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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: 1079435-H_CRS (Home and Community-Based Services-Community Residential Setting) 1068807-HCBS (Home and Community-Based Services) Investigator(s): Samantha Wueste 651-431-2278 Samantha.wueste@state.mn.us Suspected Maltreatment Reported: It was reported that there were concerns regarding a staff person (SP) that included: · The SP did not adequately supervise a vulnerable adult (VA) during community outings and during one incident, the VA stole and ingested food items that were not safe for the VA to eat; and · That the SP used derogatory language when interacting with the VA on multiple occasions that included calling the VA a “little shit” and a “fucking retard” (referred to the “R word” throughout the remainder of this report). Alleged Licensing Violation: It was reported that the SP did not allow the VA to attend a scheduled extracurricular activity the following day as a “consequence” to the VA’s behaviors during the incident outlined above. Date of Incident(s): Ongoing prior to October 12, 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 for this investigation was obtained from a site visit on October 21, 2025; from documentation at the facility; and through eight interviews conducted with the VA, the SP, two supervisory staff persons (P1 and P2), an administrative staff person (P3), the VA’s case manager (CM), and the VA’s guardians (G1 and G2) who were also the VA’s family members. Subsequent phone calls were made to G1, P2, and P3 to obtain documentation each stated that had regarding this incident and other incidents. However, the documentation was not provided by the completion of this investigation. Attempts were also made by phone to contact and interview two additional staff persons (P4 and P5), but did not respond to the requests. The VA was diagnosed with Prader-Willi syndrome (PWS) and anxiety. The VA enjoyed community outings, spending time with his/her family members, completing art and craft projects, watching movies, and going on walks. On August 2, 2022, the VA moved into the facility seeking supports and services that included health/behavior management, medication administration, meal preparation, community integration, supervision, transportation, and assistance with activities of daily living. According to https://www.mayoclinic.org, PWS was a “rare” and “complex” genetic disorder that caused a person to have/develop associated health conditions including anxiety accommodated by “skin picking,” obsessive-compulsive and/or repetitive behaviors, mild to moderate intellectual disability, low muscle mass, a heightened tolerance to pain, and hyperphagia (a feeling of extreme, insatiable hunger). Additionally, PWS caused a person to “crave” food “all the time” because s/he “never felt full” resulting in “unusual food-seeking” behaviors, overeating, obesity, and gastrointestinal complications that could become life-threatening if not adequately managed by caregivers and with a strict diet and exercise plan. The facility was located in a residential area and occupied one side of a rambler duplex with the other side being another program operated by the same license holder. The license holder provided each program with its own staffing and the staff/clients from each program did not interact with one another. The VA lived alone at the facility and occupied the main level which had a living room, a kitchen, the VA’s bedroom, a bathroom, a staff office, and access to an attached garage. Due to the VA’s health conditions and history of maladaptive behaviors, the facility the VA had a rights restriction for home modifications to maintain the health/safety of the VA which included installing an alarm system with sensors placed on “all” of the facility’s exterior doors and windows, a lock on a refrigerator located in the kitchen to secure refrigerated food items, and an automatic lock on the staff office where “all” non-refrigerated food items, medications, and “sharp” or “hazardous” items were stored/secured and only accessible by staff persons. The facility’s Program Abuse Prevention Plan and the VA’s Support Plan Addendum (CSSPA), Individual Abuse Prevention Plan (IAPP), and Self-Management Assessment provided the following information: · Due to the VA’s history of health complications and medical procedures that resulted from his/her PWS diagnosis, the VA was prescribed a soft diet that consisted of 1,100 calories per day and at least 60 minutes of walking. However, the VA also had a history of trying to access and consume food items that did not maintain his/her prescribed diet which was dangerous and potentially fatal to the VA so the rights restriction was implemented to address this. Additionally, staff persons were to transport the VA to a local emergency room if the VA “complained that [his/her] stomach hurt” and “immediately” notify G1. · The VA had 1:1 staffing 24 hours a day and no unsupervised time in the facility or the community. The VA was “very independent” and had “a lot of freedom of choice” when participating in and completing daily living and community activities. The VA had daily access to the community and a supervisory staff person was to assist the VA in “setting up” a monthly calendar with activities and appointments that staff persons then transported and accompanied the VA to. While in the community, staff persons were to remain “in proximity” and within “eyesight” of the VA at “all times.” During times when the VA was present at the facility, staff persons were to “always” remain within “visual range” of the VA and complete routine checks of the VA and of the home to ensure that the VA did not access and/or “hide” food items. · The VA had a history of self-injurious behaviors, emotional dysregulation, verbal aggression, physical aggression, leaving the facility without staff knowledge/supervision, “resisting” care/support when “upset,” calling 9-1-1 for non-emergency situations, and taking items from stores or from others that did not belong to him/her. The VA also “frequently argued about small things,” “threw tantrums,” and became “anxious” during times when the VA “felt” that others were “mad” at him/her. · The VA’s health and behaviors were managed with positive support strategies, mental health services, and daily medications. Staff persons were to provide the VA with a “structured” and “calm” environment, “consistent” routines, adequate time to process information, and opportunities to be involved in planning his/her daily activities. Staff persons were to help the VA develop/acquire the skills needed for regulating his/her emotions and maladaptive behaviors by staff persons “modeling” appropriate behaviors, redirecting escalated situations involving the VA into “teachable moments,” and using person-centered approaches when interacting with the VA. · During situations when the VA was “upset” or “anxious,” staff persons were to remain “calm,” “avoid power struggles” with the VA, and provide “reassurance” to the VA that staff persons were not “mad” at him/her. Additionally, staff persons were to “allow” the VA the time and space that the VA needed to “cool down” while maintaining visual supervision of the VA and “closely” monitoring the situation so that staff persons could “intervene” if the VA’s behaviors or situation became “unsafe” to the VA/others. During situations when the VA was not able to “calm” and engaged in maladaptive behaviors, staff persons were to provide the VA with positive behavior supports including verbal prompts to use his/her coping strategies, “calming” activities, “reassurance,” “encouragement,” and verbal redirection to de-escalate the situation. · According to the VA’s IAPP, the VA was susceptible to abuse and victimization due to a lack of preservation skills, an inability to deal with verbally/physically aggressive persons, having inappropriate actions with others, and showing verbal/physical aggression towards others. G1 provided the following consistent information to this investigator, the CM, and P1-P3: · On October 11 and 12, 2025, the SP worked with the VA at the facility during the afternoon/evening shift two consecutive days. · On October 12, 2025, at an unknown time between 3 to 4 p.m., the VA called G1 from the facility because the VA was “upset” and becoming “increasingly anxious” that the SP refused to take the VA on his/her scheduled bowling activity that was to be that afternoon due to the VA’s behaviors from the day prior. At that time, G1 was not aware of any incidents/concerns involving the VA and asked the VA what happened so that G1 could “better” understand the situation and help the VA “fix the problem.” The VA then told G1 that at some point during the previous afternoon/evening, October 11, 2025, the SP took the VA to Walmart so the SP could do his/her personal shopping. When the SP finished shopping, the SP attempted to complete his/her purchase using the store’s self-checkout services but realized that s/he left his/her credit/debit card in the facility’s vehicle, so the SP left the VA in the store at the self-checkout area and went outside to the parking lot to get his/her card. During this time, the VA “grabbed” food items, including a candy bar, that were on the store shelves nearby and “hid” the items in his/her clothes. After the SP returned and completed his/her purchase, the SP and the VA left the store and drove to a nearby liquor store where the SP left the VA alone in the facility’s vehicle for an unknown amount of time while the SP entered the store to purchase items for his/her personal use. After this, the SP and the VA returned to the facility. The VA did not provide any additional information to G1 about these incidents. · The VA told G1 that this was why the SP was “mad” at the VA and would not take him/her to bowling. The VA also told G1 that the SP “swore” at the VA but the VA did not specify what words were used. G1 asked to talk to the SP and when the SP got on the phone, G1 asked the SP about the situation. The SP told G1 that s/he would not be taking the VA bowling because the day prior when with the SP, the VA “stole” food from the store and the VA needed “to pay the consequences.” G1 tried to resolve the situation over the phone and asked the SP to call P1, but the SP “brushed the situation off” and was “rude” and “argumentative” when speaking with G1. G1 stated that s/he “started to lose [his/her] cool” with the SP during the conversation but “never swore at [the SP].” · At approximately 5:30 p.m., G1 tried to contact P1 but P1 did not respond, so G1 called and talked to P2 about the situation. P2 told G1 that s/he would try to contact staff to see if another staff person could work the remainder of the SP’s shift. However, an additional staff person was not available until later that night so G1 helped the VA “talk through” his/her anxiety and the situation “over the phone” until approximately 8:30 p.m. Throughout the afternoon/evening while on the phone with the VA, the VA told G1 that the SP “taunted” the VA including calling the VA derogatory names but G1 could not hear what the SP was saying. G1 then asked the VA to tell him/her what “names” and the VA told G1 that the SP called the VA a “little shit” and a “fucking [R word].” The next morning, G1 emailed and notified P1-P3 about the incidents. · G1 said that the incidents on October 11 and 12, 2025, were similar to prior incidents with the SP. On September 2, 2025, around 10 p.m., the VA called G1 from the facility “screaming” and “crying” because the VA’s stomach “hurt.” The VA told G1 that the SP took the VA to Applebee’s earlier in the evening and that the VA consumed “a bunch” of food items while at the restaurant which were not safe for the VA to eat. G1 then talked to the SP and told the SP that the VA needed to “get to” an emergency room (ER) “right away” but the SP refused to “bring” the VA to the ER and told G1 that the VA was “just mad about something” and trying to “get out the door.” At 10:31 p.m., G1 text P4, who was scheduled to work the overnight shift at 11 p.m. and notified P4 about the situation. P4 told G1 that s/he was “already on [his/her] way” to the facility and s/he would take the VA to the ER. [Note: Information regarding what occurred at the ER was not requested but not provided.] G1 also said there was a prior incident when the SP “swore” at the VA but G1 did not recall what “specific language” was used by the SP or an approximate date/time when the incident occurred. · Due to the VA’s diagnosis of PWS, the VA had a history of medical complications including bowel obstructions that caused the VA to undergo five “major” surgeries, with the VA being in a state of critical condition and “almost didn’t make it” after the last two surgeries. Therefore, it was “so critical” that staff persons who worked with the VA were trained on the VA’s care plans and that the VA’s care plans were followed. Additionally, there was “frequent” and ongoing communication between G1 and the facility that included multiple “reminders” that staff persons were to maintain adequate supervision of the VA and were “not supposed to” complete personal errands while working with the VA due to prior incidents and concerns. · The VA was an accurate reporter of incidents and provided consistent and “detailed” information to G1 and/or to others. G1 stated that the “only” time the VA was “not truthful” was if the VA was asked to provide information about a person’s actions while the person was “right there . . . sitting in the same room.” The VA provided consistent information on different dates to this investigator, G1, G2, the CM, and P1-P3. Furthermore, the VA provided information that was consistent with the information provided by G1 and the following additional information: · On October 11, 2025, the SP worked with the VA at the facility during the afternoon/evening shift. At an unknown time, the SP and the VA went to Walmart so the SP could do his/her personal shopping. While at Walmart, the SP left the VA inside the store in the self-checkout area and went outside to the parking lot to get his/her credit card from the facility’s vehicle. The VA then “grabbed candy and chocolate” that were in the area and “hid” the items in his/her clothes. After the SP returned and completed his/her purchase, the SP and the VA left the store and drove to a nearby liquor store where the SP went inside the liquor store leaving the VA alone in the facility’s vehicle for an unknown amount of time. After this, the SP and the VA returned to the facility. The VA did not recall additional information about the incident or the remainder of the evening, including much candy s/he took from the store and became quiet when t asked if s/he ate any of the candy and/or how/when the SP became aware that the VA had taken the candy. · The next day, October 12, 2025, the SP worked the same shift with the VA. Shortly after the SP arrived, the SP told the VA that s/he would not take the VA to his/her scheduled bowling activity that afternoon because of the incident the day prior when the VA “stole candy” from the store. The SP also told the VA that the VA “kept stealing” and had similar behaviors without “any consequences” for his/her actions and the VA should not be “rewarded” for these behaviors. The VA then felt “anxious” and s/he thought that the SP was “mad” at him/her. The VA said s/he did not “like” when his/her schedule and/or routines were not followed and that caused the VA to “feel even more anxious” about the situation, so the VA asked the SP if s/he could call and talk to G1 and did so. The VA told G1 about the incidents and then G1 spoke to the SP who told G1 that the VA should be “in trouble” for having “bad” behaviors the day prior and that the SP would not be taking the VA bowling because of this. After speaking with G1, the SP was “mad” at the VA for the remainder of the afternoon/evening and called the VA “mean things” until another staff person arrived at the facility when it was time for the VA to go to bed. The VA could not remember what words/names the SP said to the VA. The SP provided the following information: · The SP worked at the facility on Tuesdays and every other weekend (Saturday and Sunday) between late August and mid-October 2025, during the afternoon/evening shift from 3 to 11 p.m., which was single staffed. During this time, the SP and the VA were the only persons present at the facility, with staff persons using a “communication book” to provide information about the VA’s morning/afternoon/night to other staff persons while having “little to no” verbal interactions with one another during shift changes. When working with the VA, the SP was responsible for preparing the VA’s meals as directed by the VA’s care plans, administering the VA’s medications, and transporting/accompanying the VA to daily scheduled community outings, social activities, and/or appointments. · The SP was trained on the VA’s medical and behavioral history, that staff persons “couldn’t take eyes off [the VA],” and that the VA was to be supervised by staff persons at “all times” while in the facility and the community. The SP was trained on the VA’s care plans, PWS, and the facility’s policies and procedures prior to working with the VA but the SP did not believe that s/he and/or other staff persons were able to assist with the VA’s high needs. The VA shoplifted “every time” s/he was in the community with the SP and there were multiple incidents during the SP’s shifts in which the VA “stole” and/or consumed unsafe food items without the SP’s knowledge. The SP stated that there was an incident on an unknown date when the SP “first started” working with the VA, that they went to a movie theater where the VA took candy from the concession area, hid in his/her clothing, and then started eating it after sitting down in the theater next to the SP as the movie played. · During times when they were “out [in the community] to do anything,” it “didn’t matter” where or what the VA and the SP were doing because the VA “kept stealing” items including food “as soon as [the SP] turned [his/her] back,” “even for a second.” [Note: During the interview, when the SP spoke of the VA and the VA’s behaviors, the SP stated that the VA was a “big thief,” a “klepto,” that “[the VA] probably needed to be in an institution,” and that the VA did “sneaky shit.”] · On October 11, 2025, the SP and the VA went to Walmart so that the SP could purchase personal items. At that time, it was “approved” by administrative staff persons for staff persons to complete personal errands while in the community with the VA. The SP said s/he “never” left the VA alone in Walmart, that s/he maintained adequate visual supervision of the VA at “all” times, and s/he was within the VA’s “auditory and physical range” at “all” times. However, when checking out, the VA was standing behind the SP in the “self-checkout” lane as the SP completed his/her purchases. This allowed the VA to “snatch things real fast” that were nearby without the SP’s knowledge. · After checking out, the SP and the VA left the store and got into the vehicle to return to the facility when the SP “smelled” “chocolate.” The SP asked the VA what s/he took from the store and for the VA to give the SP the “[candy] wrapper.” The VA “froze up” and “stopped responding” to the SP. The SP told the VA that s/he was “not mad,” that the VA was “not in trouble,” and that the SP needed to know what “candy” and/or food the VA took/ate so that s/he could maintain the VA’s health/safety. Additionally, staff persons were to “immediately” transport the VA to a local hospital if the VA ate “something [s/he’s] not supposed to.” The VA then told the SP that s/he left the “wrappers” inside the store because the VA did not want the “alarms to go off” when they exited the building. The SP and the VA then went back to the facility. The SP did not notify any persons that day of the incident but that s/he documented the incident in the VA’s daily communication log/notes. [Note: A review of the VA’s daily communication log/notes did not show any entries by the SP on the date of the incidents.]
· The SP denied driving to a liquor store with the VA after leaving Walmart and leaving the VA in the facility’s vehicle alone. The SP said there was “never” a time when s/he left the VA alone in the vehicle. However, the SP later said s/he “sometimes” left the VA alone in the vehicle when s/he went inside a convenience store to pay for gas but said s/he maintained visual supervision of the VA from inside the store at “all” times. · The next day, October 12, 2025, the VA had a bowling activity that was scheduled for every Sunday at 4 p.m.. However, shortly after the SP arrived at the facility to work the afternoon/evening shift, the SP told the VA that s/he “refused” to transport/accompany the VA to the bowling alley as scheduled because of the incident the day prior when the VA “stole” food from Walmart. The VA became “upset” with the SP and asked to call and talk to G1 about the situation. After the VA talked to the VA, G1 talked to the SP and “demanded” that the SP take the VA bowling as scheduled. The SP continued to “refuse” and told G1 that the VA was “clever,” that the VA “knowingly” put him/herself “in danger” the day before and during prior incidents, that the SP was not going to “reward” the VA’s behaviors, and that G1 “could come and take” the VA to this activity but the SP would not be doing so. G1 “yelled” and “cussed” at the SP, which was similar to how G1 interacted with the SP during prior phone conversations after the VA “whispered lies” to G1. The SP denied using any derogatory or inappropriate language when interacting with the VA and stated that such allegations were “all false.” The SP also said that s/he “always stayed professional” and “wouldn’t degrade like that.” · At some point before or after talking with G1, the SP called and told P1 about the situation. However, the SP later stated that the supervisory/administrative staff s/he called that day was P2. The SP told P2 that the VA had ongoing behaviors with “stealing” and eating foods that the VA “knew” were dangerous to his/her health and the VA’s care team “ignored” the VA’s behaviors by allowing the VA to continue to participate in community/social activities without having “any consequences” for his/her actions. The SP also told P2 about the VA’s taking candy from Walmart the day prior so the SP was “refusing” to take the VA to a community outing that “rewarded” this behavior. P2 told the SP that s/he needed to take the VA to the community outing as scheduled but the SP continued to refuse and told P2 to “find someone else” to do this which “upset” P2. P2 then told the SP that s/he would try to contact/arrange for another staff person to take the VA to bowling and to work the remainder of the SP’s shift but alternative staffing “never” arrived at the facility to do so. The VA did not go bowling that day. P1-P3 each provided information that was consistent with the information provided by the VA, G1, G2, and facility documentation. P1-P3 and email communication between P3 and the SP also provided the following additional information: · P3 stated that the SP worked with the VA for approximately 19 shifts and received training at the main office on the VA’s care plans, PWS, and facility policies and procedures prior to working at the facility with the VA. P1 also provided training to the SP at the facility and the SP completed a “1:1 shadow shift” on August 7, 2025, prior to being able to work his/her first shift on August 12, 2025. · P2 and P3 each stated that on September 2, 2025, the SP had his/her “first infraction” with the VA in which the SP took the VA to the SP’s “personal family dinner” and provided the VA with food “outside the realm of [the VA’s] dietary restrictions.” On September 3, 2025, P2 and P3 met with the SP to discuss the incident, the VA’s care plans, and facility polices. P2 and P3 “explained” to the SP “the severity of [the VA’s] diagnosis” and that the VA “could die” if s/he “overate” or if the VA ate foods that s/he was not able to digest. A “few days later” after the meeting (September 6, 2025), P3 emailed “all” staff persons, including the SP, about the care and services that staff persons were required to provide to the VA and also what staff persons were to refrain from, so, the SP was “fully aware and trained on what was expected, required, and prohibited” from staff persons who worked with the VA. · On September 16, 2025, administrative staff received information from G1 about “another” incident involving the SP’s food items being “left out” and accessible to the VA who then consumed the items which were not safe for the VA to eat. There was also information that the SP used “foul language” when interacting with the VA. When P3 asked the SP via email about these allegations, the SP sent an email response back to P3 stating that s/he had “no clue about any of this.” · On October 12, 2025, G1 called P2 and told P2 about the SP refusing to take the VA bowling. P2 then called the SP for additional information and asked the SP if s/he was “refusing” to take the VA to a scheduled activity to which the SP “blatantly” responded, “Yes.” The SP told P2 that they day prior, the VA “stole” from a store while with the SP, that “every time” the SP took “this [girl/boy] somewhere [s/he] would steal,” and that the VA “never” had “consequences” for his/her behaviors. P2 told the SP that staff persons “must” follow the VA’s care plans and routines, that facility clients did not receive “punishments” from staff persons, and that the SP needed to take the VA to his/her activity as scheduled but the SP continued to refuse. After talking with the SP, P2 called and notified P1. P1 and P2 then called every staff person to see about replacing the remainder of the SP’s shift, but no one was able to work until approximately 9:30 p.m. · P2 called and notified P1 about the situation, then P1 also called to talk to the SP in attempt to resolve the matter. During this call, the SP told P1 information that was consistent to the information that the SP told to G1 and P2. The SP also told P1 that s/he had driven with the VA to a liquor store but “clarified” that the VA waited inside the facility’s vehicle while the SP was the “only one who actually went into the liquor store.” On October 13, 2025, P2 and P3 contacted the SP to follow up and during this conversation, the SP told P2 and P3 that s/he did not take the VA into the liquor store because “[the VA] steals.” Facility documentation showed that the SP also told administrative staff persons that the VA “stole” a chocolate candy bar from Walmart but the SP “caught [the VA] before [s/he] ate it.” · P1-P3 each stated that they did not hear the SP use derogatory language when interacting with the VA, but P1 recalled a time when the VA said that the SP was “frustrated” with the VA and called the VA “a bitch.” Additionally prior to these incidents, P2 and P3 had spoken to the SP s about the SP’s “tone [of voice]” and being “respectful” when speaking to the VA and G1. P1-P3 communicated with G1 “quite often” and “never experienced” nor were aware of any times when G1 “yelled” or “cussed” at staff persons. During times when there were concerns with the VA’s care and “something needed to be fixed,” G1 “very compassionately” and “very bluntly advocated” for the VA but not in a manner that was inappropriate or verbally abusive “in any way.” · P1-P3 each stated that the VA reported accurate information and that the VA’s diagnosis caused him/her to be “compulsive and obsessive” with food but not with “lying.” After prior incidents involving the VA’s behaviors, the VA “always” told staff persons the “truth” and/or “always owned up” to “anything [s/he] had done” if staff persons provided the VA “reassurance” that s/he was “not in trouble” and that staff persons “needed the truth” to help keep the VA healthy/safe. The “common denominator” within the incidents that occurred involving the VA was that staff persons did not follow the “protocols” and “rules” that were “put into place” to keep the VA safe.
· P1-P3 each said that the SP’s conduct while working with the VA on October 11 and 12, 2025, was “unacceptable” and was not consistent with the VA’s care plans, facility policies and procedures, and/or the SP’s training. An email dated September 6, 2025, from P3 to “all” facility staff persons, including the SP stated: Please note, effective immediately staff are not allowed to take [the VA] to any places or events that are not pre-approved by Olu's Main Office. As a REMINDER, [the VA] cannot eat anything that is not on [his/her] set menu. The illness that [s/he] has must be followed to the letter, if you cannot do this you will be removed from the schedule. Additionally, [the VA] MUST be going out for [his/her] daily walks 2x a day. [The VA’s] weight MUST be documented daily. We are still getting reports that [the VA’s] weight is not being documented and that [s/he] is not going for [his/her] walks. Lastly, the main office worked with [the VA’s] team to establish the protocol for when [s/he] is sick. If [the VA] reports to you that [his/her] stomach hurst, staff MUST take [the VA] to the hospital and call [G1] on the way. Do not pass a PRN. After you alert [G1], you can update the Olu's Home team per your chain of command. All of the numbers should be posted in the home. [Emphasis on original]
Email communication between the facility (including P1-P3), G1, and the CM dated September to October 13, 2025, provided information that was consistent to the information provided by the VA, G1, and P1-P3.
G2 provided information that was consistent with information provided by the VA, G1, and the VA’s care plans. The CM was aware of the incident and did not have any additional information to provide for this investigation. The facility’s Rights of a Person Served policy stated that clients had a right to be free from maltreatment and to live without the fear of abuse and neglect. Additionally, clients were to have services and supports provided to them that were identified in their plans in a manner that respected clients as individuals and took into consideration the person’s preferences. Facility documentation showed that the SP was trained on the VA’s care plans; the facility’s policies and procedures including the Program Abuse Prevention Plan and the Rights of a Person Served; and the Reporting of Maltreatment of Vulnerable Adults prior to the incident. Relevant Rules and/or Statutes: Minnesota Statutes, section 245D.07, subdivision 1 stated that the license holder must provide services as assigned in the coordinated services and support plan. Minnesota Rules, part 9544.0060, subpart 2, items E and J, states in part that containing, restricting, or otherwise removing a person from normal activities; and using punishment of any kind is prohibited. Conclusion: A. Maltreatment: Information showed that the VA was diagnosed with Prader-Willi syndrome (PWS) and anxiety with a history of health conditions and complications, maladaptive behaviors, and life-threatening health risks associated with the VA’s diagnosis including hyperphagia (a feeling of extreme, insatiable hunger) and ongoing attempts made by the VA to access and consume items/amounts of foods that were dangerous to the VA’s health and/or potentially fatal. Therefore, the VA received a level of care and support from the facility that included 24-hour 1:1 staffing, visual supervision and staff proximity at “all times” within the community and the facility, routine health/safety checks of the VA and of the home, a prescribed diet and exercise plan, a rights restriction to limit the VA’s access and exposure to potentially dangerous situations, and home modifications to help maintain the VA’s health and safety. G1, G2, P1-P3, the VA’s care plans, and facility documentation provided consistent information that during situations when the VA was “upset,” “anxious,” and/or had maladaptive behaviors, staff persons were to remain “calm” and “avoid power struggles” while providing the VA with positive behavior supports and person-centered approaches including coping strategies, “calming” activities, “reassurance,” and redirection that de-escalated a situation and used it as a “teachable moment” for the VA. P1-P3 and facility documentation showed that staff persons were to provide the VA with transportation and adequate supervision to all scheduled community/social activities that were planned and “pre-approved” by administrative staff persons. Additionally, staff persons were “not allowed” to complete personal errands in the community while working with the VA. Furthermore, there was ongoing communication with the SP prior to the incidents regarding the “severity” of the VA’s diagnosis and maintaining the VA’s prescribed diet in keeping the VA healthy/safe. Information from G1, G2, and P1-P3 was consistent that the VA was an accurate reporter of incidents and provided information about a person and/or a situation that was detailed, “truthful,” and maintained consistency during times when the VA provided information to multiple individuals. Regarding the SP’s supervision of the VA during community outings, including one incident when the VA stole and ingested food items that were not safe for the VA to eat: Information from all sources was consistent that on October 11, 2025, the SP completed personal errands while working with the VA that included taking the VA to Walmart where the VA accessed and took food items without the knowledge and/or visual supervision of the SP as required by the VA’s plans, the facility’s policies and procedures, and the SP’s training and was a violation of Minnesota Statutes, section 245D.07, subdivision 1. The SP and the VA provided conflicting information regarding how/when the VA obtained the items. The VA provided consistent information on different dates during his/her interview and to G1, G2, and P1-P3 that the SP left the VA alone in the store’s self-checkout area while the SP went outside to the parking lot to get his/her credit card from the facility’s vehicle. The SP denied leaving the VA unsupervised in Walmart and stated that the VA was standing behind him/her within the SP’s “auditory and physical range” in the self-checkout lane while the SP was completing his/her purchases which allowed the VA to “snatch things real fast” that were nearby without the SP’s knowledge. The VA provided consistent information during his/her interview and to G1, G2, and P1-P3 that shortly after this and prior to returning to the facility, the SP drove the VA to the liquor store and left the VA alone and unsupervised in the vehicle while the SP then entered the store for an unknown duration of time. During the SP’s interview, the SP denied going to the liquor store and leaving the VA in the vehicle alone. However, P1-P3 each stated that the SP told each that the SP drove to the liquor store and left the VA alone in the vehicle while the SP went into the store. The SP provided additional information that on other unknown dates/times, s/he left the VA alone in the vehicle when s/he paid for gas inside a store but that s/he maintained visual supervision of the VA at “all” times. Information from all sources also showed that from September 2 to October 11, 2025, there were multiple incidents involving the VA accessing and/or consuming “unsafe” food items during times when the SP worked with the VA that included an unknown date when the VA was at a movie theater with the SP, and on September 2, 2025, when the SP took the VA to his/her “family dinner” at Applebee’s. Additional information and documentation from G1, P2, and P3 regarding these incidents was requested but not provided. An email dated September 6, 2025, from P3 to “all” facility staff persons, including the SP stated that staff persons were not “allowed” to take the VA to any places within the community that were not approved and scheduled by administrative staff persons. Staff persons were also “reminded” that the VA was not able to eat food items that were not approved and listed on the VA’s food menu to maintain the VA’s health/safety. The SP stated that staff persons were to supervise the VA at “all times” and “couldn’t take eyes off [the VA]” within the facility or the community. However, the SP also stated that during times when the SP transported/accompanied the VA to community outings/social activities, the VA “always stole” things “as soon as [the SP] turned [his/her] back.” Given the VA’s history, diagnoses, and supervision requirements, and that plans were in place for staff persons who worked with the VA to follow, there was a preponderance of the evidence that failing to follow the VA’s plans regarding the VA’s supervision with food and in the community was not accidental or therapeutic conduct and was a failure or omission to supply the VA with care or service including supervision which were reasonable and necessary to obtain or maintain the VA’s physical health or safety. It was determined that 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). Regarding the SP using derogatory language when interacting with the VA including calling the VA a “little shit” and a “fucking [R word]”: G1 provided consistent information during his/her interview and to P1-P3 that on October 12, 2025, the VA called G1 from the facility throughout the afternoon/evening because the VA was “upset” and “anxious” with how the SP was treating the VA which included “swearing” at the VA, “taunting” the VA, and calling the VA “derogatory names.” G1 could not hear what the SP was saying but was told by the VA that the SP called the VA a “little shit” and a “fucking [R word].” G1 also talked to the SP on the phone during this time and stated that the SP was “rude” and “argumentative” when speaking with G1. Additionally, G1 stated that there was a prior incident in which the SP “swore” at the VA but G1 did not recall what “specific language” was used by the SP or an approximate date/time that the incident occurred. The VA stated that the SP was “mad” at him/her and called the VA “mean things” but did not recall what words/names the SP used. P1-P3 each stated that they did not hear the SP use derogatory language when interacting with the VA, but P1 recalled a time when the VA told P1 that the SP was “frustrated” with the VA and called the VA “a bitch.” Additionally prior to these incidents, P2 and P3 had spoken to the SP s about the SP’s “tone [of voice]” and being “respectful” when speaking to the VA and G1. The SP denied using any derogatory or inappropriate language when interacting with the VA and stated that such accusations were “all false.” However, throughout the SP’s interview with this investigator, when the SP spoke about the VA and his/her behaviors which were known to be directly associated/caused by the VA’s diagnosis and were situations that the SP was to help safeguard the VA from, the SP casually made statements that the VA was a “big thief,” a “klepto,” that “[the VA] probably needed to be in an institution,” and that the VA did “sneaky shit.” Due to the VA having 1:1 staffing and living alone, and that the SP and the VA were the only persons present within the facility during the times that the SP worked at the facility, it was reasonable that there was no witnesses to how the SP generally interacted with the VA. Despite the conflicting information provided by the VA and the SP, credibility was left as a determining factor. Given that the SP had reason to minimize his/her interactions for fear of repercussions, that the VA had no history of providing inaccurate information regarding staff persons interactions, that the information the VA provided was consistent with what G1 said s/he overheard, and that the VA provided consistent information to multiple people, the VA’s account of the incident was more credible than the SP’s account. In addition, the use of the “R word” was derogatory when used toward any person, but given the VA’s diagnoses and that s/he lived in a residential setting, it was particularly derogatory to the VA. Therefore, there was a preponderance of the evidence that the SP’s used repeated and/or malicious oral language which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening and could reasonably be expected to produce emotional distress. It was determined that 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). Alleged licensing violation that the SP did not allow the VA to attend a scheduled extracurricular activity the following day as a “consequence” to the VA’s behaviors during the incident outlined above. On Sunday, October 12, 2025, the SP worked with the VA at the facility during the afternoon/evening shift which began at 3 p.m. The VA had bowling scheduled every Sunday at 4 p.m. The SP, the VA, G1, P1, and P2 provided consistent information that shortly after the SP arrived at the facility, the SP “refused” to take the VA to his/her scheduled bowling activity that afternoon because of the VA’s behaviors at Walmart during the day prior. G1, P1, and P2 each talked with the SP during separate phone calls and told the SP that s/he needed to take the VA to his/her scheduled activity but the SP continued to “refuse” and said that G1 or “someone else” could take the VA to his/her activity but the SP would not “reward” the VA’s behaviors and that the VA needed to “pay the consequences.” According to P2, s/he told the SP that facility clients did not receive “punishments” from staff persons and that the SP needed to follow the VA’s care plans. However, the SP did not take the VA bowling. The SP’s refusal to take the VA to his/her scheduled activities as a “consequence” for the VA’s behaviors was inconsistent with the VA’s care plans, the facility’s policies, and the standards of a professional caregiver in a facility licensed by the Department of Humas Services and were a violation of Minnesota Rules, part 9544.0060, subpart 2, items E and J. A licensing violation was determined. 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. The SP was responsible for the care and supervision of the VA and was trained on the VA’s plans; the facility’s policies and procedures including the Program Abuse Prevention Plan and the Rights of a Person Served; and the Reporting of Maltreatment of Vulnerable Adults prior to the incidents. The SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. 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 neglect and emotional abuse for which the SP was responsible was recurring but did not meet statutory criteria to be determined as serious. The SP was responsible for two findings of maltreatment, emotional abuse and neglect. The SP was disqualified from providing direct contact services. Action Taken by Facility: The facility completed an internal review and found their policies and procedures adequate but not followed by the SP. The SP no longer worked at the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was disqualified from a position allowing direct contact with, or access to, persons receiving services from programs, organizations, and/or agencies that are required to have individuals complete a background study by the Department of Human Services as listed in Minnesota Statutes, section 245C.03. The determination that the SP was responsible for maltreatment and the disqualification of the SP are each subject to appeal. Given that the facility took immediate corrective action, a Correction Order was not issued for the violation outlined above. Given that the facility took immediate corrective action, a Correction Order was not issued for the violations outlined in this report.
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