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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: 1070932-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Anna.parkin@state.mn.us Suspected Maltreatment Reported: It was reported that two staff persons (SP1 and SP2) had concerning interactions with two vulnerable adults (VA1 and VA2), including dumping and squirting water on VA1 and encouraging VA1 to kiss VA2. Date of Incident(s): November 22 and 23, 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 site visits conducted on December 4, 2025, and January 8, 2026; from documentation at the facility and law enforcement records; and through 12 interviews conducted with three supervisory staff persons (P1-P3), four facility staff persons (P4, P5, SP1, and SP2), VA1, VA1’s and VA2’s respective guardians (G1-G4.) This investigator met VA2, but VA2 did not want to provide information for this report. VA1 was diagnosed with a mild developmental disability. According to VA1’s Individual Abuse Prevention Plan (IAPP), VA1 lacked understanding of sexuality and was not assertive. Staff persons prompted VA1 to leave unsafe areas and followed up with VA1 to discuss dangerous situations. VA2 was diagnosed with a moderate developmental disability. According to VA2’s IAPP, VA2 lacked understanding of sexuality. VA2 enjoyed hugging and did not understand appropriate boundaries. Staff persons reminded VA2 about appropriate interactions with others. The facility had two levels with an open stairwell. The lower level included VA1’s bedroom and the upper level had a kitchen, living room, and supply closet. Consistent information was provided that on November 22 and 23, 2025, SP1, SP2, and P4 worked together for a few hours each day. P4 provided the following information to this investigator and in the internal review: · On November 22, 2025, at 3 p.m., when SP2 arrived at the facility, SP1 and SP2 spoke to each other while P4 and VA2 were in the living room and VA1 was downstairs in his/her bedroom. SP2 filled a glass of water in the kitchen and SP1 and SP2 then stood near the railing of the stairs. When VA1 walked upstairs, either SP2 or SP1 poured water on VA1. · P4 heard VA1 walk back downstairs and then back up the stairs and either SP1 or SP2 poured water on VA1 again. SP1 and SP2 laughed at VA1 and told P4 that they had been dumping water on VA1 “for a little while as a joke.” VA1 was wet and asked SP1 and SP2 why they did that. P4 could tell by VA1’s facial expressions that s/he was “not happy” and VA1 told SP1 and SP2 that s/he “did not like that.” VA1 had to go change his/her clothes. Approximately five minutes later, VA2 tried pouring water on VA1 but SP1 and SP2 stopped VA2. · On November 23, 2025, at 3 p.m., when SP2 arrived at the facility, SP1 was in the kitchen and had an empty milk jug. SP1 told SP2 that they should fill the jug with water to dump on VA1. SP2 agreed and filled the jug with water while SP1 went downstairs and told VA1 there was a snack upstairs. VA1 responded that s/he did not want to go upstairs and have water poured on him/her. SP1 continued to “manipulate” VA1 to walk upstairs and as VA1 got to the stairs, SP2 “dumped” water from the jug over VA1’s head. VA1’s shirt and head were wet so s/he went to his/her bedroom to change clothes. P4 then notified P3 about the incidents. · When P4 came back from notifying P1, SP2 went to the cleaning supply closet, took out an empty spray bottle, and filled it with water. SP1 then asked VA1 to come upstairs and when VA1 did so, SP2 sprayed VA1 with water “a few times.” VA1 “shout[ed],” “Stop,” and that s/he “did not like that.” SP1 and SP2 “giggle[d]” and approximately 25 minutes later, SP1 left the facility. · P4 was not aware of SP1 and SP2 encouraging VA1 and VA2 to kiss. VA1 stated on approximately two to three previous occasions in the previous two weeks, SP1 and SP2 sprayed and poured water on VA1. VA1 was “mad” and told them to stop each time. VA1 got “really wet” and had to change his/her clothes. P1-P3 provided the following information to this investigator and in the internal review: · On November 23, 2025, at an unknown time, P4 called P3 and said that SP1 and SP2 dumped water on VA1’s head. VA1 asked SP1 and SP2 to “stop” and VA1 was afraid to come upstairs. P3 asked if SP1 was still at the facility and P4 responded that SP1 was still there but they stopped dumping water. P3 called P2 on the phone who did not answer. · On November 24, 2025, P3 called P2 again and notified him/her about the incident. P2 and P3 then notified P1 about the incident. P3 went to the facility and spoke to VA1 who told P3 “right away” that SP1 and SP2 dumped water on him/her. VA1 was “upset” and did not like it. VA1 said that it also happened on November 22, 2025. On November 25, 2025, P2 went to the facility and spoke to VA1. VA1 said s/he did not like getting wet and that s/he felt “unsafe.” · P3 stated that VA1 was “very easily manipulated” and tried “really hard to have [his/her] own control.” P2 stated that the incidents went beyond joking and they were “premeditated and malicious.” · P1 “possibly heard” from P5 about SP1 and SP2 encouraging VA1 and VA2 but did not take any actions. P5 provided the following information: · On approximately four occasions over the previous two weeks when P5 worked with SP1 and SP2, SP1 and SP2 each used a spray bottle to spray water on VA1 and/or poured water on VA1. It happened “a lot” throughout the shifts and both SP1 and SP2 participated. P5 stated that each time s/he told SP1 and SP2 to stop but SP1 and SP2 continued to do it over and over throughout the shifts to the point where VA1 went in his/her bedroom, locked the door, and did not come out. SP1 and SP2 each discussed how they squirted and poured water on VA1 during weekend shifts when P5 was not working. · On more than ten previous occasions, SP1 and SP2 verbally “encourage[d]” VA2 to kiss VA1. VA2 walked toward VA1 and VA1 would tell VA2 to stop. SP1 and SP2 also encouraged VA2 to lick VA1’s face and put his/her tongue in VA1’s mouth. SP1 and SP2 always told VA2 to stop before s/he kissed VA1. SP1 provided the following information: · On approximately November 19, 2026, SP1 and SP2 discussed using spray bottles to squirt VA1, VA2, C1, and C2. They filled up two or three water bottles and squirted each other for approximately 20 to 30 minutes. No clients asked SP1 or SP2 to stop. Afterwards, VA1 went to his/her bedroom, changed clothes, and possibly started laundry. SP1 did not recall if s/he had a conversation with SP2 about pouring water on VA1. · SP1 went downstairs and asked VA1 if s/he wanted to come upstairs and help clean up. SP1 denied that s/he or VA1 were concerned about SP2 pouring water on VA1. As VA1 walked upstairs, SP2 “dump[ed]” the jug of water over the railing onto VA1. VA1 was “shocked” but not upset. VA1 went back into his/her bedroom to change clothes and SP1 asked SP2 why s/he dumped water on VA1. SP1 denied s/he was aware that SP2 was going to pour water on VA1. After VA1 walked upstairs, SP1, VA1, and VA2 squirted each other with water. VA1 was not injured. · On approximately November 21, 2026, SP1, SP2, and an unknown staff person worked with VA1 and VA2. SP2 suggested that they use two spray bottles with water to squirt VA1 and VA2. SP1, SP2, VA1, and VA2 then took turns spraying each other with water. After approximately 10 to 15 minutes, VA1 said s/he wanted to stop so SP1 and SP2 stopped spraying them. VA1 changed his/her clothes. VA1 and VA2 did not appear in “distress” and were not injured during the incident. · SP1 acknowledged that pouring water was not appropriate but it was because SP1’s shirt got wet and s/he had to work three more hours in a wet shirt. · On one previous occasion, SP2 “encourage[d]” VA2 to kiss VA1. VA2’s annual plans addressed VA2 kissing and hugging other persons so SP1 told them to stop so VA2 did not kiss VA1. SP1 did not recall any other times where VA2 was encouraged to kiss VA1 and denied encouraging VA2 to kiss VA1. SP2 provided the following information: · On November 14, 2025, SP2 was in the kitchen cooking dinner when SP1 got a spray bottle and sprayed VA1 with water. VA1 was “in shock” and did not want to continue to be sprayed. VA2 also joined in spraying VA1. · On November 21, 2025, SP2 was cooking dinner when SP1 began squirting VA1 with a spray bottle. VA2, C1, and C2 also participated. VA1 said “you guys got me” and appeared “annoyed.” · On November 22, 2025, SP1 went down to the basement and spoke to VA1 in VA1’s bedroom. SP1 offered VA1 a “treat” to come upstairs and when VA1 did, SP2 poured water from a jug over VA1’s head. After doing so, SP2 thought to him/herself, “What am I fucking doing?” VA1 was “heartbroken” and went back to his/her bedroom to change clothes. SP1 told SP2 to not do that and SP1 did not like it because s/he did not want to wear wet clothes while working his/her remaining hours. · On November 23, 2025, SP1, SP2, and an unknown staff person (later identified as P4) were at the facility. VA1 was downstairs in his/her bedroom and C1 yelled for VA1 to come upstairs. SP2 was in the kitchen cooking dinner and looked over and saw SP1 pour a jug of water onto VA1. VA1 was “upset and cold” and said s/he was “wet.” VA1 went and changed his/her clothes and when VA1 came back upstairs and VA1, VA2, C1, and C2 squirted each other with water guns while SP1 assisted SP2 with dinner. Afterward, SP2 thought it had “spiral[ed]” and it was “not funny.” · On three previous occasions, SP1 and SP2 each verbally encouraged VA2 to kiss VA1. During a few of those occasions, VA2 kissed VA1 on the lips or forehead. VA1 looked “awkward” and said, “Quit kissing me.” G1 stated that VA1 “never spoke up” about incidents unless the incident was “really bad.” P3 notified G1 and G2 about the incidents. G1 and G2 did not have previous concerns with the facility. G3 and G4 were notified by P1 about the incidents. G3 and G4 both spoke to VA2 about it and VA2 felt it was “fun.” G3 and G4 did not have previous concerns with the facility. Facility documentation showed that staff persons, including SP1 and SP2, were trained on VA1’s and VA2’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Relevant Rules and/or Statutes:
Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a client’s protection-related right included being treated with courtesy and respect. Minnesota Rules, part 9544.0060, subpart 2, item N, stated in part that actions or procedures prohibited from use or as a substitute for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience included using a spray, including water mist. Conclusion: A. Maltreatment: VA1’s IAPP stated that VA1 lacked understanding of sexuality and was not assertive and VA2’s IAPP stated VA2 lacked understanding of sexuality. VA2 enjoyed hugging and did not understand appropriate boundaries. Staff persons were to prompt VA1 to leave unsafe areas and remind VA2 about appropriate interactions with others. Information from VA1, P4, and P5 was consistent that on multiple occasions SP1 and/or SP2 sprayed and poured water on VA1. VA1 was “mad,” “not happy,” said s/he “did not like that,” and told them to stop each time. VA1 got “really wet” and had to change his/her clothes more than once. SP1 said that on multiple previous occasions, SP1 and SP2 squirted VA1 with spray bottles and SP2 dumped water over VA1’s head. SP2 said on multiple previous occasions, SP1 and SP2 squirted VA1 with water or dumped a jug of water on VA1 and VA1 was “heartbroken.” P5 stated on more than ten previous occasions, SP1 and SP2 verbally “encourage[d]” VA2 to kiss VA1. VA2 walked toward VA1 and VA1 would tell VA2 to stop. SP1 and SP2 then told VA2 to stop. Although no other staff persons saw SP1 and SP2 tell VA2 to kiss VA1, SP2 said one time s/he “encourage[d]” VA2 to kiss VA1 but they did not, and SP2 said that on three previous occasions, SP1 and SP2 each verbally encouraged VA2 to kiss VA1 and VA2 did so on a “few” occasions. SP1’s and SP2’s actions of spraying/pouring water on VA1 and encouraging VA2 to kiss VA1 was inconsistent with their IAPPs, inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Human Services, and were violations of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), and Minnesota Rules, part 9544.0060, subpart 2, item N. In addition, given that SP1’s and SP2’s actions of repeatedly spraying/pouring water on VA1 and repeatedly encouraging VA2 to kiss VA1 were not accidental or therapeutic conduct, there was a preponderance of the evidence that SP1’s and SP2’s actions were repeated and would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could 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). 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. SP1 and SP2 were trained on VA1’s and VA2’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. SP1 and SP2 were each responsible for maltreatment of VA1 and VA2. 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 for which SP1 and SP2 were each responsible was recurring because SP1 and SP2 were each responsible for two incidents of emotional abuse involving VA1 (spraying/pouring water on VA1 and encouraging VA2 to kiss VA1) and a single incident of emotional abuse involving VA2 (encouraging VA2 to kiss VA1). It did not meet the definition of serious maltreatment. SP2 was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and determined that policies and procedures were adequate but not followed. SP1 and SP2 no longer work at the facility. Action Taken by Department of Human Services, Office of Inspector General: SP1 was notified that s/he was responsible for recurring and serious maltreatment and that any future background studies for facilities, 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, will result in his/her disqualification. The determination that SP1 was responsible for maltreatment is subject to appeal. SP2 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 SP2 was responsible for maltreatment and the disqualification of SP2 are each subject to appeal. When the facility became aware of the allegations, they took immediate corrective action, so a Correction Order was not issued for the violations outlined above.
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