AV2, and that the SP had reason to minimize his/her interactions for fear of repercussions, it was more likely that the SP engaged in the actions as described by P1, AV1, and AV2. The SP’s actions were inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services and were a violation of the facility’s policies. Given that the SP used repeated language toward AV1 and AV2 that might have hindered their ability to have a trusting relationship with the facility’s staff persons and the egregious nature of the R-word, there was a preponderance of the evidence that there was a failure to supply AV1 and AV2 with necessary care and/or a failure to protect AV1 and AV2 from actions that seriously endangered their mental health when reasonably able to do so. It was determined that neglect occurred (failure by a person responsible for a child's care to supply a child with necessary food, clothing, shelter, health, medical, or other care required for the child's physical or mental health when reasonably able to do so and/or failure to protect a child from conditions or actions that seriously endanger the child's physical or mental health when reasonably able to do so). B. Responsibility pursuant to Minnesota Statutes, section 260E.30, subdivision 4, paragraph (a), clauses (1) and (2): When determining whether the facility or individual is the responsible party, or whether both the facility and the individual are responsible for determined maltreatment in a facility, the investigating agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were according to, and followed the terms of, an erroneous physician order, prescription, individual care plan, or directive; however, this is not a mitigating factor when the facility or caregiver was responsible for the issuance of the erroneous order, prescription, individual care plan, or directive or knew or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) comparative responsibility between the facility, other caregivers, and requirements placed upon an employee, including the facility’s compliance with related regulatory standards and the adequacy of facility policies and procedures, facility training, an individual’s participation in the training, the caregiver’s supervision, and facility staffing levels and the scope of the individual employee’s authority and discretion; and (3) whether the facility or individual followed professional standards in exercising professional judgment. Facility documentation showed that the SP received training on the Reporting of Maltreatment of Minors Act and on the facility’s policies prior to the incidents. The SP was responsible for maltreatment of AV1 and AV2. 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 neglect for which the SP was responsible was determined to be recurring, the SP was responsible for the neglect of AV1 and AV2. However, the substantiated neglect did not meet the definition of serious maltreatment. Pursuant to Minnesota Statutes, section 260E.35, subdivision 6, paragraph (c) all investigative data maintained in this report will be kept by the Department of Human Services for at least ten years after the date of the final entry in the report. Action Taken by Facility: The facility completed an internal review and determined that the facility’s policies were adequate and were followed by the staff persons. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above. Certification: The information collection procedures followed in this investigation were pursuant to Minnesota Statutes, section 260E.30, subdivision 6, paragraph (c). All individuals that are subjects of data in this investigation have the right to obtain private data on themselves which was collected, created, or maintained by the Department of Human Services.
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