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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: 1070476-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Thomas Nixon/Alice Percy 651-431-2155 Suspected Maltreatment Reported: It was reported that a vulnerable adult (VA) became upset and threw rocks at a staff person’s truck. When a staff person (SP) walked out of the facility to redirect the VA, the VA lay on the ground. The SP punched the VA on the side of his/her head and told the VA that s/he was “lucky” the VA did not break the truck’s windshield. Date of Incident(s): November 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 subdivision2, paragraph (b), clause (1): 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. Summary of Findings: Pertinent information was obtained during a site visit conducted on December 4, 2025; from documentation at the facility; and through six interviews conducted with a facility staff person (P1), two supervisory staff persons (P2 and P3), the VA, the SP, and the VA’s guardian (G). The VA enjoyed playing video games, listening to music, fishing, swimming, playing sports, going on community outings, and spending time with his/her friends and family members. The VA’s diagnoses included a mild to moderate developmental delay, an impulse control disorder, Karyotype 49, and a mood disorder. The VA attended a work program each weekday. The VA’s Individual Abuse Prevention Plan stated that the VA might engage in behaviors that provoked others to aggress toward him/her. The VA might not be able to fully defend him/herself from others abusing him/her. The VA was impulsive and did not always think about possible consequences to his/her actions. The VA’s Self-Management Assessment stated that the VA was able to follow verbal directions, but might need time to process what was requested of him/her. The VA might not consistently follow directions in dangerous situations and his/her response depended on his/her agitation level. If the VA was upset, s/he might refuse to respond appropriately until the need to comply was calmly explained to him/her. The VA had an extensive history of damaging property and in the past damaged vehicles belonging to the facility and to the staff persons. The VA stated that on an unknown date, after the VA threw rocks at the SP’s car, the SP hit the VA on the right side of his/her head and on his/her right side with a closed fist. The SP also told the VA, “Come on, fight me.” At the time of the incident, P1 was also outside. The following day, the VA told P2 about the incident. P1 provided the following information: · On November 15, 2025, the SP and P1 worked at the facility with the VA and another client (C). P1 stated that when the VA became upset, s/he might spit, throw items, bite, or hit the staff persons or the C. P1 stated that “when [the VA] was too upset, there was no calming down until [s/he] gets it all out.” The staff persons were trained to redirect the VA in order to help him/her calm by offering activities the VA enjoyed, asking the VA why s/he was upset, or by giving the VA “space” and keeping out of the VA’s sight. When the VA hit others, the staff persons were trained to implement manual restraints. The VA “liked” being placed in a manual restraint and would typically “stop and calm” his/her body, but would hit his/her head on the floor and attempt to bite the staff persons if they placed their hands under his/her head to prevent injury. · The VA sometimes attempted to break the windows on cars in the facility’s driveway by throwing rocks. On one occasion, the VA broke P1’s windshield. When the VA began to throw rocks at cars, the staff persons were to go outside and try to “coax” the VA to stop throwing rocks. If the VA continued to throw rocks, the staff persons would implement a manual restraint. The VA would typically lie on the ground when the staff persons approached him/her when s/he was throwing rocks. · On the day of the incident, at approximately 2 p.m., the C did not allow the VA to watch the C play video games, which upset the VA. P1 told the VA that it was up to the C if s/he wanted the VA in his/her bedroom watching the C play video games. The VA became upset and threw his/her glasses at P1, causing them to break. When P1 asked the VA why s/he threw his/her glasses, the VA became “more upset” and went outside. P1 and the SP watched the VA from inside the facility. The VA hit P1’s car with a basketball and then a golf ball. P1 and the SP went outside and asked the VA to stop throwing rocks at the cars and to go back inside the facility. The VA walked to the SP’s car and drew pictures in the dust on the car windows and the SP and P1 went back into the facility. The VA sat by the SP’s car for a few minutes and then walked to the back yard. P1 went outside and tried to talk to the VA, but the VA told P1 to leave so P1 went back into the facility. · The VA walked back to the front of the house while the SP and P1 watched through the windows. The VA began throwing rocks at the SP’s car and the SP and P1 went outside and walked toward the VA. The VA began throwing rocks at P1 and the SP and then lay on the ground on his/her stomach and continued to throw rocks at the SP and P1. The SP and P1 were on their knees next to the SP and held the VA’s arms while the SP “pried” a large rock from the VA’s hands. P1 stated that holding the VA’s arms at that point was not a “hold.” When the SP was several feet away from the VA, the SP told the VA that s/he was lucky s/he did not break the SP’s car window because the VA would have to pay for it and the VA’s family members would be upset with the VA. The SP made the comment in a “firm authority figure kind of way.” The SP and P1 went into the facility while the VA sat on the ground and continued to throw rocks at the SP’s car. The SP went outside and sat on the porch and “yelled” at the VA for several minutes, telling the VA that no one wanted to work at the facility because of the VA’s actions. P1 remained inside and could hear the SP yelling, which “sounded pretty close.” · The SP stopped yelling for one to two minutes, but P1 did not see what the SP did during that time. P1 stated that when it “got quiet outside,” P1 went outside for “probably 20 to 30 seconds” and saw the VA “picking at rocks on the ground” while the SP was standing 40 to 50 feet away from the VA using his/her cell phone and vaping. P1 then returned to the facility and the SP was alone with the VA outside for approximately five minutes. The SP entered the facility and sat on a chair for approximately one hour. The VA sat outside and then ran into the facility and told the staff persons that s/he saw a bear. The VA “forgot” s/he was angry and the VA and the staff persons watched a movie. P1 stated that “it didn’t seem like anything happened” between the VA and the SP. P1 stated that s/he never saw the SP “get physical” with the VA or hit the VA’s head or side. P1 did not hear the SP tell the VA to “fight” the SP. · After dinner, the VA told P1 that the SP hit him/her in the face. P1 checked the VA for injuries, but did not see any marks on the VA’s head or feel any lumps on the VA’s head. Later that night, the VA told P1 that the SP kicked the VA on the left side of his/her body. P1 again checked the VA for marks or injuries and did not see any marks. P1 stated that the VA typically told the staff persons the “basis of a story,” but then added details that sometimes got into “misleading information” so that it was hard to tell what was true or untrue. The VA asked for ibuprofen, but did not appear hurt or upset. The SP told P1 that s/he never got close to the VA when s/he was alone with the VA outside and did not hit the VA. P1 stated that the VA initially told P1 that s/he was kicked in the head, then said that s/he was hit in the stomach, then that s/he was kicked in the stomach, and then that s/he was hit in the head and kicked in the stomach. P1 did not see any marks or bruises on the VA’s face or body that day or the next day when they all went bowling. · P1 stated that the VA’s memory was “iffy” and it was sometimes difficult to understand the VA because s/he had a speech disorder. P1 stated that s/he never knew the SP to be violent or talk about wanting to hit any of the clients. P2 and P3 provided the following information: · P2 stated that when the VA became upset, the staff persons were to talk to the VA, ask the VA to go for a walk, remove the VA from the area, play music, or attempt to get the VA involved in an activity. If the VA was not harming anyone, the staff persons “let [the VA] get it out of [his/her] system.” If the VA did not deescalate, the staff persons sometimes had to implement a manual restraint. P2 stated that when the VA believed the staff persons were preparing to implement a manual restraint, the VA often lay on the ground because s/he did not want the staff persons to touch him/her. · P2 stated that on November 15, 2025, the SP texted P2 and told him/her that the VA threw rocks at his/her car, but did not mention anything about the VA being hurt. P1 worked at the facility on the day after the incident and went bowling with the VA, the other clients, P1, and the SP. P2 did not observe any marks or bruises on the VA’s face and the VA did not act “differently” than s/he usually did. The VA told P2 that on the previous day s/he “got mad” and broke his/her glasses when s/he threw them, which the VA had done before. The VA “loved” the sound of shattering glass. · P3 stated that on November 18, 2025, the G told P3 that the VA told the G that s/he threw rocks at the SP’s car and the SP “punched” the VA in the side of his/her head. P3 called P2 to ask about the incident. P2 told P3 that s/he was told the VA threw rocks at the SP’s car, but not about the VA being hit. P3 asked the SP to go to the main office to talk to P3 about the incident, which the SP did. The SP told P3 that when the VA threw rocks at the SP’s car, the SP and P1 went outside and the VA lay on the ground. The SP stated that neither of them touched the VA. When the VA sat up, the SP and P1 went inside and watched the VA through the window. The VA entered the facility and apologized. P1 told P3 that there were a few minutes when P1 was inside working with another client and not watching the VA or the SP outside. The VA told P3 that the SP hit the VA with his/her fist on the right side of the VA’s head. · P2 stated that the VA “knows what’s going on,” but might not be an accurate reporter of events “all the time.” In the past, if the VA “got mad” at a staff person, the VA said the staff person hit him/her. When the VA was upset with a staff person, s/he “instantly” called the G and told him/her what occurred. P3 believed that the VA had a “very good” memory. The VA was not always an accurate reporter of events, but there was typically at least “a little bit of truth” to what the VA said. · P3 stated that when the VA was outside, the staff persons could monitor the VA from the porch or by watching the VA through the window. The VA sometimes needed time away from the staff persons to calm. P3 was not aware of any previous conflicts between the VA and the SP or of any concerns about the SP’s interactions with the clients. The SP provided the following information: · On the day of the incident, the VA became upset when the C did not allow the VA to play his/her video game. The VA threw his/her glasses at P1 and broke them and then yelled at the staff persons before going outside and throwing rocks at their cars. The other clients were in their bedrooms. P1 and the SP went outside, stood on the porch, and asked the VA why s/he was upset and if s/he wanted to talk about it. The VA became more upset, so the SP and P1 went inside and watched the VA through a window. The VA walked into the woods at the edge of the yard while the SP and P1 watched him/her. The VA returned to the SP’s car and started to throw rocks again. The SP and P1 went outside to talk to the VA and the VA lay on the ground. The SP and P1 were going to implement a manual restraint and held the VA’s arm for “two seconds,” but released the VA when s/he lay down. The VA spit at P1 and the SP pushed the VA’s shoulder down to stop him/her from spitting. The SP took the rocks from the VA’s hands. The VA hit his/her head on the ground a couple of times, so the SP and P1 returned to the facility and the SP watched the VA from the porch. P1 went into the facility for approximately five minutes to start cooking dinner. · The SP got into his/her car and played music to help the VA relax. The VA told the SP that s/he saw a bear in the woods. The SP remained sitting in his/her car for 10 or 15 minutes until the VA entered the facility. The SP followed the VA inside and talked with him/her and “everything seemed good.” The VA told the SP that s/he fell when s/he walked in the woods and hit his/her head, but the SP did not see any marks on the VA. · The following day, the SP went bowling with the VA and the other clients and staff persons. The VA had fun and the SP did not see anything unusual with the VA’s behavior and did not see any marks on the VA’s face. · The SP did not recall telling the VA that no one wanted to work at the facility because of the VA’s actions. The SP “said something” to the VA about the VA having to pay for damage to the SP’s car if s/he broke the windows. The SP stated that s/he was not screaming at the VA, but spoke “firmly.” The VA did not “go after” the SP and the SP did not hit the VA in the face or side. · The SP stated that when the VA became upset, the staff persons tried to give the VA space to calm him/herself because interventions made by the staff persons sometimes made the situation worse. The G stated that the VA “told on” him/herself when s/he did something s/he was not supposed to do. The day after the incident, the G saw the VA when s/he was bowling and the VA told the G that a staff person hit him/her in the head. When asked which staff person hit him/her, the VA pointed at the SP. The G could not see any bruise through the VA’s hair so was unsure if the VA had a bruise or not. The facility’s Program Abuse Prevention Plan stated that all of the clients had the right to be free from abuse and all of the staff persons were to immediately intervene to protect all of the clients from abuse. Facility documentation showed that the SP, P1, P2, and P3 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 incident. Conclusion: On November 15, 2025, the SP and P1 worked at the facility. At approximately 2 p.m., the VA became upset because the C did not allow the VA to watch the C play video games. The VA went outside and began throwing rocks at the staff persons’ cars. The SP and P1 went outside and asked the VA to stop throwing rocks. The VA walked around the yard and the SP and P1 went inside the facility and watched the VA through a window. When the VA returned to the cars and again threw rocks at them, the SP and P1 went back outside and approached the VA. The VA lay on the ground and the SP took the rocks from the VA. P1 stated that the SP told the VA that s/he was lucky s/he did not break the SP’s car window because the VA would have to pay for it. P1 and the SP again returned inside and watched the VA from a window. P1 stated that when the VA continued to throw rocks at the SP’s car, the SP went outside and sat on the porch and “yelled” at the VA for several minutes, telling the VA that no one wanted to work at the facility because of the VA’s actions. The SP stated that s/he spoke “firmly” to the VA, but did not recall telling the VA that the staff persons did not want to work with the VA. The VA stated that while s/he lay on the ground, the SP hit the VA on the right side of his/her head and on his/her right side with a closed fist and that P1 was outside at the time of the incident. The SP also told the VA, “Come on, fight me.” Later that night, the VA told P1 that the SP hit the VA in the head. P1 checked the VA for injuries or marks, but did not find any. Throughout the evening, the VA told P1 that s/he was hit in the stomach, that s/he was kicked in the stomach, and that s/he was hit in the head and kicked in the stomach. P1 did not see any marks or bruises on the VA’s face or body that day or the next day when they all went bowling. While at bowling, the VA told the G that the SP hit the VA on the head. The G and P2 did not see any marks on the VA’s head. Although the VA provided consistent information that the SP hit him/her, given that the VA provided inconsistent information about where the SP hit him/her; that the SP stated that s/he never hit the VA; that P1 did not see the SP hit the VA or tell the VA to “fight” him/her; and that the VA had no marks or bruises, there was not a preponderance of the evidence whether SP’s hit the VA. 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). 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 SP. After the incident, the SP was retrained on the facility’s policies and worked at another residential program operated by the license holder. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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