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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: 1071024-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Jason Pehler/Alice Percy Minnesota Department of Human Services 651.431.4830 Suspected Maltreatment Reported: It was reported that a supervisory staff person (SP) was “aggressive” with four vulnerable adults (VA1, VA2, VA3, and VA4), yelled at them, swore at them, and slammed items down while yelling. The SP “punished” the VAs by taking away outings and other things the VAs looked forward to. Date of Incident(s): Ongoing, prior to November 25, 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); and subdivision 17, paragraph (a): 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. 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 December 16, 2025; from documentation at the facility; and through thirteen interviews conducted with three facility staff persons (P1, P2, and P3), a supervisory staff person (P4), the SP, VA1, VA2, VA3, VA4, VA1’s guardian (G1), VA2’s guardian (G2), VA3’s guardian (G3), and VA4’s guardian (G4). NOTE: Although the initial report included VA3 and VA4, information provided during the investigation showed no concerns about the SP’s interactions with either. VA1 enjoyed going to church, going out to eat, working on art projects, shopping, fishing, bowling, playing bingo, and spending time with his/her family members and friends. VA1’s diagnoses included mild intellectual disability, dementia, Alzheimer’s disease, anxiety, and a benign brain tumor. VA1’s ISSA Assessment Detail stated that due to his/her diagnoses, VA1 might be forgetful at times and ask the same questions repeatedly. VA1 might get upset if the other clients did not want to be around him/her. VA1’s Risk Assessment Detail stated that VA1 was not a reliable reporter and may not report abuse. VA1 might engage in attention seeking behavior. VA1’s Action Plan stated that VA1 was very sensitive to non-verbal cues and noticed when the staff persons were inattentive. If the staff persons were distracted, VA1 might have challenging behaviors. VA1 sometimes told others that s/he was not taken care of or that s/he had fallen even when that did not occur. VA2 enjoyed going out to eat, shopping, watching videos, working on craft projects, and spending time with his/her family members and friends. VA2’s diagnoses included bipolar disorder, depression, anxiety, hypothyroidism, and classical phenylketonuria. VA2 attended a day program five days a week. VA2’s Risk Assessment Detail stated that VA2 might not defend him/herself against abuse and might not recognize that s/he was being abused. VA3 enjoyed watching television, bowling, listening to music, shopping, going out to eat, painting, and spending time with his/her friends and family members. VA3 was diagnosed with dementia. VA3’s Risk Assessment Detail stated that VA3 might not be able to remember specific details about events or be able to report them accurately. VA4 enjoyed bowling, going to movies, camping, shopping, going out to eat, and spending time with his/her family members and friends. VA4’s diagnoses included moderate intellectual disability, disruptive mood dysregulation disorder, and reactive attachment disorder. VA4’s Risk Assessment Detail stated that VA4 might not recognize that s/he was being verbally or emotionally abused and might not defend him/herself. VA4 might not know who to report abuse to. VA1 stated that s/he did not get along well with the SP. The SP yelled when s/he talked to VA1 and swore at VA1, but VA1 did not recall the words the SP used. On one occasion, the SP told VA1 that s/he could not go to the candy store because VA1 did not put his/her seat belt on, so VA1 stayed at the facility. The SP sometimes told VA1 to sit in the back seat of the van because VA1 “was talking too much.” VA1 stated that it made VA1 “kind of sad,” but it was VA1’s “fault” because s/he was talking. VA2 stated that the SP was “real nice” and VA2 got along with him/her, but on one occasion, the SP became “real frustrated” with VA2 and wanted to leave. The SP did not yell, but s/he spoke loudly. Sometimes the SP raised his/her voice when speaking to VA1. Sometimes VA2 was not allowed to go on outings, but “that was nothing” and VA2 stayed home and “that’s it.” VA3 stated that the SP never said anything that made VA3 sad or angry and VA3 felt safe living at the facility. VA4 stated that VA1 told him/her that the SP yelled at VA1, but VA4 was at work at the time. On one occasion, the SP told VA4 that if s/he did not clean his/her room, s/he would not be able to go on a community outing, but VA4 cleaned his/her room. P1 provided the following information: · P1 stated that s/he frequently worked with the SP. The SP “would kind of yell” at the VAs on a daily basis and would sometimes say, “Fuck you,” to the VAs. P1 described the yelling as “almost screaming.” On several occasions, the SP punctuated his/her words with slamming his/her hand on the table after every word. The VAs “didn’t want to say anything” after the SP yelled, but P1 did not see the VAs cry or appear upset. · P1 did not hear the SP call any of the VAs derogatory names and did not see the SP throw anything at the VAs. Most of the SP’s comments were directed toward VA1 and, to a lesser degree, VA2. · P1 stated that on one July 4th, VA2 was not allowed to go watch the fireworks because s/he took extra coffee that day. On another occasion, VA1 was not allowed to go to the candy store. P1 did not recall why VA1 was not allowed to go on the outing. The SP did not allow VA2 to bring any money to the candy store so VA2 was unable to purchase candy. P1 believed the reason given for VA2 not bringing any money was because s/he took soda belonging to one of the other VAs. P2 provided the following information: · The “main things” P2 noticed about the SP’s interactions with the VAs were yelling and “kind of being aggressive” toward the VAs, especially VA1, on multiple occasions. The SP became frustrated with VA1 because VA1 repeatedly asked questions. P2 saw VA1 “make a very shocked face and kind of go quiet” after the SP yelled at him/her, but P2 never saw VA1 cry after the SP yelled at him/her. Although the SP had a normally loud voice, it would “definitely be amplified and directed” towards the VA s/he was most upset with. · When the SP became frustrated with the VAs, s/he yelled and did not allow them to participate in events. On some occasions, the SP told VA1 that s/he had to remain at the facility when the other VAs went on a community outing. On other occasions, if VA2 took food or drinks from another VA, the SP told him/her that s/he could not go on a community outing. P3 stated that on one occasion, VA1 was eating a meal and making numerous requests about his/her food and the SP “kind of just lost it” and “got in [VA1’s] face” and yelled. VA1 “just kind of sat there,” but the SP’s actions made P3 “uncomfortable.” When VA2 took off his/her glasses, the SP “raised [his/her] voice to the point where it was unnecessary.” P3 never saw the SP throw items and did not see any of the VAs cry when the SP yelled at them. On one occasion, VA1 told P3 that s/he was not allowed to go on a community outing to a store because s/he did not eat food s/he was served. P4 stated that s/he talked to the VAs about the SP’s interactions with them. VA1 and VA2 told P4 that the SP “would get on them,” but did not provide additional information. Although the SP had a loud voice, P4 never saw the SP yell at the VAs, call the VAs names, swear, or make derogatory comments to the VAs. P4 believed that the SP was “rough around the edges,” but was not trying to be “mean” to the VAs. The SP provided the following information: · The SP tried to keep VA1 safe and healthy, but it was “challenging” because VA1 did not want to eat and when s/he did eat s/he continually talked, which created a choking hazard. VA1 also talked constantly when the staff persons drove him/her in the facility van, which was a safety concern. The staff persons tried different techniques for working with VA1, including having a behaviors team work with VA1 and the staff persons on a weekly basis, but they were not successful. The SP told P4 that the facility was not a “good fit” for VA1. · VA2 had a complicated diet due to his/her health concerns and the staff persons had to “have eyes on” him/her all the time because VA2 would take food or drinks that were not allowed on his/her diet. VA2 had a fairly restrictive diet because of his/her health issues and not following the diet had a negative impact on VA2’s health. VA2 frequently took off his/her glasses even though wearing them helped control his/her hallucinations and headaches. When VA2 took off his/her glasses, the SP reminded VA2 to put them on. · The SP was a “loud” person and believed that his/her voice could sound like s/he was “yelling” even though that was his/her normal tone of voice. The SP believed that s/he did not “do a good job” of telling the other staff persons why s/he told the VAs to do things like watch their diet or wear their glasses. · G2 requested that VA2 have “consequences” for “stealing” food from the other VAs that was not allowed on his/her diet, so there were occasions when VA2 did not go out to eat with the other VAs because of his/her behaviors. At times, some of the VAs did not go on a community outing because they were at their day programs. The SP stated that s/he did not “punish” the VAs by excluding them from community outings. · None of the staff persons raised concerns with the SP about his/her interactions with the VAs. The SP never called the VAs names or made derogatory comments to them. The SP did not swear at the VAs. At times, when the SP set something in front of VA1, VA1 asked the SP why s/he threw the item at VA1 even though the SP did not throw it. G1 stated that VA1’s memory issues were increasing and s/he sometimes had false memories that s/he would later say did not occur. G2 stated that VA2 had a very specialized diet and the SP made changes to VA2’s diet that were beneficial to VA2. VA2 was able to choose foods s/he wanted to eat and the SP ensured that they fit into his/her diet. VA2 was “close” to the SP. G3 stated that the SP “went above and beyond” when working with VA3. The SP was a “loud person” and G3 got used to that. The SP held the other staff persons responsible for doing their jobs, which might have “rubbed them the wrong way.” The SP saw VA3’s physical decline and was able to work with it. G4 stated that VA4 did not like to say anything to hurt anyone’s feelings. VA4 was an accurate reporter of events. The facility’s Recipient Rights policy stated that the clients had the right to be treated with courtesy and respect and to engage in their choses activities. Facility documentation showed that the SP, P1, P2, P3, and P4 each received training on the Reporting of Maltreatment of Vulnerable Adult Act, on the facility’s policies, and on the VAs’ plans prior to the incidents. Conclusion: Regarding the SP yelling and swearing at the VAs: Consistent information was provided that the SP had a loud voice. P1 stated that the SP would “kind of yell” at the VAs and on several occasions slammed his/her hand on the table, but P1 never saw the SP throw things or call the VAs names. P2 stated that the SP had a normally loud voice which would “definitely be amplified and directed” towards the VA s/he was most upset with. On one occasion, P3 saw the SP yell at VA1 and on another occasion, the SP yelled at VA2. P4 stated that s/he never saw the SP yell at the VAs. None of the staff persons provided additional information about the incidents. The SP stated that s/he was a “loud” person and believed that his/her voice could sound like s/he was yelling even though that was his/her normal tone of voice. The SP never threw anything at the VAs or swore at them. The SP believed that s/he did not “do a good job” of telling the other staff persons why s/he told the VAs to do things like watch their diet or wear their glasses. Although information was provided that the SP yelled at the VAs, given that consistent information was provided that the SP had a loud voice; that the staff persons did not provide additional details about the incidents; that the VAs provided inconsistent information about the SP yelling; and that the SP denied the allegations, there was not a preponderance of the evidence whether the SP used repeated oral language toward the VAs that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening and could reasonably be expected to produce emotional distress to the VAs. 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). Regarding the SP “punishing” the VAs by taking away outings and other things the VAs looked forward to: P1 stated that on one occasion, VA1 was not allowed to go to a candy store and VA2 was not allowed to take money to the candy store. P2 stated that on some occasions, the SP told VA1 and VA2 they could not go on community outings. P3 stated that on one occasion VA1 told P3 that s/he was not allowed to go on a community outing. The SP stated that VA2 had a fairly restrictive diet because of his/her health issues and not following the diet had a negative impact on VA2’s health. The SP worked with G2 to ensure that VA2 did not eat foods that were unhealthy. G2 also requested that VA2 have “consequences” for “stealing” food that was not allowed on his/her diet, so there were occasions when VA2 did not go out to eat with the other VAs because of his/her behaviors. At times, some of the VAs did not go on a community outing because they were at their day programs. The SP stated that s/he did not “punish” the VAs by excluding them from community outings. While it was reported that the SP punished the VAs by taking away community outings, given that limited details were provided about when the incidents occurred and what the impact was on the VAs and that the SP stated that there were dietary reasons as well as scheduling issues that kept some VAs from joining in on community outings, there was not a preponderance of the evidence whether there was a failure to supply the VAs with care or services which were reasonable and necessary to maintain the VAs’ physical or mental health or safety. It was not determined whether neglect occurred (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). 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 staff persons. After the incident, the staff persons were trained on the facility’s policies. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: No further action taken.
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