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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: 1070367-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Anna Parkin Suspected Maltreatment Reported: It was reported that there were multiple concerns regarding a staff person’s (SP) interactions with two vulnerable adults (VA1 and VA2). Date of Incident(s): unknown prior to December 8, 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): 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 8, 2026; from documentation at the facility; and through nine interviews conducted with a supervisory staff person (P1), six facility staff persons (P2-P6 and the SP), VA1’s guardian (G), and VA1’s case manager (CM). This investigator met VA1 but VA1 did not provide information because of his/her limited verbal communication. During the course of the investigation, VA2 passed away for reasons unrelated to this report. Attempts were made to contact and interview VA2’s guardian and case manager, but neither responded. The initial allegation included concerns that when VA1 requested his/her over the counter cold medication, the SP refused to give it to VA1 and P6 did not intervene. There was no information provided in documentation or interviews to corroborate this information so this will not included in this report. Information was also provided that there was a concern with P6’s interaction with VA1 on one occasion. Given that it was a single incident and there was no information provided that any staff persons had any other concerns regarding P6’s interactions with clients, P6’s actions did not meet the definition of emotional abuse so this will also not be included in this report. Facility documentation showed that all staff persons interviewed for this investigation were trained on VA1’s and VA2’s plans and the Reporting of Maltreatment of Vulnerable Adults Act prior to the incident. Regarding VA1: VA1 was diagnosed with a moderate developmental disability. According to VA1’s Individual Abuse Prevention Plan, VA1 may not respond to verbal aggression by leaving the area or getting help. Staff persons were to intervene “immediately” and removed VA1 from the situation. The G and P6 each stated on November 22, 2025, at approximately 1 p.m., the G arrived at the facility. VA1 walked up to the G and said that the SP was “mad” at VA1. Right after, the SP walked over and said, “Oh? What’d I do now to get in trouble for?” VA1 “hugged” the G, buried his/her face in the G’s chest, and did not say anything and each thought VA1 was “scared.” Shortly after, when the SP walked past VA1, VA1 put his/her head down again and looked “afraid.” P6 said the SP’s tone was not the correct tone of voice and was not something to say to clients. When the SP was “crabby” s/he affected the facility environment. Neither the G nor P6 had any prior concerns regarding the SP’s interactions with VA1. P2 stated on December 6, 2025, VA1 asked P2 for cold medication and appeared “visibly frightened” because VA1’s body was “tense” and s/he “cried.” VA1 told P2 that earlier that day, s/he requested his/her cold medication and the SP was “mad” for VA1 so VA1 was afraid to request it again. P2 did not have any prior concerns regarding the SP’s interactions with VA1. P3 stated on one occasion, VA1 told P3 that the SP “did not like” VA1 and that the SP was “mad” and yelled at VA1. VA1 had a history of not always providing accurate information but P3 noticed VA1’s nonverbal cues such as staying in his/her bedroom when the SP worked. On at least four other occasions, P3 heard the SP swear and use “dirty language” around the clients, but P3 did not have any prior concerns regarding the SP’s interactions with VA1. P5 stated that on previous occasions, the SP spoke to VA1 with more authority than s/he needed to. The SP was not negative and did not yell at VA1. P5 spoke to the SP about it and P5 did not have concerns afterwards. P2, P3, and P4 each stated that on several previous occasions, each told P1 about their concerns with the SP’s interactions with the clients. P1 stated s/he did not have any concerns with SP1’s interactions with VA1 and denied being aware of concerns with the SP’s interactions with VA1. The SP denied being mad at VA1, denied yelling and swearing around VA1, and denied VA1 being upset with the SP. The SP did not remember the above incidents. Regarding VA2: VA2 was diagnosed with a mild developmental disability and had limited verbal communications. According to VA2’s Support Plan Addendum, staff persons cooked food that was gluten free for VA2 and staff person were to stay within the doctor’s ordered fluid limit and diet. P2-P6 provided the following information: · P2 stated that on approximately December 7, 2025, while the SP, P2, and VA2 were getting ready for breakfast, the SP asked VA2 what s/he wanted to eat for breakfast and VA2 responded that s/he wanted pancakes. VA2 “loved” pancakes and would eat them daily if allowed. P2 stated that the SP stood over VA2’s wheelchair, crossed his/her arms while his/her face turned red, and in a loud voice told VA2 that s/he was not allowed pancakes since VA2 ate them for breakfast the day prior. VA2 put his/her head down and said, “Oh.” · The SP continued to stand in front of VA2 and told VA2 to “knock it off.” VA2 put his/her head down. The SP then asked if VA2 wanted oatmeal and VA2 appeared “fearful and discouraged” with his/her head down but did not respond. The SP repeated asking the question in a “snarkier impatient tone” when VA2 began responding but the SP walked away and began making oatmeal before VA2 was able to finish speaking. VA2 then “quietly” said, “Okay.” The SP documented in VA2’s notes that s/he requested oatmeal for breakfast even though it was not accurate. P4 also had concerns with the SP not allowing VA2 pancakes for breakfast. · VA2 was not given choices and “intimidated” by the SP on a daily basis. P2-P6 did not have any additional details regarding the SP’s actions on a daily basis. VA2 became withdrawn from interactions, reduced his/her self-advocation, and increased his/her behavioral issues. VA1 and VA2 had an increase in behaviors when interacting with the SP, including slamming bedroom doors when frustrated because they were limited on decisions. VA1 and VA2 did not have an increase in behaviors when interacting with staff persons who spoke to them appropriately and allowed them choices. · P5 and P6 heard about the incident and were trained that staff persons offered VA2 options for breakfast but they did not refuse to give VA2 an item if s/he requested it. P1 did not have any concerns with the SP’s interactions with VA2. The SP stated that s/he was trained that VA2 was limited on his/her carbohydrates intake so on one occasion, s/he told VA2 that s/he was not allowed to eat pancakes because s/he had them the day prior [Note: there was no documentation of limiting VA2’s carbohydrates in VA2’s documents]. The SP denied yelling and was not angry with VA2. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a), clause (6), stated that a client’s protection-related right included being treated with courtesy and respect. Conclusion: Regarding VA1: The G and P6 each stated on November 22, 2025, at approximately 1 p.m., the G arrived at the facility. VA1 walked up to the G and said that the SP was “mad” at VA1. Right after, the SP walked over and said, “Oh? What’d I do now to get in trouble for?” VA1 buried his/her face in the G’s chest and was “scared.” On multiple occasions, VA1 told P2 and P3 that the SP was “mad” for VA1 and yelled at VA1. Although information provided showed that VA1 might have “visibly frightened” and/or “scared” around the SP, given that there were minimal details regarding the SP’s interactions with VA1; that there were no prior concerns regarding the SP’s interactions with VA1; and that the SP denied being mad at VA1, denied yelling and swearing around VA1, there was not a preponderance of the evidence whether all of the SP’s action were therapeutic conduct or whether the SP’s engaged in repeated oral language toward VA1 that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 VA2: On approximately December 7, 2025, P2 stated that the SP asked VA2 what s/he wanted to eat for breakfast and VA2 responded that s/he wanted pancakes. P2 stated that the SP stood over VA2’s wheelchair, crossed his/her arms while his/her face turned red, and in a loud voice told VA2 that s/he was not allowed pancakes since VA2 ate them for breakfast the day prior. The SP then asked if VA2 wanted oatmeal and VA2 appeared “fearful and discouraged” with his/her head down but did not respond. The SP’s actions were a violation of Minnesota Statutes, section 245D.04, paragraph (a), clause (6). However, given that it was a single incident and there were no prior concerns regarding the SP’s interactions with VA2, there was not a preponderance of the evidence whether all of the SP’s actions therapeutic conduct or whether the SP engaged in repeated oral language toward VA2 that would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening. 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 policies and procedure were adequate and followed. Although the facility did not feel additional training was necessary, discussions were had regarding improving person-centered services. Action Taken by Department of Human Services, Office of Inspector General: On March 11, 2026, the facility was issued a correction order for the violation outlined in this report.
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