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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: 1071706-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Emily Kearns 651-431-6513 Suspected Maltreatment Reported: It was reported that a staff person (SP) yelled at a vulnerable adult (VA), prevented the VA from doing laundry, and told the VA to stay in his/her bedroom. Date of Incident(s): January 3, 2026 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 a site visit conducted on January 14, 2026; from documentation at the facility; and through ten interviews conducted with facility staff persons (P1 and P5), three supervisory staff persons (P2, P3, and P4), the VA’s guardians who were also family members (G1 and G2), a facility client (C), the SP, and the VA. The VA was diagnosed with mild intellectual disabilities and generalized anxiety disorder. The VA enjoyed crafting, working on diamond paintings, visiting his/her family members, playing games on a tablet, and bowling. The VA’s Action Plan listed one of the VA’s goals as managing his/her worries and anxiety. Staff persons were to give the VA suggestions that s/he enjoyed that would be “calming or relaxing” such as “sewing, embroidering, playing on [his/her] tablet, watching a movie, etc.” The VA lived at the facility with the C and two other clients. The VA’s bedroom, along with the two other clients’ bedrooms, were located on a main floor while the C’s bedroom and laundry room were in a lower level. A gate that opened into the main floor was installed at the top of a stairway leading to the lower level. A kitchen, living room, and dining area were an open layout with no walls between a kitchen island counter area and the stairway. The VA stated that about a week prior to this interview, on a weekend, the SP told the VA that s/he could not do his/her laundry, but that later, P1 told the VA that s/he could do his/her laundry. The SP told the VA that the VA “lied” about taking an early shower and this made the VA “uncomfortable.” The VA did not like being in his/her bedroom. The VA did not recall any other details about the incident. P1 and P2 provided the following information: · According to P1, at about 6:30 p.m., on the evening of January 3, 2026, P1 and the SP were at the facility with the VA, the C, and two other clients. P1 was in the lower level and heard something fall upstairs and went up to check. P1 asked the SP what was going on and the SP stated that the VA was “being defiant,” “getting mad,” and was pushing things off the counter. The SP and the VA verbally went “back and forth” on who pushed a bottle of hand sanitizer off the counter. The SP told the VA to go to his/her bedroom and the VA went to his/her bedroom. The SP told P1 that s/he told the VA that the VA could not go to church the following day because the VA needed to “think about [his/her] actions because they have consequences.” The SP then told P1 that the SP knew that the VA would go to church, but that the SP wanted the VA to think about things. · P1 stated that the VA then exited his/her bedroom two to four times, and each time, the SP stood in the hallway partially “blocking” the hallway and told the VA to go back to his/her bedroom. The SP did not touch the VA when s/he stood, blocking in the hallway. The third time the VA exited his/her bedroom, s/he exited with a basket of laundry and headed toward the stairway gate. The SP, who had been standing by the counter, “jumped at” the gate and “took a big leap” to “block” the VA from opening the gate and going down the steps. The SP did not physically touch the VA. The SP told the VA to go to his/her bedroom one more time and the VA left his/her laundry basket in the hallway and went to his/her bedroom. The VA came out a final time and the SP told the VA to sit at a dining table and “think about” what the VA had done. · According to P2, P1 and P2 had spoken on the phone earlier in the day. P1 told P2 that the SP was being “overbearing” and “controlling.” P2 told P1 to call back if there were any problems. According to P1 and P2, at around 6:45 p.m., P1 called P2, but did not speak to P2, and sent P2 a text that said, “Listen, don’t talk.” The phone call remained open so P2 could listen to an interaction between the SP and the VA. P1 estimated that the incident had been ongoing at this point but was unsure at what point during the incident s/he called P2, because the incident was happening fast. The SP told the VA to go to his/her room, and that s/he thought s/he called P2 when the SP “jumped” at the gate. · According to P1, the SP then assisted another client and P1 told the VA that s/he could get water, that s/he did not have to sit at the table, and that the VA could do his/her laundry. The VA had a “shaky voice” and had a tear coming down his/her face. The VA went downstairs, and the SP returned to the kitchen area and asked P1 if the VA asked for permission to leave the dining table and P1 affirmed that. The VA later came up the stairs and spent most of the rest of the evening in his/her bedroom. · According to the Internal Review, P1 stated that the VA was “crying intensely” and that P1 offered the VA “comfort” with a “side hug.” The VA continued to be “inconsolable,” crying “very hard.” The SP told the VA that s/he could not get water until s/he had calmed. P1 told the VA s/he could get water. · P1 described the SP’s voice volume as a “seven” on a scale of one being a whisper and ten being screaming at the top of his/her lungs, but that the SP did not swear at the VA. P1 said that the SP was not “screaming,” but was using a “raised tone,” and it was “sharp.” The VA was “on the verge of tears” as the SP reminded the VA that the SP and VA had talked about the VA “being defiant and lying to staff [persons]” earlier in the week. The VA stated that s/he was “trying.” The SP said, “I don’t think you’re trying at all.” P1 thought the incident lasted approximately ten minutes. · Although P2 was not in the facility, P2 stated that s/he heard the SP “screaming” at the VA from the phone when P1 called him/her at a volume of a “seven or eight.” P2 stated that s/he could not understand everything that was being said by the SP, but that P2 heard the SP tell the VA, “I told you to stay in your room,” and “You’re not allowed to come out yet.” P2 said that the call was only approximately two minutes long, and P2 told P1 to call P2 right away if that happened again. The C stated that on the night of the incident, the SP prevented the VA from washing his/her clothes on the lower level. The SP told the VA to go into his/her bedroom and “not come out.” The C did not like the way that the SP treated the VA. The C said that s/he did not like what s/he saw and that the SP had “no right coming down” on the VA “like that,” and that the SP “overstepped.” The SP and the SP’s shift note from January 3, 2026, provided the following information: · The SP arrived at the facility at about 3 p.m. and learned that the VA’s morning had been “rough.” The VA “seemed fine” to the SP and at around 6:30 or 7 p.m., the VA took a phone call and then the VA seemed “triggered,” causing a “spike in behaviors.” The VA usually bathed after the other clients, but “self-initiated” a bath first. The SP asked the VA to wait to allow another client to bathe first and the VA said that P1 said s/he could bathe first. After talking to P1 and finding that the VA did not talk to P1 first, the SP stated that s/he entered the bathroom “mid-bath” and told the VA that it was not okay to “lie” about things because it made staff persons “not trust” the VA. · The SP’s progress notes stated the following: o The SP waited until the VA was finished bathing prior to talking to the VA about “lying” to which the VA responded, “It was an accident.” The progress notes indicted that the SP then told the VA, “A lie is usually deliberate.” o Next, the VA “attempted to ignore” the SP and began to take laundry downstairs. The SP asked the VA to stay upstairs and to “calm down” in his/her bedroom. The VA kept leaving his/her bedroom and the SP “kept asking” the VA to stay in his/her bedroom. The VA asked for his/her tablet and the SP said that s/he could have the tablet after s/he stayed in his/her bedroom so s/he would not be “distracted” by it “considering [his/her] choice of lying behavior.” The VA then became “increasingly defiant.” · The SP told the VA, “Why don’t you go sit in your [bed]room for a little bit and think about lying and shift gears?” The SP stated this was “common practice.” The SP did not say how long the VA had to stay in his/her room · The VA still wanted his/her tablet and the SP told this investigator that s/he should have just let the VA have the tablet but that the SP wanted the VA to “think about” things and “stay on track.” The progress notes stated that the SP was near the counter next to the tablet. The VA “pushed” and attempted to get past the SP to get the tablet, pushing “into” the SP several times. The SP then stepped into the VA’s “path to block” the VA. The SP stated that s/he used a “basketball” stance with his/her arms outstretched to “block” the VA from getting the tablet. The progress notes stated that the VA grabbed the tablet and went to his/her bedroom. The SP told this investigator that s/he held the tablet under his/her underarm when the VA grabbed it from the SP. · The progress notes stated that the VA later came out of his/her bedroom with the tablet and the SP asked the VA to sit down at the table, without playing a game on his/her tablet, and to think about what it meant “to tell lies.” The SP told this investigator that when the VA got the tablet from the SP, the SP gave the VA a choice of going to his/her room to “calm down” or to sit at the table, but that the SP did not want the VA to use his/her tablet so the VA could “think” about his/her choices. The VA sat at the table, asked to get up from the table, and the SP told the VA, “No.” The SP denied seeing the VA cry. When the VA stood up to leave the table a couple of times, and opened his/her tablet, the SP reminded the VA that s/he had been asked to sit quietly at the table for a few minutes to think about “lying” and that the VA chose his/her “behavior.” The SP reminded the VA that it was “not okay” to tell “lies.” · In the interview with this investigator, the SP could not recall if s/he asked the VA or told the VA to go to his/her bedroom but stated that s/he may have “gotten to the point” where s/he told the VA to “go” to his/her bedroom. The SP told the VA to go to his/her room two or three times because s/he kept coming out. The SP could not recall if s/he prevented the VA from doing laundry but stated that if s/he prevented him/her from doing it, it would have been because the SP wanted the VA to “focus.” · The SP denied “screaming” at the VA and stated that s/he was speaking loud and firm with a volume of a “six” on a scale of one being a whisper and ten being screaming as loud as possible. The SP stated that s/he was “worn down” from the VA, and that the evening of the incident was not his/her “best night.” The SP tried not to “single out” the VA. The Facility’s Internal Review stated that the SP was trying to “moderate” the VA’s behaviors related to “lying” and that the SP stated that not “lying” would be a goal that was “mixed in” to the VA’s plans. The SP admitted to telling the VA to go to his/her bedroom, and that the VA’s continued exits from the bedroom were related to the VA’s “defiance” and “pushing limits.” The SP denied telling the VA that s/he could not go to church for lying and went on to say that if “anything was said,” it was “in the heat of the moment.” According to the SP, while the SP was not trained to tell the VA to go to his/her bedroom, it was “common practice” among staff persons. P3 provided the following information: · P3 was out of town when the incident occurred and was not informed of the incident until January 7, 2026. P3 heard about the incident from P2, and the information P3 provided was consistent with what P2 told this investigator. P3 talked to the C about the incident and the C said that it was “really bad.” · The SP was not always a “team player” and tended to “boss around” staff persons. · The VA tended to talk “in circles” but could provide information, but s/he would not always provide a “straight answer” if s/he was uncomfortable. P4 provided information consistent with P2 and added the following information: · P4 arrived at the facility on January 7, 2026, and found a note left by P1. The note described the incident between the VA and the SP. · P4 and P3 talked to the VA about the incident in “vague” terms and the VA said s/he made the SP “upset” and should “probably apologize” for being “bad.” The VA said that the SP made the VA feel “not good,” and said s/he went into his/her bedroom when the SP said to and cried into his/her pillow. · P4 and P3 then spoke with the C, who provided limited information and “shut down.” According to the C, s/he liked the SP but the VA got on the SP’s “nerves.” · Staff persons were trained to be patient with clients, including the VA, and to redirect the VA into doing an activity, like a puzzle. Staff persons were expected to work on how they talked to clients and try to work on ways to prevent behavior escalation. P5 provided the following information: · P5 knew of the incident and knew that P1 called P2 so P2 could hear the VA and the SP “getting into it.” · The SP was “hyper-focused” on the VA and would “almost terrorize” the VA. The VA typically would not “stand” for that, so the VA’s behaviors would “escalate” with the SP and the two would “butt heads.” Sometimes the SP would talk to the VA when s/he returned from day program to help the VA with solutions to some frustrations, but then sometimes the SP would be “straight up rude” to the VA. The SP would get into a “power struggle” with the VA and VA tended to have “behaviors” when s/he was “overstimulated.” · Sometimes the VA would get “repetitive,” but staff persons were trained to get to the “root problem” of what was bothering the VA, and s/he would calm. The VA did not always remember things, but some things “stuck” with the VA long-term. G1 stated that s/he was informed of the incident by P4 but did not provide details about it to this investigator. G1 stated that the VA needed “consistency,” and that over the last few months, there was a change with a staff person leaving that affected the VA negatively. The VA had also suffered a personal loss in recent years and had since been “a little different.” The VA sometimes did things for “attention” and had learned to repeat the same questions “over and over” to “get what [s/he] want[ed].” G2 stated that the VA called G2 several times per week and would repeat the same questions to G2. G2 said that the VA had a “pretty good understanding” of what was going on around him/her and looked forward to church weekly. During the investigation, P5 and progress notes written by P5 provided information regarding an incident on December 24, 2025. P5 was in the lower level of the facility and heard a “yelling argument” between the SP and the VA. P5 did not know what the yelling was about, but the SP’s voice was a “ten” on a scale of one to ten, with one being a whisper and ten being screaming at the top of his/her lungs. The VA asked for butter and was looking in the refrigerator when P5 arrived upstairs. P5 saw the SP closing the refrigerator door while the VA was still “semi in the fridge,” and the SP and the VA ended up in a “back and forth pushing” match with the refrigerator door, two to three times. P5 documented that s/he stepped in the middle of them, told the VA to sit down, and said s/he would make the VA food. The VA was not hurt during the incident. P5 told the SP that it was “uncalled for,” and that the SP “needed to step back and calm down.” The shift note written by the SP on this date did not include the refrigerator incident. When asked by this investigator, the SP denied “yelling” at the VA and denied “pushing” the refrigerator door “back and forth” with the VA. The SP stated that s/he may have put his/her hand on the top of the refrigerator door to prevent the VA from pushing it into the SP, but that s/he did not push it back on the door. The SP stated that s/he said, “Noooo,” to the VA at a five or six on a scale of one to ten with one being a whisper and ten being screaming at the top of his/her lungs so that s/he would not go into the refrigerator because s/he had either already eaten or was going for bread next to the refrigerator that the VA should not eat. All staff persons interviewed for this investigation were trained on the Reporting of Maltreatment of Vulnerable Adults Act and the VA’s plans. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), states in part that a person’s protection-related rights include the right to be treated with courtesy and respect. Minnesota Statues, section 245D.06, subdivision 5, stated that the license holder is prohibited from using time out or any other aversive or deprivation procedure for behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience. Conclusion: According to P1, at about 6:30 p.m., on the evening of January 3, 2026, P1 was in the lower level and heard something fall upstairs. After going upstairs, the SP told P1 that the VA was “being defiant” and the SP and VA verbally went “back and forth.” The SP then told the VA to go to his/her bedroom. The VA went to his/her bedroom but left his/her bedroom two to four times and each time, the SP “blocked” the VA by standing in the hallway. The SP did not touch the VA, but each time told the VA to go back to his/her bedroom. The VA then exited his/her bedroom another time with a laundry basket. The SP “jumped at” the gate and “took a big leap” to “block” the VA from going downstairs to do laundry, but did not touch the VA. At or around 6:45 p.m., P1 called P2 and sent a text to P2 telling him/her to listen over the phone to the interaction between the VA and the SP. P1 was unsure exactly what part of the incident was occurring while the phone call was ongoing, but the SP again told the VA to go back to his/her bedroom. The VA put down the laundry basket in the hallway and returned to his/her bedroom. The VA came out of his/her bedroom again, and the SP told the VA to sit in the chair at the dining table. While the VA was sitting at the table, the SP told the VA s/he was “being defiant and lying to staff [persons].” The VA stated that s/he was “trying,” and the SP replied, “I don’t think you’re trying at all.” The SP then left to assist with another client and P1 told the VA that s/he did not have to sit at the table, that s/he could get water, and that s/he could go do laundry. When P1 called P2, P2 listened and described the SP as “screaming” at the VA at a volume of a “seven or eight” and telling the VA, “I told you to stay in your room,” and, “You’re not allowed to come out yet.” P1 stated that the SP was not “screaming” but used a volume of a “seven” and a “raised tone” which was “sharp” toward the VA. According to the SP, the VA was “lying” to the SP and P1 and the VA told the SP that lying “was an accident” to which the SP replied, “A lie is usually deliberate.” According to the SP, the VA “attempted to ignore” the SP and began to bring his/her laundry to the stairs, however the SP could not recall if s/he prevented the VA from doing laundry, but stated that if s/he had, it would have been to get the VA to “focus.” The SP asked the VA to stay upstairs and “calm down” in his/her bedroom. The VA repeatedly came out of the bedroom and the SP repeatedly “kept asking” the VA to stay in his/her bedroom. The VA then wanted his/her tablet and “pushed” past the SP and the SP stepped into the VA’s path to “block the VA” from getting his/her tablet. The Internal Review showed that the SP said that the VA’s continued exits from the room were related to the VA’s “defiance” and “pushing limits.” The SP denied telling the VA that s/he could not go to church for lying and went on to say that if “anything was said,” it was “in the heat of the moment.” According to the SP, the VA later exited his/her bedroom with the tablet, and the SP asked the VA to sit down at the table without using his/her tablet to think about what it meant “to tell lies.” When the VA attempted to get up, the SP reminded the VA that s/he had been asked to sit and think about “lying” and choosing his/her “behavior.” The SP denied seeing the VA crying and denied “screaming” at the VA, instead describing his/her volume as a “six.” The SP denied attempting to “single out” the VA. The SP engaged in a power struggle with the VA and engaged in behavior including raising his/her voice, telling the VA repeatedly to go to his/her bedroom, telling the VA to sit at the table to think about his/her actions, attempting to keep the VA’s tablet from him/her, and telling the VA that s/he could not do laundry and could not go to church. The SP’s behavior was inconsistent with the standards of a professional caregiver in a facility licensed by the Department of Humas Services and were in violation of Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), and Minnesota Statues, section 245D.06, subdivision 5. However, given that there was no information that the SP had similar past incidents, there was not a preponderance of the evidence whether the SP’s conduct was repeated or rose to the level of emotional abuse. It was not determined whether 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). Action Taken by Facility: The facility completed an internal review and determined that the policies and procedures were adequate but not followed. There was a need for additional staff training, and corrective action by the facility. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The facility was not issued a Correction Order for the violations outlined in this report because they took immediate corrective action.
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