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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: 1069979-H_CRS (Home and Community-Based Services-Community Residential Setting) 1069963-HCBS (Home and Community-Based Services) Investigator(s): Jason Pehler 651-431-4830 Suspected Maltreatment Reported: It was reported a staff person (SP) hit a vulnerable adult (VA) during an argument. Date of Incident(s): December 9, 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 January 7, 2026; from documentation at the facility and law enforcement records; and through five interviews conducted with the VA, a facility supervisor (P2), the VA’s case manager (CM), the VA’s family member (FM), and the SP. A staff person (P1) was contacted via telephone for an interview. P1 was unable to complete the interview at the time of the phone call and stated s/he would call the investigator back. However, by the time of this report, P1 had not done so. Facility documentation showed the VA had a cell phone and iPad and did not require assistance to use the items. The VA was independent and alert regarding the services s/he needed. The VA was “quick to severe anger, agitation, heightened irritability.” The VA also engaged in severe verbally aggressive, threats of harm, and derogatory comments. The VA was diagnosed with post-traumatic stress disorder, anxiety, depression, and developmental disabilities. The VA’s Individual Abuse Prevention Plan showed the VA was susceptible to physical abuse, and was easily moved to severe agitation, quick to anger, and was capable of using inappropriate language toward others. Staff persons reminded the VA to take a deep breath and attempted to redirect the VA when escalated. Law enforcement (LE) records provided the following information: · On December 9, 2025, around 5 p.m., LE was contacted due to a disturbance between the SP and the VA at the facility. · Upon arriving at the facility, LE spoke with the SP who said the VA had “some issues” earlier in the day due to concerns regarding medications, and that “spilled over” into the current incident. · The SP said the VA got into his/her face and was “very animated and excited.” The VA yelled at the SP and started to punch him/herself in the face which caused a cut on the VA’s cheek. The SP denied touching the VA, and said the VA acted “erratically,” so the SP asked P1 to intervene. After P1 intervened, 9-1-1 was contacted. · The SP said the VA had a history of erratic behavior including hitting him/herself in the face. · The VA said s/he had an argument with the SP and they were in “each other’s faces.” The VA said the SP slapped the VA on the face and the VA response by slapping the SP. The VA said they had “mutually” pushed each other prior to the slapping. · The VA had a laceration on his/her cheek and was offered a medical assessment at a hospital, but the VA declined. · P1 said s/he was doing dishes and assisting another client during the incident, when the SP asked P1 to intervene. P1 did not witness any “fight” take place, but intervened to end the incident between the SP and the VA. · LE determined the information was conflicting and no charges were filed regarding the case. LE noted that there was no evidence to prove or indicate in any way that the SP mistreated the VA during the incident. The VA said s/he was attacked by the SP because the SP was not providing the VA with his/her medications. The SP hit the VA multiple times and caused a cut to the VA’s face, and multiple scratches on the VA’s arm, wrists, and abdomen. P1 saw the SP hit the VA once, but not the other times. The VA called 9-1-1 and told them about the physical altercation including that the SP punched the VA in the face with a closed fist, and that the SP’s ring may have cut the VA’s face. The VA took photos of his/her injuries. Pictures taken by the VA of injuries s/he stated occurred during the incident showed the following:
· Two pictures were of the VA’s face. There was an approximate two-inch-long scratch on the VA’s cheek below his/her eye, moving towards his/her ear. A second scratch was approximately ½ inch long and just above the two-inch scratch. Both scratches had broken the skin and appeared to have started to scab over the cut. No bruising was observed with scratch. [Note: At the time of the interview the scratches on the VA’s face appeared healed.]
· Three additional pictures showed scratches on the VA’s abdomen, arm, and wrist that had fresh broken skin and were red.
The General Event Report (GER), provided the following information: · On December 9, 2025, at 5 p.m. the VA and the SP “were in each other[’s] face” having an argument. P1 separated them but the VA and the SP continued arguing and 9-1-1 was called. · The VA had a mark on his/her face, and said the SP had slapped the VA. · The VA was offered to be taken to the hospital but declined any medical care. · The facility retrained staff persons on deescalating situations and respectful boundaries. The facility’s Internal Review provided the following information: · On December 9, 2026, P1 called P2 and said that the VA and the SP had an heated argument and were fighting. P2 then went to the facility and spoke to the VA, the SP, and P1. · The VA said the SP had slapped him/her and caused the scratches on his/her face. · The SP denied slapping the VA and said s/he tried to remove him/herself from the situation. · P1 said s/he saw the altercation. The SP was arguing with the VA so P1 stepped between them to protect the VA. P1 told P2 that the SP slapped the VA. The CM and the FM each stated that the VA told each that s/he hit the SP and the SP responded by slapping the VA. The CM said from his/her experience, the VA provided pretty accurate information, but at times exaggerated some details. The CM and the FM each had concerns about the facility’s ability to provide services to the VA, and the performance of staff persons and supervisors at the facility. P2 said the VA had a history of providing false information and adding details to alleged incidents. P2 did not have any prior concerns with the SP’s interactions with clients. The SP denied hitting the VA, did not know why the VA was bleeding, and the VA was not aware s/he was bleeding until the SP told him/her. The SP denied wearing jewelry, including a ring. The SP said the VA tried to hit and push the SP, but the SP moved away from the VA. The VA continued to escalate, including raising his/her voice and swearing. The SP explained to the VA that s/he ensured the VA received his/her medication and also offered the VA an as needed medication, but the VA declined. The VA had a history of verbal and physical aggression and not providing accurate information. P1, P2, and the SP received training on the VA’s client specific plans, the facility’s policies and procedures, and the Reporting of Maltreatment of Vulnerable Adults Act. Conclusion: Information obtained was consistent that on December 9, 2025, there was an incident between the VA and the SP. The VA provided inconsistent information regarding how and where the SP hit him/her. The VA told P1, LE, the CM, and the FM that the SP slapped him/her causing a scratch on his/her face, but told this investigator that the SP punched the VA with a closed fist and that the SP’s ring had caused the scratch to the VA’s face. Pictures showed that the VA had two scratches on his/her face, but no bruising. The VA also told this investigator s/he had other scratches located on abdomen, arm, and wrist as a result of the SP hitting him/her. P1 did not provide information for this report but provided inconsistent information to LE and P2 regarding what s/he observed. P1 told LE that s/he did not witness any physical contact between the SP and the VA, but told P2 that the SP slapped the VA. P2 and the SP said the VA had a history of not providing accurate information and exaggerating details. The CM said the VA provided mostly accurate information but would exaggerate details. Given the inconsistent information provided by the VA and P1 regarding the SP’s actions and that the SP denied hitting the VA, there was not a preponderance of the evidence whether the SP hit, slapped, or punch the VA or whether the VA sustained the injuries by any 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.) Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate, but were not followed. The facility completed additional staff training. The report was not similar to past events. The SP no longer worked for the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action was taken.
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