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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: 1125296-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Heidi Murphy/Emily Kearns 651-431-6544 Suspected Maltreatment Reported: It was reported that a staff person (SP) did not provide adequate supervision to a vulnerable adult (VA) and subsequently the VA and a family member (FM) had sexual contact at the facility. Date of Incident(s): February 22, 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 17, paragraph (a): 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 March 25, 2025; from documentation at the facility and law enforcement records; and through nine interviews conducted with the VA, four facility supervisors (P1, P2, P3, and P4), the VA’s case managers (CM1 and CM2), a community person (CP), and the SP. The VA was not subject to guardianship. The facility was a single-family, split-entry residence in a residential neighborhood that was to be staffed 24 hours a day. There was one client that had a bedroom upstairs (C1). The VA and another client (C2) both had bedrooms downstairs. The VA had a diagnosis of schizophrenia, borderline personality disorder, post-traumatic stress disorder, and depression. The VA enjoyed playing cards. The VA’s Individual Resident Placement Agreement dated October 22, 2024, stated the VA needed “24 hour support to ensure [his/her] mental health remains stable, takes [his/her] medications and attends scheduled appointments.” The plans stated the facility “will provide oversight to [the VA] 24 hours of the day including awake overnight staff.” The VA’s Individual Abuse Prevention Plan (IAPP) dated effective from December 7, 2024, to December 8, 2025, stated the VA was susceptible to abuse because of a lack of understanding of sexuality and was susceptible to abuse in likeliness to seek or cooperate in an abusive situation. The plans stated that the VA had frequent overnight visits from a family member (FM) of the opposite gender. The VA said that in the past (prior to residing at the facility) the FM would give him/her money in exchange for performing sexual acts on him/her. The facility was staffed “with at least one wake staff 24/7. At this time, [the VA] is supervised at a ratio of 2:3 while in the [facility]. [The VA] receives safety checks every 30 minutes or every hour when sleeping.” C1’s Individual Abuse Prevention Plan (IAPP) dated November 25, 2024, and January 15, 2025, stated that C1 had 24 hour 1:1 support. C1’s Individual Resident Placement Agreement dated November 27, 2024, also stated C1 required a 24-hour care plan and required 1:1 direct care staff ratio. C2’s Individual Resident Placement Agreement dated October 22, 2024, stated the facility “will provide oversight to [C2] 24 hours a day including overnight.” C2’s State of MN Support Plan, effective date range October 28, 2024, to September 30, 2025, stated that C2 “resides in [the facility] with 24 [hour] staffing and 1:1.” Information showed that a report was made to law enforcement regarding a sexual assault that occurred at the facility on February 22, 2025, at approximately 12:20 a.m. Video footage from the facility showed the VA engaged in sexual activity with the FM in a common area of the facility. The FM was charged with criminal sexual conduct for this incident. Probation records showed that the FM had been on supervised release as of July 7, 2022, and had been a registered predatory offender since May 15, 2015. The FM’s predatory offender level did not require public notice. There had been previous allegations of sexual misconduct between the FM and the VA in “the fall” but no charges were ever filed. The FM’s probation officer stated that s/he told the FM that s/he was not to spend the night at the facility and the facility was aware the FM was not supposed to spend the night at the facility before the incident occurred. The FM’s probation officer was notified by the county licensor on February 7, 2025, that the FM had stayed at the facility 26 times since October 2024. On February 10, 2025, the FM was notified by his/her probation officer that s/he was not allowed to stay at the facility given his/her predatory offender status. The probation officer also met in-person with the FM and the VA on February 14, 2025, and the FM was again told s/he could not spend the night at the facility. At the time of the incident, the FM was allowed to spend time with the VA. County licensor notes and emails provided the following information: · On November 27, 2024, P4 contacted the county licensor, and inquired about limiting overnight visits with the VA’s family members and added that one of the family members (determined to be the FM) was a “level one sex offender.” The county licensor told P4 that s/he would reach out to DHS regarding P4’s question. The notes then stated that the county licensor left a voice message and emailed “DHS triage.” In an email, the county licensor told P4 that s/he did not “believe” that there could be any type of restriction of visits unless approved/discussed with the case manager and guardian of the client. The county licensor told P4 s/he had reached out to DHS and other county licensors and would let P4 know when s/he heard back. · On November 28, 2025, P1 emailed the county licensor and said that the FM spent the night at the facility two nights without the other family member present and also spent the night when the other family member was present. One occasion, the FM was wearing a tank top undershirt and underwear. P1 stated the facility addressed this with the FM and the FM agreed to ensure s/he was fully clothed in the common areas of the facility. P1 stated that the VA “reports wanting to have these overnights.” · An email from the county licensor to the facility and the CP dated February 3, 2025, stated, “DHS let us know that the provider can put parameters in place to decease the overnight visits,” “When an overnight visit does occur that staff are checking in on the client and the family often, by knocking on the door, if they are in the room alone,” and “DHS also advised for the provider to have team meetings with the other clients’ teams” to see how the teams felt about the frequent overnight visits but that “you cannot share the concerns regarding [the FM’s] background, unless it’s public information.” · On February 7, 2025, the county licensor met with P3 who stated that the facility installed cameras in common areas of the facility for safety and supervision purposes. When the FM visited after the cameras were installed, the FM did not like the cameras and unplugged them. Staff plugged the cameras back in. The county licensor explained to the FM that cameras were allowed, and it was not an infringement on any rights and that as a guest, the FM needed to follow the policies of the facility including visits needing preapproval from the facility. · On February 26, 2025, the county licensor sent an email to P1 and asked for an update on the FM’s frequent visits. P1 replied that the facility implemented a visitor policy and talked to the FM about the rules but at the time they talked the facility did not have a paper copy of the policy for the FM to sign in acknowledgement. P1 stated that the county licensor advised that the facility convenes team meetings with C1’s and C2’s teams to inform them of the frequency of the FM’s overnight visits to determine whether team members, C1, or C2 had concerns regarding the visits. The county licensor also “clarified” that the facility was “not permitted” to disclose concerns related to the FM’s background “unless that information was publicly available.” P1 stated that on February 20, 2025, the facility discussed the “situation” with C2 and C2’s case manager to ensure they were informed and comfortable with the visits. C2 was not subject to guardianship. C2 and C2’s case manager said they had no concerns. The facility communicated with C1’s guardian (C1 could not communicate verbally) regarding the frequency of the visits and C1’s guardian expressed no concerns. (Note: The FM’s criminal records were public information and easily available through a public records search.) The facility’s J&K Comfort Home’s Visiting Guidelines and Procedures for Residents, Staff, and Visitors did not have a date and provided the following information: · All overnight stays must be scheduled in advance which was “ideally” supposed to occur two days in advance of the visit. The number of overnight visits was at the discretion of management and could be adjusted. · Visitors were supposed to sign in and out of the logbook. Visits were allowed only during designated visiting hours, which were 7 a.m. to 11 p.m. but exceptions could be made in special circumstances. · Visits may be supervised by staff. Cameras were not to be tampered with. Vistors were to conduct themselves appropriately. The VA provided the following information: · On an unknown date, several weeks prior to this interview, the VA had the FM visit the facility. There was an “incident,” and the FM was arrested. There was a domestic abuse no contact order (DANCO) put in place between the VA and the FM. · The VA did not know what staff persons were working on the night of the incident or where staff persons were during that shift. The VA’s visitors (two family members, one being the FM) arrived at the facility around 8 p.m. for a prearranged visit. The VA believed the incident occurred around 9-10 p.m. after the other family member went to sleep. · At the time of the incident, the VA stated his/her supervision ratio was “regular staff.” The VA stated s/he could have unsupervised time in the community and go for walks and to local dollar stores. The VA also had unsupervised time at the facility. There was usually two staff persons at the facility “all the time,” both during the day and at night. The VA went to sleep around 9 p.m. and got up around 8 a.m. The night shift started at 11 p.m. and the VA never saw the night staff. The VA stated staff persons did not check on him/her overnight when s/he was sleeping, and staff persons did not do routine checks throughout the day. · The VA had family members visit regularly, as frequent as every weekend. Visitors had to be preapproved and there was a sign in policy. The VA and family members were allowed “privacy” during visits. No extra safety checks were done, and the VA’s bedroom door was allowed to be closed during visits. · The VA’s supervision since the incident had been changed to a 1:1 ratio. The SP provided the following information: · The SP worked the overnight shift on February 21, 2025. There was another staff person scheduled to work that night, however, they “didn’t come that day.” The “manager was at another facility [location]. Then if we have something, we can report to [him/her].” The SP worked alone with the VA, C1, and C2. · The SP called P3 when the other staff person did not show up for their shift. P3 told the SP s/he “could work [by] myself because [s/he] is sick.” · When the SP arrived for work, the VA’s two family members including the FM were at the facility and “all of them” were awake. The two family members spent the night at the facility. The SP stated everyone went to sleep around 3 a.m. The SP stated the VA’s family members had been at the facility every day since the VA moved in, “they were like permanent.” · Safety checks were conducted every 30 minutes for the VA and every hour for C1 and C2. The SP stated during the overnight shift on February 21 to 22, 2025, s/he checked on C2 four times. The SP did not check on the VA because “the [family] members were there.” The SP stated, “When the [family members] are there, you know that [the VA] is safe,” and “It’s like they are taking care of her.” The SP did not see anything inappropriate between the FM and the VA. · The SP stated prior to February 21, 2025, one staff person worked overnight, and two staff persons worked during the day. The SP later stated that February 21, 2025, was the only overnight shift s/he had worked alone. · When only one staff person worked, the staff person would be upstairs with C1, and the staff person would go downstairs for the VA’s and C2’s safety checks. P1 provided the following information: · P2 told P1 that on February 22, 2025, at 7 p.m., (not at the same time the incident occurred but the evening after) the FM was at the facility and P2 saw C2 downstairs only in his/her undergarments after the FM went upstairs from that area. P1 requested P4 review camera footage. P4 reviewed camera footage around that timeframe and saw video of sexual contact between the VA and the FM and scheduled a meeting with the VA’s care team. · C2 stated the FM tried to get C2 to engage in sexual activity and C2 refused. Nothing of concern regarding C2 and the FM was observed on the video footage when it was reviewed. · The SP was the staff working the night shift (11 p.m. to 7 a.m.) on February 21, 2025. Another staff person was scheduled to work, however, called in sick. P1 did not know if anyone covered the second staff person’s shift. · After P1’s normal working hours, any staff persons that called in sick would call P3 or P4 and they would resolve the shift coverage. · P1 stated during the day, staff ratios were 1:2 for the VA and C2, and 1:1 for C1 for a total of two staff persons for three clients. At night, there was “just one staff.” P1 was unsure if C1 was 1:1 on the overnight shift. · Safety checks were to be done once per hour for every client on the overnight shift. On the day shift, if clients were awake, checks were done every half hour. If a client was asleep, checks were one to two hours. Staff persons would “use their judgment based on [the clients’] daily routine.” · The VA’s team had previous concerns over the frequency of the family members’ visits and that the FM was visiting the VA alone. Prior to the incident, the facility, the VA, and the family members came to an agreement that the FM would only visit when a family member the same gender as the VA was also visiting the VA. P2 provided the following information: · Staffing ratios were 2:3 (one staff person upstairs and one staff person downstairs, shared between the clients) at the time of the incident. At times, staff persons would run to another facility location down the street to get dinner and leave one staff person at the facility briefly, as the other facility was “a two-minute drive.” · The overnight shift (11 p.m. to 7 a.m.) would have two staff persons. C1 was a 1:1 staff ratio at all times. The VA and C2 shared one staff person overnight. One would be upstairs and the other would be downstairs. Overnight staffing issues were handled by P3 or P4. · The VA had visitors three to four times a week. The VA was not subject to guardianship and due to rights restriction concerns, the facility did not restrict who would visit the VA. When the VA had visitors and staff persons were downstairs, the VA would tell the staff person to go upstairs as s/he “has a right to [his/her] privacy.” Staff persons “did what they could aside from having an escalated situation happen.” · Guests did not need to be preapproved. P3 provided the following information: · The VA moved into the facility in November of 2024 and there had been challenges regarding the VA and visitors. The facility had concerns and spoke to the county licensor and DHS licensor and was told that they could not stop the VA from having certain visitors because the VA was not subject to guardianship. Cameras were installed in common areas of the facility at the end of January or beginning of February 2025, to help monitor activity. · Staffing requirements for the facility were two staff persons during the morning, afternoon, and night shifts. When staff “called in [sick], we try to find a backup. If I can’t find a backup, I will just be on call.” On call meant, “I do rounds to each house to see how things are going” and not be only at one facility location. · When the incident occurred, there was supposed to be two staff persons working the overnight shift. One staff person would be with C1 and the other staff person would be downstairs. “If the family [the VA and two family members] was watching a movie, they might ask [the staff person] to go upstairs,” and the staff person would “just check on them.” · The day of the incident, a staff person called in sick to P4 and P3 was not able to find anyone to cover the shift. P3 told the SP to “let [him/her] know what was going on.” P3 came by the facility that night, however, stayed outside and called the SP to check in. The SP told P3 everyone was sleeping at that time. · The VA’s plans stated the VA had safety checks every 30-60 minutes. C2 also had safety checks every 30-60 minutes. Safety checks were conducted by putting an “ear to make sure you can hear them at the door.” Supervision policies were not any different when visitors were present. · Visitors were preapproved and had a log they signed in on. · After the incident, the FM was no longer allowed at the facility and had been verbally trespassed from the property. P4 provided the following information: · The VA frequently had two family members visit and spend the night in the VA’s room with the VA. The FM visited the VA at the facility alone and spent the night on several occasions. The facility had concerns about the FM and had conversations with the VA’s team, which included the county licensor, regarding the concerns and they came to an agreement that the FM could not spend the night without the other family member who was the same gender as the VA present. The VA started to push back over supervision and wanted privacy when visitors were over. · When the VA and his/her family asked for privacy, staff persons would go upstairs. Cameras were installed “for the safety of [the VA].” · P4 reviewed the camera footage after staff persons raised concerns over the frequency of the family members’ visits and the requests for privacy from the family. P4 observed the incident of sexual contact between the FM and the VA and called for a team meeting. The footage was reviewed within a week of the incident. · The facility had two staff persons during the “morning and [afternoon] shift, some night shifts we have two staff.” The day of the incident, “one of the night staff called in, we were short during that time.” · The VA was 1:1 for eight hours a day and had shared staffing at night. C1 had shared staffing and C2 was a 1:1 staff ratio. “With the shortage, what seemed to work with us, with the proximity of management, I just walk from the other house here so it’s walking distance. My staff is aware that in any case you need help, we are minutes away. That is what we had in place.” · P4 later said that C2’s plans had not been approved yet for 1:1 and at the time of the incident, s/he was shared staffing. P4 also stated C1’s plan had not been approved for 1:1 staffing yet, so s/he was also shared staffing. P4 originally stated a minimum of 2 staff persons were needed on the overnight shift and then later stated that a minimum of one staff person was needed, due to clients’ plans not being approved at that time. · P4 stated all three clients resided at the facility since October or November of 2024 and the plans had not been approved yet due to an incorrect billing number and because the facility was a “new license.” · Safety checks were conducted on clients every 60 minutes. When clients were sleeping, staff persons “just have to listen.” · Expectations of staff persons when the VA had visitors was if the family was watching television, “I would assume staff would hear them talk down there and not be a concern.” Staff persons were experiencing “resistance” from the VA regarding safety checks and P4 stated, “I would expect staff would choose not to have trouble. Staff would choose to have peace instead of having trouble with [the VA].” · Nothing inappropriate was observed between the FM and C1 or C2. Throughout the investigation, information that was gathered conflicted with information that was given during interviews with staff persons, including: · A staff schedule was provided by P3. Staff persons who worked at the facility were highlighted in pink. On the night of February 21, 2025, there was only one staff person highlighted, which was the SP. A staff person who P3 stated called in sick on the night of February 21, 2025, was scheduled to work, however, according to the schedule, was scheduled to work at a different facility location. · P1, P2, P3, P4, and the SP all provided conflicting information on staffing ratios for each client and the minimum number of required staff on the overnight shift. P4 stated the clients’ plans had not been approved yet and the facility was going off the clients’ previous plans from their previous residences. (Note: Even if every team member had not signed a client’s plans, the plans went into effect after 10 days, whether they were signed or not.) CM1 provided the following information: · CM1 worked with the VA since 2022. Prior to the incident, the VA did not have any restrictions and would go with family members for extended periods of time. There were “suspicions of relations, concerning boundaries,” however, “they never had evidence or a reason to stop [the VA] from going.” · CM1 was “under the impression” that the VA’s staff ratio was 1:1. CM1 also believed C2 was a 1:1 staff ratio. · CM1 had concerns over lack of supervision in the facility and lack of communication. There was a time when the VA had not taken medication for a month before the facility notified CM1. C2’s case manager was at the facility for a visit and observed the VA and a family member using substances in the VA’s bedroom. CM1 met with P4 and P4 stated the VA used substances outside and it was not a concern. · CM1 believed the FM was bringing illegal substances to the VA. · The VA was not reliable at providing information as s/he would “cover tracks” so the FM would not get in trouble. The VA had previously told a peer that s/he was doing sexual favors for the FM in exchange for substances. CM2 provided the following information: · CM2 was a case manager for the VA and C2. At the time of the incident, CM2 stated the VA had a supervision ratio (per the rate sheet dated October 28, 2024) of 16 hours shared staff during the day with a staff ratio of 1:3 and eight hours of 1:1 during the day, and eight hours shared care overnight. On February 26, 2025, the VA’s supervision was changed to 16 hours of 1:1 during the day and 16 hours of shared care overnight. · C2’s rate sheet from when C2 moved into the facility on October 28, 2024, stated C2 was 1:1 staff ratio 24 hours/day and 16 hours 1:1 overnight. · Conversations were had at the VA’s intake meeting in October 2024, about concerns of previously reported inappropriate sexual activity between the VA and the FM. The allegations were all “hearsay,” and the VA denied the allegations. CM2 confirmed the facility was aware of the concerns. The CP provided the following information: · The FM was not supposed to be spending the night.
· There should have been two staff persons working the overnight shift. · The CP had voiced concerns about the FM being at the facility unsupervised. In an email sent on February 3, 2025, the facility was advised to have meetings with the other clients’ teams and discuss the overnight visitors and their concerns. “Since it is not only [the VA’s] home the other clients and teams need to be informed and be comfortable with it.” The email also stated that the facility “can put parameters in place to decrease the overnight visits,” and “When an overnight visit does occur that staff are checking in on the family often, by knocking on the door, if they are in the room alone.” P2 and P4 stated to the CP that they did not receive an email that stated the FM was not allowed to spend the night. The facility’s Internal Review stated, “It was determined that supervision lapses occurred. It was also determined that [the VA’s] constant resistance to having staff downstairs while having [family members] over led to staff hesitation to discharge their duties regarding supervision to avoid confrontation.” Facility training records showed that all staff persons interviewed each received training on the Reporting of Maltreatment of Vulnerable Adults Act and on the VA’s plans. Relevant Rules and Statutes: Minnesota Statues, section 245D.07 subdivision 1a, paragraphs (a) and (b) stated that the license holder must provide services in response to the person’s identified needs as specified in the support plan and support plan addendum. Services must be provided in a manner that supports the persons preferences, daily needs, and activities. Conclusion: A. Maltreatment: Information showed that on February 21 to 22, 2025, the SP worked the overnight shift at the facility alone. The SP, P1, P3, and P4 stated a second staff person was scheduled to work that shift, however, called in sick and a replacement staff was not found. P3 was then “on call” and stopped by the facility that night to check in with the SP. P3 told the SP to let him/her know if anything was going on. That night, the VA had the FM and another family member visit and spend the night and video showed that the VA and the FM had sexual contact. Based on the VA’s, C1’s, and C2’s plans, the staff ratio at the facility was two staff persons to three clients. Overnight, one staff person was to supervise C1 upstairs and a second staff person was to supervise C2 and the VA downstairs. The VA was to be checked on overnight every hour. The VA wanted privacy when s/he had visitors. The SP stated s/he did not check on the VA hourly the night of the incident because the VA had visitors, but the SP heard they went to sleep around 3 a.m. According to the VA’s plans, the VA’s staffing ratio was one staff person for the VA and C2 during the overnight, but the SP was the sole staff person working and the SP did not check on the VA hourly because the VA had visitors, which was a violation of Minnesota Statues, section 245D.07 subdivision 1a, paragraphs (a) and (b). Prior to the incident, it was documented that facility supervisors had concerns over the amount of time the FM stayed at the facility. There were also concerns regarding inappropriate interactions and sexual relations between the FM and the VA. The facility did not increase supervision when the FM visited, and checks were decreased because the VA requested privacy. The VA was not subject to guardianship, had the choice to have the FM visit at the facility, and did not have a rights restriction. However, the VA and the FM had a history of sexual contact including information in the VA’s IAPP that in the past, the FM gave the VA money for performing sexual acts and the facility knew that the FM was a registered sex offender both of which posed a substantial risk to the VA’s health and safety. Given that there was an identified risk of harm to the VA by having the FM spend the night because of the FM and VA’s history and the FM’s sex offender status, both of which the facility knew about; that the county licensor told the facility that they could have restrictions to overnight visits in place and that staff persons should check on the family often and knock on the door; that although the facility talked with the FM and the VA and created a visitor policy at some point, the facility did not enforce either with the FM and did not implement precautionary measures such as checking on the family often; and that it was facility practice to supervise the VA less when the FM was present, there was a preponderance of the evidence that there was a failure to provide the VA with reasonable and necessary care and services. It was determined that neglect occurred (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. Although the SP did not check on the VA hourly the night of the incident, given that facility supervisors knew the SP was the only staff person working, that the SP was supervising C1 upstairs who required 1:1 supervision, and that the SP conducted some checks of C2 in the lower level which was also where the VA was, the SP’s responsibility was mitigated and the facility was responsible for maltreatment of the VA. C. Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by a facility meets the statutory criteria to be determined as “serious.” 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 maltreatment for which the facility was responsible was not “serious” maltreatment because the VA did not sustain an injury as outlined in statute. Although the incident resulted in sexual contact between the VA and the FM, the maltreatment for which the facility was found responsible was regarding how the facility addressed the risk of harm posed to the VA, but it was not known whether increased supervision would have prevented the incident. Action Taken by Facility: The facility’s Internal Review stated that the facility’s policies and procedures were followed but were not adequate. The facility retrained staff persons on safety check procedures and implemented a more thorough safety checklist to document service. The VA’s supervision was increased to 1:1 while in the community and 3:3 at the facility. The VA no longer had any unsupervised time while in the community and would always be accompanied by a staff person. The facility was equipped with three security cameras in common areas of the facility. Action Taken by Department of Human Services, Office of Inspector General: On February 19, 2026, the license holder was ordered to forfeit a fine of $1000 as a result of the substantiated maltreatment for which facility was responsible. The maltreatment determination and the Order to Forfeit a Fine are each subject to appeal.
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